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

Sat Dec 8 20:13:11 EST 2007

Cute typo's Michael. ..a dangerous "think"

tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Friday, December 7, 2007 11:48:14 AM
Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient

yup - they were also looking for a magnet to turn off his pacemaker (that is
the box connected to those funny thin wires coming out of his chest - which
was not even on at the time)

the take home message is that a little knowledge is a dangerous think - and
with more knowledge, comes more danger.

-michael

On 12/7/07, hgrmd at aol.com <hgrmd at aol.com> wrote:
>
> Michael,
> ? God, that's a scary story!!? Just goes to show you that
> well-intentioned, but ignorant residents, armed with a pen, are a pretty
> scary entity.
>
> Hal
>
>
> -----Original Message-----
> From: Michael Firstenberg <msfirst at gmail.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Fri, 7 Dec 2007 8:10 am
> Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient
>
>
>
> Hal,
>
> I agree - these misadventures were from a different time and a different
> place - many years ago and clearly they stuck in my mind and I use them as
> teaching examples.  I agree with everything said here 100% (and I remember
> also many times being at the bedside wanted/needing to open the chest   or
> go
> back to the OR and being told "no" with less than ideal longterm
> outcomes).
> I guess the point that I keep trying to make is that the reflex to open a
> chest should not be the same as the reflex to put in a chest tube for the
> tension pneumonthorax.  It needs to be a well planned (hopefully in
> advance), thought out, and executed procedure with appropriate insight and
> judgement or else it is doomed to failure.  These are dramatic events in
> any
> ICU.  We had a recent post-op patient arrest - even to this day the
> etiology
> was unclear - and when I got the call I was going to ask them to open the
> chest, but they got him back without doing so - I found out that the
> medicine residents running the code (another story for another day)
> thought
> this peri-operative patient who bled a lot post-op might have had a PE and
> wanted to give him tPA because they ran out of other ideas.  Our nurses,
> knowing much much better, refused and the PharmD assisted refused to mix
> it
> up.  In situations like these, smart and insightful people need to be
> making
> decisions.
>
> -michael
>
>
> On 12/6/07, hgrmd at aol.com <hgrmd at aol.com> wrote:
> >
> >
> > Michael,
> >
> > ? From what you've said, your CT surgeons could possibly use a little
> > refresher course on open resuscitation.? As far as I know, I've never
> put my
> > thumb through anyone's RV.
> >
> >
> >
> > Hal
> >
> >
> > -----Original Message-----
> > From: Michael Firstenberg <msfirst at gmail.com>
> > To: OpenHeart-L at lists.hsforum.com
> > Sent: Thu, 6 Dec 2007 6:00 pm
> > Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient
> >
> >
> >
> > Although I do not disagree with what is being said - I vividly recall
> > opening the chest of an elderly women post-op day 2 after an
> > ascending/hemi-arch who arrested. We coded her for a while before I
> opened
> > her chest (with the approval of the Attending over the phone) and a
> junior
> > Vascular attending assisting who agreed. While it looked like tamponade
> the
> > finding were not clear and probably a respiratory arrest in the
> retrospect -
> > the Attending never forgave me (the patient did survive to discharge but
> was
> > neurologically impaired). I felt clearly hung out to dry. I also
> remember
> > watching a CT surgeon fellow put his thumb thru a friable RV - game
> over.
> > Seen grafts ripped off, attempts at repairs only to make things
> worse.... my
> > point is that these thing must be well controlled, organized, and
> > orchestrated.?
> > ?
> > -michael?
> > ?
> > ?
> > On Dec 6, 2007, at 4:40 PM, Prasanna Simha M wrote:?
> > ?
> > > Why was the rhythm asysole one of the points is a possible RCA graft?
> > > occlusion. at least if you had opened the chest that could have > been
> > ruled?
> > > out. You (and all of us) are now neither wiser nor have been able to?
> > > formulate a secondary plan if the same thing repeats again > tomorrow.
> > That is?
> > > also another reason to reexplore.patients do develop tamponade > upto
> > weeks?
> > > after cardiac surgery. You yourself said that the patient was > having
> > low?
> > > mixed venous sats etc even after day 3. Something was not right and
> he?
> > > needed to have further monitoring.?
> > >> Prasanna?
> > >?
> > > On Dec 6, 2007 10:23 PM, <zzhoumd at pol.net> wrote:?
> > >?
> > >> Thanks! I have done that in the past. For immediate open heart >>
> > patients,?
> > >> it make sence. For patients in post-op day 5 with no TEE evidence of?
> > >> tamponade, and the rythm is asystole, it is usually not a
> salvagable.?
> > >> because open chest dose not solve the problem.?
> > >>?
> > >> Z?
> > >>?
> > >> Sent via BlackBerry by AT&T?
> > >>?
> > >> -----Original Message-----?
> > >> From: "Prasanna Simha M" <prasannasimha at gmail.com>?
> > >>?
> > >> Date: Thu, 6 Dec 2007 21:54:35?
> > >> To:OpenHeart-L at lists.hsforum.com?
> > >> Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient?
> > >>?
> > >>?
> > >> Rule in my ICU - one wire cutter and scalpel are kept in a sterile >>
> > ETO?
> > >> pack?
> > >> at all times. That is all that is required to open the chest. >>
> Chests
> > can?
> > >> be?
> > >> opened by any resident and internal massage can be instituted. It >>
> > doesn,t?
> > >> need a consultant to come from home to inititate it. I tell my >>
> > residents?
> > >> to?
> > >> open and inititate massage and they do so well before I even come. >>
> > In my?
> > >> hospital we tell our residents to open the chest if we do not get an?
> > >> effective rhythm within a few minutes and definitelyby 10 minutes. >>
> I
> > have?
> > >> reexplored patients etc (as I am sure all of us must have done) in >>
> > the?
> > >> ICU.?
> > >> Zhou, if you cannot do it in your ICU then a radical change neeeds >>
> > to be?
> > >> done. If you can initiate fem fem ECMO or install a Bivad but cannot?
> > >> reeplorein your ICU (and I bet I have less resources in my set up >>
> > than?
> > >> yours) your hospital needs to critically readdress this problem. >>
> > Every?
> > >> cardiac surgical ICU should be able to reexplore a patient andd >>
> > should in?
> > >> fact be able to place a patient on CPB also if required there).?
> > >>?
> > >> Prasanna?
> > >>?
> > >> On Dec 4, 2007 11:44 PM, Edward Bender <ebender001 at charter.net> >>
> > wrote:?
> > >>?
> > >>> I would bet that this was right coronary graft occlusion. Not?
> > >>> necessarily due to the anastamosis, but perhaps due to mediastinal?
> > >>> compression in the very obese. I think this sort of event >>>
> demands
> > re-?
> > >>> opening the sternum as the first act after you have arrived in the?
> > >>> icu. Let the other people do closed chest CPR while you are on your?
> > >>> way to the hospital. On my cell phone, in the car, I tell the ICU?
> > >>> personnel to have the re-opening tray at the bedside, open with a
> >>>
> > pair?
> > >>> of gloves ready for me to put on. I have not saved many like this,?
> > >>> but I have saved some. Especially in morbidly obese patients, open?
> > >>> cardiac compression is better than closed chest compressions. You?
> > >>> also get to definitively rule out tamponade.?
> > >>>?
> > >>> Ed Bender, MD?
> > >>>?
> > >>>?
> > >>> On Dec 3, 2007, at 10:41 PM, zzhoumd at pol.net wrote:?
> > >>>?
> > >>>> To forum members,?
> > >>>>?
> > >>>> This weekend I was on call. One of my partners patients developed?
> > >>>> cardiac arrest. He is only 57 year old had redo CABGx5 4 days ago.?
> > >>>> Weight about 300LB. After 30 minutes CPR, he is still asystole.?
> > >>>> Considering his young age, I placed him on ECMO. I thought about?
> > >>>> BiVAD, but I just do not know if his brain will come back. Just?
> > >>>> wonder if anybody will do anything different. I did not reexplore?
> > >>>> him as TEE show no tampnade and he has no more conduit.?
> > >>>>?
> > >>>> Thanks!?
> > >>>>?
> > >>>> Z Zhou?
> > >>>> Sent via BlackBerry by AT&T?
> > >>>> _______________________________________________?
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> > >>?
> > >> --?
> > >> Prasanna Simha M?
> > >> _______________________________________________?
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> > > --> Prasanna Simha M?
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