[HSF] Cardiac arrest after redo CABG in a young patient

[Rwmfglycar at aol.com]

Yes, opening a chest with retracted clot around the heart demands great  
skill and delicacy not to do great damage. However opening the lower end of the  
incision and releasing the fluid part of postoperative tamponade was something  
our PA's and resident's were trained and obliged to do. You mention what 
happens  to pressuresin :  tamponade is the consequence of pericardial pressures  
rising above  the diastolic
pressures of the ventricle/s. If we were in a situation where we were  trying 
to differentiate between particularly right heart failure and tamponade  we 
would quickly measure a pericardial pressure. With right heart failure and no  
tamponade the CVP is higher than the pericardial pressure. With tamponade  the 
 pericardial pressure is equal to the  CVP/LAP.    
.  Frater  RWM: Pericardial Tamponade and Intrapericardial  
Pressures.  Ann Thorac Surg  1970;10:563-565. 
I don't like rules such as:  Never open  the chest in the ICU and Always open 
the chest in the ICU. However there was one  rule about cardiac massage: if 
your hand is big enough open  cardiac compression  is done with four fingers 
touching each  other side by side behind the heart and the thenar eminence in 
front. The  thumb is dorsiflexed. If your hands are too small then massage is 
done two  handed. The result is always confirmed by evidence of a good arterial 
pressure  and pulse. 
Bob 


I  would beg to differ - while many of you who have been around the block a 
few  times may be quick to open the chest. We were always trained that unless 
clear  tamponade, opening a chest emergently usually leads to more trouble - in 
the  midst of chaos, grafts (esp IMAs) get pulled off, manual CPR results in 
RV  thumb holes, critical pacing wire get torn. My question to the group is, 
in my  limited experience tamponade comes up quickly but not instantly - the 
tubes  slow down, or even stop, the PA pressures go up, CVP goes up, systemic  
pressures go down, increasing drips doesnt work, unless a true disaster - like  
a hole in the aorta or similar, usually there is sometime. While the comments 
 about how no open heart patient should die without having their chest open 
has  some merit, it should not be the first intervention, not in my opinion be  
performed lightly without the input of the attending (or very senior)  
surgeon.?
?
We have lost a few very obese patients and I suspect PEs (or  mucus plugging 
from poor pulm mechanics) - which may be in this case. Very  obese, dont move 
around much, these patients are often chronically dry,  etc.?
?
-michael?







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