Large pericardial effusion may be associated with muffled heart sounds and rales in the lung fields secondary to fluid compression.1 Dullness to percussion and bronchial breathing below the left scapular angle is rarely appreciated (Ewart’s sign). Sinus tachycardia and hypotension are signs of hemodynamic compromise. Tachycardia is usually absent in patients with hypothyroid and uremia. In advanced cases, pulseless electrical activity cardiac arrest can be a challenging scenario, where urgent pericadiocentesis can be life-saving where external chest compression is effortless.7,17 A careful examination of the peripheral pulse characteristics may anticipate the presence of pulses paradoxus with >10 mmHg drop in systolic pressure because of the impairment of left ventricular filling by the displaced septum during right ventricular filling and then a drop in systolic pressure readings, particularly in patients with tamponade, a phenomenon known by ventricular interdependence.1 The assessment of pulsus paradoxus should always be performed during normal respiration because deep inspiration may result in false-positive readings.8 Pulsus paradoxus is not specific for cardiac tamponade