The study in this post was conducted in southern Gaza, where attacks continue. If you want to want to support medics in the region, consider donating to Doctors Worldwide.
Last week on St Emlyn’s we wrote about the SWIFT study, which is hot-off-the-press and available to read here. The trial involved a high-resource intervention — whole blood — delivered by specialist air ambulance teams. This is the absolute bleeding edge (no pun intended) of emergency care.
But a lot can be done with less! I wanted to briefly cover a very different study published last month in Injury. This was a case series from southern Gaza involving twenty-five patients treated for cardiac tamponade during a critical shortage of personnel and specialist equipment.
Abstract
Objective: To describe the outcomes of a protocol using ultrasound-guided pericardiocentesis with pericardial drain placement as definitive treatment for penetrating cardiac injury with tamponade in a resource-limited war zone setting, where emergency thoracotomy is often unavailable.
Qandil, M […], Abughali, S. Pericardiocentesis, drainage and instilled tranexamic acid: definitive management in a 25-case series of penetrating cardiac tamponade.
Design: Single-center prospective case series.
Setting: Nasser Medical Complex, a major tertiary trauma center in southern Gaza, over a period of 24 months during active conflict.
Participants: 25 patients (21 male, 4 female), aged 4-65 years, not in cardiac arrest, with traumatic pericardial effusions and hematoma caused by penetrating injury presenting within approximately 3 hours.
Interventions: Ultrasound-guided pericardiocentesis via a large-bore 16 gauge dialysis catheter, aggressive aspiration of fresh blood, instilling 1 gram of intrapericardial tranexamic acid (TXA) and pericardial drain placement for 48 hours with serial echocardiographic monitoring.
Results: This study demonstrated a high survival rate of 96%, with 24 out of 25 patients surviving to hospital discharge (the sole non-survivor died from other injuries). The protocol successfully prevented the need for thoracotomy in 100% of cases, establishing it as a definitive treatment. A recurrence rate of 8% was observed, requiring repeat drainage in two patients, while follow-up was maintained for 83% of survivors.
Conclusions: In a warzone setting, a protocol of pericardiocentesis with pericardial drain placement and intrapericardial TXA served as definitive management for selected patients with penetrating cardiac tamponade, resulting in high survival and avoiding the need for thoracotomy. This approach challenges current practice and offers a life-saving alternative in resource-constrained environments.
Injury. 2026 Feb.
What was the study design?
The authors describe the study design as a ‘prospective case series,’ which I think might be underselling it slightly. Standardised data were collected in real-time from twenty-five patients. I mentally upgraded this to a prospective cohort study.
The difference might appear semantic, but remember that case reports and series are frequently excluded from review articles and meta-analyses.
Can you tell me about the patients?
These were twenty-five patients treated at a tertiary hospital in southern Gaza (Nasser Medical Complex) for penetrating injuries from shrapnel (n=24) or bullets (n=1) between 2024 and 2025.
A crucial point of context: only one cardiac surgeon was available for the region during this period. This is was why thoracotomy was, for most of these patients, off the table, although the authors also mention a lack of availability of cardiac instruments and theatre space.
The sample (sadly) included both children and adults. All were in obstructive shock with echocardiographic evidence of haemopericardium. Patients who had arrested or were proceeding directly to thoracotomy were excluded, as were those with injuries deemed unsurvivable. Most effusions were sizeable (2.5 – 3.5cm) and associated with a reduced MAP, typically in the 30-40 range.
What was the intervention?
To temporise patients to cardiac surgery, the study clinicians performed periocardiocentesis using a dialysis catheter (12Fr) and an ultrasound-guided Seldinger technique. Essentially, they used a Vascath kit and a giving set.
After aspirating blood, one gram of TXA was instilled into the pericardial space and then the catheter secured as a drain. It was left in place for at least two days, with serial ultrasound monitoring to check for re-accumulation.
What were the main outcome measures?
The primary outcomes were mortality and the need for cardiothoracic surgery. The researchers also collected data on adverse events associated with the procedure.
What were the main results?
All but one patient survived to hospital discharge and none needed a thoractomy. Recurrence of the tamponade occurred in two patients and this required repeat drainage.
There were some pulmonary complications (effusion, infection, atelectasis) but their incidence (n = 4) is roughly what I would expect in thoracic injuries.
What did the authors conclude from these results?
The authors concluded that their procedure yielded ‘unexpectedly definitive results’ — i.e. it emerged as an alternative, rather than a bridge, to surgery. This, they argue, ‘challenges current practice and offers a life-saving alternative in resource-constrained environments.‘
What should we take away from this study?
There are many limitations to this paper which will be obvious to regular readers of St Emlyn’s. The numbers are small, only one centre was involved, and the outcomes, including adverse events, were assessed by the same clinicians who performed the procedure. I will not dwell too much on these. Given the context of an ongoing genocide, the richness of data collected by the authors (including follow-up!) is impressive.
Clearly, as this is a non-randomised study, selection bias will have shaped the results. The doctors excluded patients who were in cardiac arrest or deemed non-salvageable. It is unsurprising, then, that their outcomes were more positive than similar studies that we have covered on St Emlyn’s (here and here) where these cases were included. I suppose this is less of a problem if the researchers’ selection procedure is replicable. In this instance, it is. Think about the narrow criteria we use to decide when to perform a thoractomy in ED.
It is worth adding that the clinicians in this study practiced and refined their procedure in a warzone, where the volume and severity of penetrating trauma was unusually high. Their outcomes may reflect a level of procedural experience that would be difficult for clinicians in other settings (e.g. the UK!) to match.
Should this study change our practice?
Sort of.
For resource-limited hospitals with limited access to thoracotomy, this study describes an alternative procedure that does not require advanced equipment. Doctors working in these settings who read this article will know whether it is feasible for their practice or not.
Otherwise, this is a great example of dogmalysis in emergency medicine. I have always been taught that pericardiocentesis does not work in traumatic haemopericardium because the blood is too clotted to aspirate out. Clearly, this is not always the case.
The use of peri-cardial TXA is interesting, and would make a great topic for a Best Evidence Topic (BET) review. I gather it is sometimes administered in cardiac surgery but I have never seen it used here in Virchester…
References
Mahaffey R, Wang L, Hamilton A, Phelan R, Arellano R. A retrospective analysis of blood loss with combined topical and intravenous tranexamic acid after coronary artery bypass graft surgery. Journal of cardiothoracic and vascular anesthesia. 2013 Feb 1;27(1):18-22.
Qandil M, Ransom P, Shamal MA, Srour A, Khafaja M, Alkhateeb N, Abughali S, Jafar AJ. Pericardiocentesis, drainage and instilled tranexamic acid: definitive management in a 25-case series of penetrating cardiac tamponade. Injury. 2026 Feb 16:113106.
Smith JE, Cardigan R, Sanderson E, Silsby L, Rourke C, Barnard EB, Basham P, Antonacci G, Charlewood R, Dallas N, Davies J. Prehospital Whole Blood in Traumatic Hemorrhage—a Randomized Controlled Trial. New England Journal of Medicine. 2026 Mar 17.
