Case Report
Anesthetic Considerations for Cardiac Tamponade after Internal Jugular Central Line Placement during Trauma Resuscitation: A Case Report
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Vasc Specialist Int (2023) 39:17
Published online June 29, 2023 https://doi.org/10.5758/vsi.230030
Copyright © The Korean Society for Vascular Surgery.
Abstract
Keywords
INTRODUCTION
The immediate complications of central line placement include arrhythmias, bleeding, or damage to anatomic structures. The sequelae of this damage include, but are not limited to, pneumothorax, pneumomediastinum, nerve injury, hematoma, or cardiac tamponade [1]. Extraluminal placement of an internal jugular central line catheter can cause rapid extravasation of intravenous fluid or blood into the mediastinum, subsequently causing cardiac tamponade. Patients with rapid pericardial fluid accumulation have less time to accommodate the increased volume, resulting in significant hemodynamic impairment due to reduced right heart filling [2]. Anesthetic agents and positive-pressure ventilation in cardiac tamponade can further reduce cardiac filling, presenting a challenge in maintaining cardiac output before the surgical drainage of fluid [3]. In this case presentation, we discuss a patient with the reaccumulation of a large pericardial effusion from the right internal jugular central line placement, resulting in cardiac tamponade.
The Institutional Review Board at Baylor College of Medicine in Houston exempted this case report from review. Informed consent was obtained.
CASE
A 22-year-old otherwise healthy male presented to the emergency department in the evening with Code 1 trauma due to gunshot wounds in the abdomen. Upon arrival, the patient was intubated by emergency medical services for airway protection and had a Glasgow Coma Score of six. Initially, he appeared diaphoretic, accompanied by a heart rate of 140 beats/min and a blood pressure of 81/51 mmHg. The massive transfusion protocol was promptly activated, and the patient was subsequently transported to the operating room for emergency surgery.
Exploratory laparotomy, with a right internal iliac artery repair, a small bowel resection, and a pelvic packing was performed. The patient was transferred to the intensive care unit (ICU) where a 7 French right internal jugular central line was placed for trauma resuscitation. Portable chest radiography showed the right internal jugular catheter projecting over the superior vena cava (Fig. 1). Despite receiving large-volume resuscitation, the patient remained persistently tachycardic and hypotensive in the ICU overnight. In order to facilitate resuscitation, a femoral central line was placed and the right internal jugular line was no longer used due to the possibility of extraluminal placement. The following morning, a chest/abdomen/pelvis computed tomography (CT) scan revealed a large-volume pericardial effusion, large right supraclavicular hematoma, pneumomediastinum, and large bilateral pleural effusions with atelectasis, which were attributed to the extraluminal central line (Fig. 2, 3). The cardiology department was consulted for transthoracic echocardiography and possible pericardiocentesis; however, the effusion volume was not large enough or anterior for pericardiocentesis.
-
Figure 1.Initial bedside portable single-view chest X-ray showed the right internal jugular central line catheter overlying the superior vena cava.
-
Figure 2.Computed tomography with contrast demonstrated large bilateral pleural fluid collection and pericardial fluid (arrow).
-
Figure 3.Computed tomography with contrast revealed pneumomediastinum around the superior vena cava extending up towards the aortic arch.
The patient was transported to the operating room, where emergent median sternotomy was performed. Opening the pericardium resulted in the release of a large volume of clear fluid. This prompted an exploration to assess any superior vena cava injuries. Anesthesia was maintained using inhaled isoflurane. Intraoperatively, the right internal jugular vein was pierced by a central-line catheter. The anesthesia team retracted the catheter until it was once again intraluminal and the surgical team repaired the defect (Fig. 4). Bilateral chest tubes and a pericardial drain were placed due to the possibility of fluid accumulation.
-
Figure 4.Right internal jugular central venous catheter through internal jugular vein into the surgical field.
Over the next week, the patient continued to recover from the small bowel resection and was transferred to the surgical ward after extubation. However, the patient remained persistently tachycardic in the range of 120’s, and there was a downward trend in hemoglobin levels from 11.6 g/dL to 7.3 g/dL, two weeks after being transferred out of the ICU.
The volume of the pericardial drain volume was decreased to 20 mL per day, and eventually the drain was removed. A few days after the removal of the pericardial drain, the patient began to develop worsening tachycardia and vomiting, initially suspected due to pulmonary embolism (PE). However, the CT PE protocol demonstrated no embolus but it did indicate the recurrence of a large pericardial effusion. Transthoracic echocardiography revealed large pericardial effusion with right ventricular diastolic collapse. Patient also exhibited orthopnea, hypotension, tachycardia, and increased pulse pressure variation on arterial line tracing, leading to the diagnosis of cardiac tamponade (Fig. 5).
-
Figure 5.Computed tomography pulmonary embolism protocol demonstrated large pericardial effusion.
An emergency pericardial window was performed with cardiopulmonary bypass on standby. The patient was preoxygenated, and midazolam and dexmedetomidine were administered for sedation. Pre-induction femoral venous access and radial arterial lines were established. Induction was achieved using ketamine and etomidate, while maintaining spontaneous ventilation. The airway was secured using video laryngoscopy, and the endotracheal tube was advanced past the open vocal cords during inspiration.
The pericardial window was created, draining 400 mL of serosanguineous pericardial fluid. The patient’s tachycardia improved, with the heart rate dropping from 125 to 90 beats/min almost immediately after the drainage of the large pericardial volume. The patient was discharged nine days after the pericardial window procedure.
DISCUSSION
1) Acute complications of central line placement
The puncture of inappropriate tissue planes during the placement of central line catheters can cause immediate complications due to disruption of anatomical barriers. Extraluminal placement results in bleeding, leading to a hemothorax, hemopericardium, or hematoma formation. Furthermore, the resuscitation fluids are entrained in the pericardium worsened this condition. Bleeding leads to hypovolemia, shock, and decreased oxygen-carrying capacity. The sudden expansion of potential spaces can affect the physiology of the lungs and heart. Hemothorax restricts lung parenchyma expansion during inspiration, resulting in atelectasis, ventilation-perfusion mismatch, and hypoxemia [1]. Hemopericardium, especially with sudden volume expansion of the pericardium, may cause cardiac tamponade due increased in pressure. Additionally, extraluminal placement can disrupt the pleura, leading to pneumothorax and pneumomediastinum, both of which can cause atelectasis and hypoxemia [4].
Abnormal anatomy or guidewire entrapment in the vessel wall can result in large tears in a vessel wall along with dilation or central line placement. Misplacement can occur even with proper technique; however, inexperienced users or poor ultrasound visualization of the guidewire may predispose them to injury. Early identification of extravascular placement can prevent tamponade by minimizing fluid infusion into the pericardial space. Possible indicators of incorrect placement include absence of blood return upon aspiration of the catheter, or minimal to no response to medications infused through the catheter [4].
Large injuries to major venous structures often prompt direct surgical repair. Repair options include suture repair or reconstruction of the vascular structures [4]. Cardiopulmonary bypass may be required for major injuries.
2) Cardiac tamponade
The classic hallmark of cardiac tamponade is Beck triad, consisting of jugular venous distention, hypotension, and distant heart sounds [5]. Jugular venous distention and hypotension could indicate cardiogenic shock in the presence of a large pericardial effusion. During the acute phase, the pericardial sac acts as a fixed space. With the rapid accumulation of blood, the compliant right atrium and ventricle share their intraluminal space with the pericardial blood, decreasing their filling during each cardiac cycle. As stroke volume and tissue perfusion decrease, native catecholamine release increases heart rate and contractility to maintain cardiac output [6]. However, if the pericardial pressure increases above the ventricular filling pressure, it results in reduced cardiac input and, subsequently lowers the cardiac output [7].
3) Additional considerations of cardiac tamponade
The induction of anesthesia, airway instrumentation, and mechanical ventilation affect the cardiac output and intrathoracic pressure. In the case of cardiac tamponade, it is crucial to maintain the compensatory mechanisms of increased heart rate and contractility to preserve the remaining cardiac function and prevent further reduction in preload [6]. Although the time from anesthesia induction to evacuation of the pericardial fluid is short, significant disruption in these parameters can lead to cardiac arrest, as the physiologic reserve becomes depleted. The initiation of positive-pressure ventilation in the presence of cardiac tamponade could result in further reduction of right ventricular filling and cardiac output, which can cause cardiac compromise and possible cardiac arrest [8].
In our patient, we maintained the cardiac preload by avoiding an increase in intrathoracic pressure. To preserve spontaneous ventilation during anesthesia induction, a mixture of dexmedetomidine, ketamine, and etomidate was carefully titrated. These agents also maintain contractility better than alternative intravenous induction agents. Furthermore, paralytics were avoided to preserve spontaneous ventilation, and limited pressure support was administered for patient-generated breaths.
Prolonged or highly stimulating airway manipulation can further increase intrathoracic pressure, which can result in a decrease in cardiac output. To expedite the establishment of a protected airway, a video laryngoscopy placing an endotracheal tube through the open vocal cords on inspiration was used by the most senior provider. Additionally, patient hemodynamics were monitored with pre-induction arterial line placement, and atropine was readily available to address the potential decrease in heart rate.
4) Conclusion
Extraluminal placement of an internal jugular central line catheter can lead to rapid extravasation of intravenous fluid or blood into the mediastinum, resulting in cardiac tamponade. Although surgical evacuation of the pericardial fluid effectively treats the tamponade, the induction of anesthesia may pose as a challenge to native compensatory mechanisms. To maintain cardiac output, clinical management should focus on maintaining preload by minimizing increased intrathoracic pressure, avoiding agents that decrease contractility, and preserving the heart rate until surgical correction of the tamponade.
FUNDING
None.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
AUTHOR CONTRIBUTIONS
Concept and design: AN. Analysis and interpretation: JH, AN. Data collection: KMC, AN. Writing the article: all authors. Critical revision of the article: JH, AN. Final approval of the article: all authors. Statistical analysis: none. Obtained funding: none. Overall responsibility: all authors.
References
- Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Central line catheters and associated complications: a review. Cureus 2019;11:e4717. https://doi.org/10.7759/cureus.4717.
- Madhivathanan PR, Corredor C, Smith A. Perioperative implications of pericardial effusions and cardiac tamponade. BJA Educ 2020;20:226-234. https://doi.org/10.1016/j.bjae.2020.03.006.
- Grocott HP, Gulati H, inathan S Sr, Mackensen GB. Anesthesia and the patient with pericardial disease. Can J Anaesth 2011;58:952-966. https://doi.org/10.1007/s12630-011-9557-8.
- Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci 2015;5:170-178. https://doi.org/10.4103/2229-5151.164940.
- Sternbach G. Claude Beck: cardiac compression triads. J Emerg Med 1988;6:417-419. https://doi.org/10.1016/0736-4679(88)90017-0.
- Appleton C, Gillam L, Koulogiannis K. Cardiac Tamponade. Cardiol Clin 2017;35:525-537. https://doi.org/10.1016/j.ccl.2017.07.006.
- Ariyarajah V, Spodick DH. Cardiac tamponade revisited: a postmortem look at a cautionary case. Tex Heart Inst J 2007;34:347-351.
- Ho AM, Graham CA, Ng CS, Yeung JH, Dion PW, Critchley LA, et al. Timing of tracheal intubation in traumatic cardiac tamponade: a word of caution. Resuscitation 2009;80:272-274. https://doi.org/10.1016/j.resuscitation.2008.09.021.
Related articles in VSI

Article
Case Report
Vasc Specialist Int (2023) 39:17
Published online June 29, 2023 https://doi.org/10.5758/vsi.230030
Copyright © The Korean Society for Vascular Surgery.
Anesthetic Considerations for Cardiac Tamponade after Internal Jugular Central Line Placement during Trauma Resuscitation: A Case Report
Kevin M. Chen1 , Jamal Hasoon2
, and Anvinh Nguyen1
1Department of Anesthesiology, Baylor College of Medicine, Houston, TX, 2Department of Anesthesia, Critical Care, and Pain Medicine, UTHealth McGovern Medical School, Houston, TX, USA
Correspondence to:Jamal Hasoon
Department of Anesthesia, Critical Care, and Pain Medicine, UTHealth McGovern Medical School, 6431 Fannin St, Houston, TX 77030, USA
Tel: 1-713-500-4472
Fax: 1-713-486-6324
E-mail: Jamal.J.Hasoon@uth.tmc.edu
https://orcid.org/0000-0001-8227-1864
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Numerous complications are associated with central venous catheters. Among them, cardiac tamponade is a rare but well-documented catastrophic complication. A 22-year-old healthy male presented with Code 1 trauma resulting from gunshot wounds in the abdomen. Upon examination, he was found to have a large pericardial fluid collection, a large right supraclavicular hematoma, and significant amount of bilateral pleural effusions secondary to extraluminal placement of the right internal jugular central line during resuscitation. After repairing the internal jugular injury and draining the pericardial fluid, the patient was transferred from the intensive care unit to the regular hospital floor. However, 15 days later, imaging revealed re-accumulation of a large pericardial effusion, which was eventually treated with a pericardial window operation. This case report explores potential complications that could arise from central line placement and the anesthetic considerations in a patient with cardiac tamponade from extraluminal central line placement.
Keywords: Central line, Complications, Vascular system injuries, Cardiac tamponade
INTRODUCTION
The immediate complications of central line placement include arrhythmias, bleeding, or damage to anatomic structures. The sequelae of this damage include, but are not limited to, pneumothorax, pneumomediastinum, nerve injury, hematoma, or cardiac tamponade [1]. Extraluminal placement of an internal jugular central line catheter can cause rapid extravasation of intravenous fluid or blood into the mediastinum, subsequently causing cardiac tamponade. Patients with rapid pericardial fluid accumulation have less time to accommodate the increased volume, resulting in significant hemodynamic impairment due to reduced right heart filling [2]. Anesthetic agents and positive-pressure ventilation in cardiac tamponade can further reduce cardiac filling, presenting a challenge in maintaining cardiac output before the surgical drainage of fluid [3]. In this case presentation, we discuss a patient with the reaccumulation of a large pericardial effusion from the right internal jugular central line placement, resulting in cardiac tamponade.
The Institutional Review Board at Baylor College of Medicine in Houston exempted this case report from review. Informed consent was obtained.
CASE
A 22-year-old otherwise healthy male presented to the emergency department in the evening with Code 1 trauma due to gunshot wounds in the abdomen. Upon arrival, the patient was intubated by emergency medical services for airway protection and had a Glasgow Coma Score of six. Initially, he appeared diaphoretic, accompanied by a heart rate of 140 beats/min and a blood pressure of 81/51 mmHg. The massive transfusion protocol was promptly activated, and the patient was subsequently transported to the operating room for emergency surgery.
Exploratory laparotomy, with a right internal iliac artery repair, a small bowel resection, and a pelvic packing was performed. The patient was transferred to the intensive care unit (ICU) where a 7 French right internal jugular central line was placed for trauma resuscitation. Portable chest radiography showed the right internal jugular catheter projecting over the superior vena cava (Fig. 1). Despite receiving large-volume resuscitation, the patient remained persistently tachycardic and hypotensive in the ICU overnight. In order to facilitate resuscitation, a femoral central line was placed and the right internal jugular line was no longer used due to the possibility of extraluminal placement. The following morning, a chest/abdomen/pelvis computed tomography (CT) scan revealed a large-volume pericardial effusion, large right supraclavicular hematoma, pneumomediastinum, and large bilateral pleural effusions with atelectasis, which were attributed to the extraluminal central line (Fig. 2, 3). The cardiology department was consulted for transthoracic echocardiography and possible pericardiocentesis; however, the effusion volume was not large enough or anterior for pericardiocentesis.
-
Figure 1. Initial bedside portable single-view chest X-ray showed the right internal jugular central line catheter overlying the superior vena cava.
-
Figure 2. Computed tomography with contrast demonstrated large bilateral pleural fluid collection and pericardial fluid (arrow).
-
Figure 3. Computed tomography with contrast revealed pneumomediastinum around the superior vena cava extending up towards the aortic arch.
The patient was transported to the operating room, where emergent median sternotomy was performed. Opening the pericardium resulted in the release of a large volume of clear fluid. This prompted an exploration to assess any superior vena cava injuries. Anesthesia was maintained using inhaled isoflurane. Intraoperatively, the right internal jugular vein was pierced by a central-line catheter. The anesthesia team retracted the catheter until it was once again intraluminal and the surgical team repaired the defect (Fig. 4). Bilateral chest tubes and a pericardial drain were placed due to the possibility of fluid accumulation.
-
Figure 4. Right internal jugular central venous catheter through internal jugular vein into the surgical field.
Over the next week, the patient continued to recover from the small bowel resection and was transferred to the surgical ward after extubation. However, the patient remained persistently tachycardic in the range of 120’s, and there was a downward trend in hemoglobin levels from 11.6 g/dL to 7.3 g/dL, two weeks after being transferred out of the ICU.
The volume of the pericardial drain volume was decreased to 20 mL per day, and eventually the drain was removed. A few days after the removal of the pericardial drain, the patient began to develop worsening tachycardia and vomiting, initially suspected due to pulmonary embolism (PE). However, the CT PE protocol demonstrated no embolus but it did indicate the recurrence of a large pericardial effusion. Transthoracic echocardiography revealed large pericardial effusion with right ventricular diastolic collapse. Patient also exhibited orthopnea, hypotension, tachycardia, and increased pulse pressure variation on arterial line tracing, leading to the diagnosis of cardiac tamponade (Fig. 5).
-
Figure 5. Computed tomography pulmonary embolism protocol demonstrated large pericardial effusion.
An emergency pericardial window was performed with cardiopulmonary bypass on standby. The patient was preoxygenated, and midazolam and dexmedetomidine were administered for sedation. Pre-induction femoral venous access and radial arterial lines were established. Induction was achieved using ketamine and etomidate, while maintaining spontaneous ventilation. The airway was secured using video laryngoscopy, and the endotracheal tube was advanced past the open vocal cords during inspiration.
The pericardial window was created, draining 400 mL of serosanguineous pericardial fluid. The patient’s tachycardia improved, with the heart rate dropping from 125 to 90 beats/min almost immediately after the drainage of the large pericardial volume. The patient was discharged nine days after the pericardial window procedure.
DISCUSSION
1) Acute complications of central line placement
The puncture of inappropriate tissue planes during the placement of central line catheters can cause immediate complications due to disruption of anatomical barriers. Extraluminal placement results in bleeding, leading to a hemothorax, hemopericardium, or hematoma formation. Furthermore, the resuscitation fluids are entrained in the pericardium worsened this condition. Bleeding leads to hypovolemia, shock, and decreased oxygen-carrying capacity. The sudden expansion of potential spaces can affect the physiology of the lungs and heart. Hemothorax restricts lung parenchyma expansion during inspiration, resulting in atelectasis, ventilation-perfusion mismatch, and hypoxemia [1]. Hemopericardium, especially with sudden volume expansion of the pericardium, may cause cardiac tamponade due increased in pressure. Additionally, extraluminal placement can disrupt the pleura, leading to pneumothorax and pneumomediastinum, both of which can cause atelectasis and hypoxemia [4].
Abnormal anatomy or guidewire entrapment in the vessel wall can result in large tears in a vessel wall along with dilation or central line placement. Misplacement can occur even with proper technique; however, inexperienced users or poor ultrasound visualization of the guidewire may predispose them to injury. Early identification of extravascular placement can prevent tamponade by minimizing fluid infusion into the pericardial space. Possible indicators of incorrect placement include absence of blood return upon aspiration of the catheter, or minimal to no response to medications infused through the catheter [4].
Large injuries to major venous structures often prompt direct surgical repair. Repair options include suture repair or reconstruction of the vascular structures [4]. Cardiopulmonary bypass may be required for major injuries.
2) Cardiac tamponade
The classic hallmark of cardiac tamponade is Beck triad, consisting of jugular venous distention, hypotension, and distant heart sounds [5]. Jugular venous distention and hypotension could indicate cardiogenic shock in the presence of a large pericardial effusion. During the acute phase, the pericardial sac acts as a fixed space. With the rapid accumulation of blood, the compliant right atrium and ventricle share their intraluminal space with the pericardial blood, decreasing their filling during each cardiac cycle. As stroke volume and tissue perfusion decrease, native catecholamine release increases heart rate and contractility to maintain cardiac output [6]. However, if the pericardial pressure increases above the ventricular filling pressure, it results in reduced cardiac input and, subsequently lowers the cardiac output [7].
3) Additional considerations of cardiac tamponade
The induction of anesthesia, airway instrumentation, and mechanical ventilation affect the cardiac output and intrathoracic pressure. In the case of cardiac tamponade, it is crucial to maintain the compensatory mechanisms of increased heart rate and contractility to preserve the remaining cardiac function and prevent further reduction in preload [6]. Although the time from anesthesia induction to evacuation of the pericardial fluid is short, significant disruption in these parameters can lead to cardiac arrest, as the physiologic reserve becomes depleted. The initiation of positive-pressure ventilation in the presence of cardiac tamponade could result in further reduction of right ventricular filling and cardiac output, which can cause cardiac compromise and possible cardiac arrest [8].
In our patient, we maintained the cardiac preload by avoiding an increase in intrathoracic pressure. To preserve spontaneous ventilation during anesthesia induction, a mixture of dexmedetomidine, ketamine, and etomidate was carefully titrated. These agents also maintain contractility better than alternative intravenous induction agents. Furthermore, paralytics were avoided to preserve spontaneous ventilation, and limited pressure support was administered for patient-generated breaths.
Prolonged or highly stimulating airway manipulation can further increase intrathoracic pressure, which can result in a decrease in cardiac output. To expedite the establishment of a protected airway, a video laryngoscopy placing an endotracheal tube through the open vocal cords on inspiration was used by the most senior provider. Additionally, patient hemodynamics were monitored with pre-induction arterial line placement, and atropine was readily available to address the potential decrease in heart rate.
4) Conclusion
Extraluminal placement of an internal jugular central line catheter can lead to rapid extravasation of intravenous fluid or blood into the mediastinum, resulting in cardiac tamponade. Although surgical evacuation of the pericardial fluid effectively treats the tamponade, the induction of anesthesia may pose as a challenge to native compensatory mechanisms. To maintain cardiac output, clinical management should focus on maintaining preload by minimizing increased intrathoracic pressure, avoiding agents that decrease contractility, and preserving the heart rate until surgical correction of the tamponade.
FUNDING
None.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
AUTHOR CONTRIBUTIONS
Concept and design: AN. Analysis and interpretation: JH, AN. Data collection: KMC, AN. Writing the article: all authors. Critical revision of the article: JH, AN. Final approval of the article: all authors. Statistical analysis: none. Obtained funding: none. Overall responsibility: all authors.
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References
- Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Central line catheters and associated complications: a review. Cureus 2019;11:e4717. https://doi.org/10.7759/cureus.4717.
- Madhivathanan PR, Corredor C, Smith A. Perioperative implications of pericardial effusions and cardiac tamponade. BJA Educ 2020;20:226-234. https://doi.org/10.1016/j.bjae.2020.03.006.
- Grocott HP, Gulati H, inathan S Sr, Mackensen GB. Anesthesia and the patient with pericardial disease. Can J Anaesth 2011;58:952-966. https://doi.org/10.1007/s12630-011-9557-8.
- Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci 2015;5:170-178. https://doi.org/10.4103/2229-5151.164940.
- Sternbach G. Claude Beck: cardiac compression triads. J Emerg Med 1988;6:417-419. https://doi.org/10.1016/0736-4679(88)90017-0.
- Appleton C, Gillam L, Koulogiannis K. Cardiac Tamponade. Cardiol Clin 2017;35:525-537. https://doi.org/10.1016/j.ccl.2017.07.006.
- Ariyarajah V, Spodick DH. Cardiac tamponade revisited: a postmortem look at a cautionary case. Tex Heart Inst J 2007;34:347-351.
- Ho AM, Graham CA, Ng CS, Yeung JH, Dion PW, Critchley LA, et al. Timing of tracheal intubation in traumatic cardiac tamponade: a word of caution. Resuscitation 2009;80:272-274. https://doi.org/10.1016/j.resuscitation.2008.09.021.