Cardiac Tamponade

About this case

A 55-year-old with a malignant pericardial effusion presents compensated but with tamponade physiology on echocardiography. Anaesthesia is consulted for two possible plans — echo-guided pericardiocentesis under sedation, or a surgical window requiring general anaesthesia — and the examiner will make you defend the choice.

Key clinical features

• Beck's Triad

  Hypotension + JVD + muffled heart sounds — tamponade until proven otherwise

• Induction Risk

  GA induction causes vasodilation + myocardial depression → arrest

• Ketamine Preferred

  Maintains sympathetic tone — safest induction agent in tamponade

• Equalization of Pressures

  RA = RV = LA = PA diastolic = PCWP — pathognomonic on cath

What the examiner is testing

• Whether you recognise that induction of general anaesthesia is the highest-risk moment, and how that reshapes the whole plan.
• Your reasoning about the haemodynamic goals tamponade imposes, and which routine interventions become dangerous.
• How you weigh pericardiocentesis against a surgical window on clinical grounds rather than convenience.
• Your contingency planning if the patient decompensates during induction — the examiner will force this branch.

Where candidates lose points

• Treating the compensatory tachycardia as a problem to correct.
• Proceeding to general anaesthesia without arranging for drainage to be immediately available.
• Giving a generic induction plan that ignores the fixed-preload physiology.

How it is scored

Every BoardSim case is scored across the same five phases — pre-operative evaluation, anaesthetic plan, intra-operative management, crisis management, and emergence — for a total of 100 points, with a pass set at 70 and no missed critical action. You receive a written report against each phase rather than a single number. Read the scoring methodology.