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A 57-year-old man with a motor vehicle accident and blunt chest trauma developed refractory hypotension and hypoxia. His external jugular veins were filled, pulsated with an indiscernible waveform. It was difficult to insert a central line into right subclavian vein, because of exceedingly brisk and pulsatile backward blood flow. No murmur was audible in auscultation. No specific cardiac abnormality was indicated in chest X-ray. Creatine kinase-MB was 30.89 and cardiac troponin T (CTnT) was 0.6. The ECG revealed an intermittent right bundle branch block pattern (see online supplementary figure S1). A subcostal view transthoracic echocardiogram with pulse wave Doppler study was shown in Figure 1A (a colour Doppler study was shown in online supplementary video 1). A contrast chest CT was shown in Figure 1B.
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