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. Single-center prospective case series. Nasser Medical Complex, a major tertiary trauma center in southern Gaza, over a period of 24 months during active conflict. 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. 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. Survival to hospital discharge, need for subsequent thoracotomy and complications. 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. 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.