Cardiac Tamponade

[BlackSails]

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I just saw a case where the patient had severe tamponade, along with a giant plural effusion, all due to metastatic adenocarcinoma.

The right side of the heart was barely visible on TEE, and the effusion was gigantic. It was amazing seeing the effusion shrink and the heart expand as the surgeon drained it. The heart was a mess, mostly because of the tamponade, but also because it was riddled with tumors. Poor guy.

Question: Instead of the whole "prepare the patient awake and have the surgeon ready to cut as soon as you induce," why dont you use something that does not lower BP like ketamine?

 

[rn29306]

While I have never given ketamine for cardiac tamponade, it is used for these cases....it avoids cardiac depression, vasodilation, and bradycardia.

We have traditionally either done them under local only or gone GA with etomidate as induction drug with patient prepped, draped, and surgeon standing with knife in hand....with a big fat syringe / needle on the tech's table just in case.

Neva seen it, but most texts indicate ketamine for these cases.

 

[dbiddy808]

In order to maintain cardiac output in tamponade you must maintain your preload (CVP must exceed LVEDP). If you induce, make the patient apneic and have to provide positive pressure ventilation (breath for the patient), the increase in intrathoracic pressure will decrease your preload and viola....no more stroke volume and you are screwed. That's what the resident was trying to explain.

 

[SouthSideSteve]

That's what the resident was trying to explain.

lol, fun will be had with this one....

 

[Masseter Spasm]

Ketamine might be a good choice. However, if this patient's sympathetic tone is already strained to the maximum, recognize that ketamine will depress the myocardium. (although not as much as other induction agents.)

Your goals with tamponade are to keep the heart rate fast (CO = SV x HR), the heart full (volume), and vascular tone tight (avoid vasodilation). In addition to avoiding myocardial depression and vasodilation with induction agents, you may need to provide support with dopamine or epinephrine.

While this oncology patient sounds like alot of fun to manage, imagine if the tamponade was secondary to a big anterior mediastinal mass. Now that would really be fun...

 

[VentdependenT]

if they can't needle decompress at least some of the tamponade and you absolutely have to go to sleep NOW while the surgeon is already gowned. pt prepped. Then I'd go preload the patient with some fluids (colloid would get the job done faster I suppose, but not a big deal), induce with fentanyl some ketamine or etomidate. Skip the muscle relaxant OR use low dose sux. Slap the tube in and GO.

Sticks of Epi Lyte and Ephedrine ready to go just in case.

Run it like a modified code situation. Which, if the surgeon has to go right friggen now, it is. A-line would be nice but what ya gonna do.

Per the books you are supposed to TRY and keep the patient spontaneous ventillating hence I'd try and skip the sux.

 

[dbiddy808]

I've seen a few patients go from breathing, speaking with relatively stable vital signs to pulseless within seconds after inducing with etomidate/sux in our trauma bay. The next time I encounter a patient with gunshot wounds anywhere near the mediastinum its gonna be an awake intubation with versed or ketamine and no paralytic.

 

[jetproppilot]

if they can't needle decompress at least some of the tamponade and you absolutely have to go to sleep NOW while the surgeon is already gowned. pt prepped. Then I'd go preload the patient with some fluids (colloid would get the job done faster I suppose, but not a big deal), induce with fentanyl some ketamine or etomidate. Skip the muscle relaxant OR use low dose sux. Slap the tube in and GO.

Sticks of Epi Lyte and Ephedrine ready to go just in case.

Run it like a modified code situation. Which, if the surgeon has to go right friggen now, it is. A-line would be nice but what ya gonna do.

Per the books you are supposed to TRY and keep the patient spontaneous ventillating hence I'd try and skip the sux.

Amen to that, Venty.

Lemme make something clear here:

THERE IS NO ANESTHETIC ON PLANET EARTH THATS GONNA SAVE THIS PATIENT, OR MAKE THINGS BETTER FOR THIS PATIENT.

This dude needs his pericardium cut open.

Anesthetic or no anesthetic....but heres a kicker for ya:

THE QUICKER THE BETTER.

Do whatever you have to do to let the surgeons knife hit the pericardium quickly.

Next case....

 

[BlackSails]

THERE IS NO ANESTHETIC ON PLANET EARTH THATS GONNA SAVE THIS PATIENT, OR MAKE THINGS BETTER FOR THIS PATIENT.

TBH, there is no surgery that can save him either. Sure, he didnt die today (tuesday actually), but he has no more than a month or two.

Its the first patient whom I realized would die, soon. Very odd moment realizing that.

 

[jetproppilot]

TBH, there is no surgery that can save him either. Sure, he didnt die today (tuesday actually), but he has no more than a month or two.

Its the first patient whom I realized would die, soon. Very odd moment realizing that.

Not that its important, but what is TBH?


I'm struggling like Noy with the abbreviations now......

 

[deleted87716]

Not that its important, but what is TBH?


I'm struggling like Noy with the abbreviations now......

I think it's "to be honest."

 

[Planktonmd]

Here is how I would do a real tamponade case:
put him on the OR table hook monitors and oxygenate while they prep and get ready to cut, make sure arms are tied down so he doesn't pull out his IV, when they are ready give 1 mg /kg Ketamine, and supplement with small boluses as needed, support circulation ( Ephedrine, Epi) continue with mask O2 and spontaneous ventilation, once they enter the pericardium you can give a touch of Sux and intubate.
Keep it simple.

Notice that I said REAL tamponade, meaning an acute increase of the pressure in the pericardium, causing real circulatory compromise, and at least obvious pulsus paradoxus. Not an accumulation of fluid over a period of several months that suddenly became an emergency because the surgeon is leaving on vacation, or the cardiologist freaked out when he did an Echo, and classified it as a tamponade although the patient is in no real distress.