cardiac tamponade induction

[morri493]

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I was wondering if anyone has a go-to induction for a "crashing" patient with cardiac tamponade?
I know the idea is to keep spontaneous breathing to maintain negative intrathoracic pressure... so with an emergent case using RSI do you avoid SCh? Would you just induce with ketamine and attempt intubation without relaxation?

 

[Arch Guillotti]

Depends on how bad it is.

 

[morri493]

Depends on how bad it is.

How about... GSW to the RV, as well as one to the belly. pt is a hemodynamically unstable level 1 trauma emergently brought up to the OR. Awake and talking when he comes to the OR. Free fluid in abdomen, and large pericardial effusion on initial eval in trauma bay.

 

[Arch Guillotti]

Art line, prep/drape, surgeon in room, go.

 

[deleted87051]

Not that I’ve ever done this but if the effusion is large enough, I think it’s worth considering an awake ultrasound guided pericardiocentesis prior to induction.

 

[Ronin786]

Not that I’ve ever done this but if the effusion is large enough, I think it’s worth considering an awake ultrasound guided pericardiocentesis prior to induction.

This x100. If you're worried enough about a patient coding on induction from tamponade, put a drain in it or have your surgeon do a sub-xiphoid window.

Otherwise, it's volume, volume, volume. You need to keep the intracardiac pressure greater than intrapericardial pressure to prevent collapse. Drop at least 1 L into this patient before you think of pushing a sedative.

As far as spontaneous ventilation, think about the exact mechanism why it is desirable in a patient with tamponade. Then think about how you can mimic that as closely as possible with a ventilator and you'll have your answer.

Obviously the board answer is an awake intubation with ketamine. It doesn't have to be that way in real life though.

 

[heavyd85]

I just did a similar case yesterday. Your job is to move patient to table and keep everyone in the room calm. The key is not to induce before you need to. Make sure thoracic surgeon is in room and understands the severity of situation. Then prep, drape, and induction du jour. I think everyone focuses on how to induce so and so, but the good anesthesiologist keeps everyone on task and gets the job done. Midaz, propofol, ketamine; it doesn’t matter.

 

[sevoflurane]

Hole in RV <<< hole in LV.

 

[sevoflurane]

A quick TTE looking for systolic atrial collapse is helpful in determining severity before induction.

 

[Mman]

hold mask on face, turn up sevo gradually telling them the mask might start to smell kinda funny. Once deep enough put tube through cords and just let them keep breathing spontaneously. And yes this is with an art line already in and surgeon standing there with knife/needle in hand.

 

[T-burglar]

CTS consult. Perfusion builds a pump in the room. Treat as imminent cardiac arrest if the guy truly has a hole in the ventricle. Maybe provide a tiny dose of midazolam while surgeons Numb groin Femoral bypass as soon as humanly possible to be prepared for sucker bypass if needed following pericardiotomy.

Trauma surgeons make the mistake of thinking that they just need to get in there and whipstitch the ventricle. They aren’t prepared for the exsanguinsting hemorrhage into the mediastinum. I’ve seen it more than once unfortunately. If the there’s truly transmural penetrating myocardial trauma the patient can bleed out and arrest in seconds. Not all medical conditions tolerate sedation or GETA. True Transmyocardial penetrating cardiac trauma shouldn’t be induced until you’re ready for cardiac arrest on induction, and you aren’t ready for arrest on induction unless you’re ready to emergently enter the pericardium, and you aren’t ready to emergently enter the pericardium unless you’re ready to scavenge liters per minute of hemorrhage back into circulation.

 

[Arch Guillotti]

hold mask on face, turn up sevo gradually telling them the mask might start to smell kinda funny. Once deep enough put tube through cords and just let them keep breathing spontaneously. And yes this is with an art line already in and surgeon standing there with knife/needle in hand.

What about a full stomach?

 

[Mman]

What about a full stomach?

haven't yet had that situation. I guess I would measure the fullness in their stomach against the fullness in their pericardium and decide which I cared about more. 🙂

 

[DM27]

If it is an actual tamponade as in tamponade physiology and not just "a big effusion" I am a fan of the ketamine induction with a preference for drainage pre-induction if possible.

 

[dhb]

Not feasable in a trauma case but yes the best induction is lidocaine... for a drainage.
It also depends on the surgeon if he can get into the pericardium under 2min then fire away. I had one patient we couldn't get back because imho the decompression was too slow. Otoh the patient was blue and thrashing so i don't know if it would have been possible to drain it under local...

 

[deleted87051]

Not feasable in a trauma case but yes the best induction is lidocaine... for a drainage.
It also depends on the surgeon if he can get into the pericardium under 2min then fire away. I had one patient we couldn't get back because imho the decompression was too slow. Otoh the patient was blue and thrashing so i don't know if it would have been possible to drain it under local...

I’ve seen a cardiologist put a cordis in the pericardial sac (during an EP ablation) in about 2min but I agree it’s very operator dependent.

 

[sethco]

I’ve seen a cardiologist put a cordis in the pericardial sac (during an EP ablation) in about 2min but I agree it’s very operator dependent.

House of God Law #6: There is no body cavity that cannot be reached with a #14G needle and a good strong arm.

 

[dchz]

Had a pericardial effusion today and the TTE read as collasping RA.

Attending did a positive pressure RSI anyways. the effusion wasn't that bad, i wouldn't even call it tamponade.

For the record, positive pressure ventilation makes it worse.

 

[Noyac]

Hole in RV <<< hole in LV.

I thought the hole in the LV would leak less (depending on size of the hole) because the thick strong LV squeezes tightly enough to prevent the large leaks. But the pressure generated may overcome this. Idk.

But when the first plane hit the WTC on 9/11 I was rolling a pt into the OR with a 8” knife protruding from his chest and basically thumping to the beat of his heart. We left it in place and prepped and draped him. Then the sternotomy and removed the knife after sewing a purse string suture around the knife. I remember when I placed the cordis in the RIJ I thought I had put it in the carotid. The back pressure was so high. I don’t remember how I induced him.

The worst tamponade case I ever did, I gave a small dose of ketamine and kept the pt in a seated position because she couldn’t tolerate lying flat. The surgeon did a pericardial window under that sedation. It was amazing to watch the BP come back as the blood was removed.

 

[Noyac]

Had a pericardial effusion today and the TTE read as collasping RA.

Attending did a positive pressure RSI anyways. the effusion wasn't that bad, i wouldn't even call it tamponade.

For the record, positive pressure ventilation makes it worse.

And?

 

[Noyac]

What about a full stomach?

That is way down the list of my concerns in this situation.

 

[abolt18]

I thought the hole in the LV would leak less (depending on size of the hole) because the thick strong LV squeezes tightly enough to prevent the large leaks. But the pressure generated may overcome this. Idk.

But when the first plane hit the WTC on 9/11 I was rolling a pt into the OR with a 8” knife protruding from his chest and basically thumping to the beat of his heart. We left it in place and prepped and draped him. Then the sternotomy and removed the knife after sewing a purse string suture around the knife. I remember when I placed the cordis in the RIJ I thought I had put it in the carotid. The back pressure was so high. I don’t remember how I induced him.

The worst tamponade case I ever did, I gave a small dose of ketamine and kept the pt in a seated position because she couldn’t tolerate lying flat. The surgeon did a pericardial window under that sedation. It was amazing to watch the BP come back as the blood was removed.

Did it look something like this art line when their BP came back?

This is an iatrogenic tamponade during a TAVR not long ago. Patient expressed they had chest pain. BP shot up for a minute or so. Then dropped to MAP of ~25-30. Cardiologist rapidly did pericardial drain. The recurring fluctuations in BP are the reaccumulation of blood/waiting for the epi bolused to circulate before we intubated and put the patient on ECMO.

 

[sevoflurane]

I thought the hole in the LV would leak less (depending on size of the hole) because the thick strong LV squeezes tightly enough to prevent the large leaks. But the pressure generated may overcome this. Idk.

But when the first plane hit the WTC on 9/11 I was rolling a pt into the OR with a 8” knife protruding from his chest and basically thumping to the beat of his heart. We left it in place and prepped and draped him. Then the sternotomy and removed the knife after sewing a purse string suture around the knife. I remember when I placed the cordis in the RIJ I thought I had put it in the carotid. The back pressure was so high. I don’t remember how I induced him.

The worst tamponade case I ever did, I gave a small dose of ketamine and kept the pt in a seated position because she couldn’t tolerate lying flat. The surgeon did a pericardial window under that sedation. It was amazing to watch the BP come back as the blood was removed.

In my experience major RV injuries make it to the OR. Major LV injuries die in the field or come in very unstable. As you mentioned, mechanism of injury and size of the hole make a difference (GSW vs epicardial knife would).

 

[morri493]

this has all been very helpful!! thank you everyone! The benefits of this forum for clinical questions has been pleasantly surprising - I only wish I had utilized this earlier in my training.

for context with our case: pt was unstable coming to the OR with GSW to flank and abdomen. Pt was prepped and draped with trauma surgery ready to open the thorax. We induced with ketamine followed by SCh and intubated. Pt promptly coded with initiation of PPV. Fortunately, the trauma surgeons were able to rapidly enter the pericardium which was followed by a signifcant release of blood, upon which the pt rebounded. RV was repaired and he did well otherwise. In fact, he was extubated POD1 and seems to be doing well now.

If we plan on paralyzing I suppose there really isnt any benefit for ketamine or any other induction agent that maintains ventilation...

 

[pgg]

Inhalation inductions are a good option for tamponade. Slow but stable.

 

[vector2]

this has all been very helpful!! thank you everyone! The benefits of this forum for clinical questions has been pleasantly surprising - I only wish I had utilized this earlier in my training.

for context with our case: pt was unstable coming to the OR with GSW to flank and abdomen. Pt was prepped and draped with trauma surgery ready to open the thorax. We induced with ketamine followed by SCh and intubated. Pt promptly coded with initiation of PPV. Fortunately, the trauma surgeons were able to rapidly enter the pericardium which was followed by a signifcant release of blood, upon which the pt rebounded. RV was repaired and he did well otherwise. In fact, he was extubated POD1 and seems to be doing well now.

If we plan on paralyzing I suppose there really isnt any benefit for ketamine or any other induction agent that maintains ventilation...

As other have stated, try not to paralyze as PPV is essentially worst thing for right-side filling. If you have to paralyze so you can get the tube in, push some norepi before sch and then make sure you bag very, very gently. Then, set the vent to 0 PEEP and like 270cc tidal volumes with an 18 rate.

Until the pericardium is open, your main concern with the vent should be mostly just ventilating dead space plus one or two alveoli and passively oxygenating. If you bag 900cc in the attempt to do something stupid like listen to breath sounds your patient will def arrest.

 

[MoMoGesiologist]

Inhalation inductions are a good option for tamponade. Slow but stable.

What are intubating conditions with just gas and no paralytic?

 

[Mman]

What are intubating conditions with just gas and no paralytic?

same as any other induction without paralytic. If you get them deep enough, which you can do with them still breathing just fine, just put the blade in their mouth and slide the tube through the cords. If you are worried just use a glidescope (or whatever VL you prefer) to make it slightly easier on yourself.

The key is that it is an inhalation induction and not a just mask them down induction. No squeezing the bag. Just let them get themselves nice and deep without helping. It takes a little time, but these are not the patients to rush on.

 

[MoMoGesiologist]

same as any other induction without paralytic. If you get them deep enough, which you can do with them still breathing just fine, just put the blade in their mouth and slide the tube through the cords. If you are worried just use a glidescope (or whatever VL you prefer) to make it slightly easier on yourself.

The key is that it is an inhalation induction and not a just mask them down induction. No squeezing the bag. Just let them get themselves nice and deep without helping. It takes a little time, but these are not the patients to rush on.

How long does it take to induce a 80kg male with just gas? I’ve never done it on an adult unfortunately

 

[pgg]

What are intubating conditions with just gas and no paralytic?

How long does it take to induce a 80kg male with just gas? I’ve never done it on an adult unfortunately

If you rush it, the patient is light and conditions are terrible and instrumenting the airway is liable to provoke emesis and aspiration, and then you're screwed. (I'm convinced that the reason the ER gets away with sedating so many full stomachs is because they don't touch the airway.)

If you go slow, and a true spontaneously ventilating inhalation induction in an adult is a 10+ minute process, conditions are OK. I haven't done a lot but I favor a video laryngoscope and lidocaine LTA to minimize the stimulation.

 

[pgg]

The key is that it is an inhalation induction and not a just mask them down induction. No squeezing the bag. Just let them get themselves nice and deep without helping. It takes a little time, but these are not the patients to rush on.

+1

Don't even ask the patients to take deep breaths. Just let them breathe the same way they were 5 minutes ago.

Tamponaaaahhhhde

 

[Mman]

How long does it take to induce a 80kg male with just gas? I’ve never done it on an adult unfortunately

depends on how slow you are turning up the dial. I mean if you get a cooperative healthy patient you can get them in 2 vital capacity breaths (the old 1 breath induction rarely works IMHO) if you have the circuit charged with 70% nitrous and 8% sevo. If you just want to start out with 1% sevo and maybe inch it up by 1% every 30 seconds they will be pretty damn deep in 4-5 minutes. I usually just leave them breathing 8% for a good 2-3 minutes, though, if I am not using paralytic and want to make sure they aren't going to gag.

 

[Noyac]

Inhalation inductions are a good option for tamponade. Slow but stable.

Except when they can’t lie flat. They get air starved even sitting straight upright.

 

[T-burglar]

I think inhalation induction is playing with fire. Any induction plan that includes “deep anesthesia” is playing with fire

 

[Beeftenderloin]

My n=2 but both times they got 1-2mg Midaz and 2mg/kg of ketamine. Patients were able to tolerate a video laryngoscope in < 60s and stayed spontaneous. Turned on some Sevo and surgeon went to work.

 

[Iso4ane]

House of God Law #6: There is no body cavity that cannot be reached with a #14G needle and a good strong arm.

Well, nowadays you would need a long long 14G needle for some of our patients.

 

[Mman]

I think inhalation induction is playing with fire. Any induction plan that includes “deep anesthesia” is playing with fire

probably the most stable induction possible for a tamponade patient, safer than positive pressure ventilating or trying to intubate them light and then watching them cough and gag

 

[dchz]

And?

She was 35 and she lived just fine. The TTE didn't give a good picture. because we dropped the TEE while she was on pos press vent and everything was filling just fine.

so essentially we did an RSI on a lady with some pericardial effusion, but i was still worried.

 

[deleted87051]

Redirect Notice

 

[dchz]

Redirect Notice

Wow they took him to the Cath Lab after they removed the wires and thought it was tamponade?

 

[bcat85]

I think inhalation induction is playing with fire. Any induction plan that includes “deep anesthesia” is playing with fire

I fully agree. I’ve done this both ways. With the inhalational induction, you can end up with an “unstable, but not quite ready for intubation” situation in short order.

Bad tamponade: prep, drape, a boatload of epinephrine, some anesthesia and sux.