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Cardiac tamponade was diagnosed in 197 patients admitted over 20 years (1955–1974) to the Charity Hospital of New Orleans, for emergency treatment of penetrating mediastinal injuries. Of the 197, 174 definitively treated patients followed one of three patterns of management: 96 had OR thoracotomy, 68% were unstable, and preoperative pericardiocentesis reduced mortality from 25 to 11% (p < 0.01); 44 had emergency thoracotomy, 91% were unstable, and prethoracotomy pericardiocentesis decreased mortality from 94 to 63% (p> < 0.05); 34 patients primarily with isolated stab wounds, were treated nonsurgically with pericardiocentesis and observation, only 50% were unstable and there was 15% mortality. Recurrent tamponade did not significantly increase overall or operative mortality in patients with pericardiocentesis. Recommendations: early, even presumptive, diagnosis of tamponade; immediate pericardial decompression via pericardiocentesis; and rapid transfer to OR for thoracotomy or sternotomy and cardiorrhaphy with continous pericardial decompression via intrapericardial catheter.