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A 43 year old female is admitted to ICU with acute pancreatitis. She develops acute respiratory distress syndrome and is managed with difficulty with high oxygen requirements, prone positioning, high levels of PEEP and vasopressor. On day 29 following admission, the patient, who had been hemodynamically stable, without support, on minimal ventilation settings, acutely deteriorates. Her blood pressure falls to 60/40. SpO2 is 80%, heart sounds are inaudible, heart rate is 45, jugular veins are distended.

What is going on here?

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