3.12 Tamponade

Question 1

Clinical features of Tamponade

Answer 1

Becks triad
Hypotension
JVP
Muffled heart sounds

Hypotension resistant to fluid and inotropes

Pulsus paradox (absent if severe LV dysfunction)
 an exaggerated drop in blood pressure  on inspiration

Kussmaul’s sign
(rise JVP during inspiration)

Pericardial rub

Pleuritic chest pain
Dyspnoea

Oliguria
Metabolic acidosis

PAC - equalisation of pressure in LVEDP + Atria

Question 2

Investigations

Answer 2

Gold standard TOE
(sedated + ventilated still)

1cm pericardial separation
Unexplained deterioration is sensitive in detecting

TTE Unreliable

CXR Widened mediastinum
globular cardiac silhouette
difficult to interpret

EWCG
Pulsus alternans
Arterial pulse waveform showing alternating strong and weak beats
Small voltage QRS

Question 3

Management

Needle pericardio?

Answer 3

In CABG patient
D/T excess mediastinal bleeding
Accumulation of pericardial clot
=
Chamber compression + CO reduction

Re-sternotomy under GA
Drain pericardium + remove clots
Require senior anaesthetist w/ CTs experience

Not remove all clots
risk damaging grafted

Question 4

Management

Answer 4

1. If stable enough transfer to theatre for optimal conditions
2. Occasionally the patient may require sternotomy on ICU if too unstable to move
3. Ensure cross match blood available prior to transfer
4. Awake give 15l/min O2
   NRB fm
   sedated ensure adequate
   o2 /ventilation/ sedation available for transfer
5. Transfer with full monitoring / inotropes / fluids PRN
6. Already ventilated
   transfer to theatre vent + maintain w/ volatile of iv agent and admin muscle relax
7. Awake patient - challenge
   loss sympathetic drive maintain CO during indcution

Question 5

Induction

Answer 5

On OR table
prepped and draped
Iv opiate Fentanyl
Induction agent 
NMB

Baseline abg and teg

Sternal opening - inotrope requirements may fall considerable because of improved pump efficiency and output
and endogenous catecholamine release