Crashing Pericardial Tamponade

[jetproppilot]

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I was late call yesterday, meaning I'm the doc backing up the on-call doc who arrives at 3PM.

I can leave when he can handle The Show, which usually translates to around 6-7 pm.

Sure enough, right at 3pm when the non-call docs are trying to get outta the hospital Dr R the heart surgeon comes sauntering into the OR.

"I NEED WANNA YOU GUYS TO HEAD TO ICU 17 AND GET THE GUY OVER HERE. HE'S TAMPONADING SO MAKE IT AS QUICK AS POSSIBLE, OK?"

Dr R's a pretty nice guy.....and if he injects urgency into a situation HE AIN'T BULLS HITTING.

Tamponading Dude is 4 days s/p CABG...

Ten minutes later dudes in the OR.

He's conscious but barely.

About 8 people in the room.

I'm usually casual, talkative, but not now......I'm focused on what I've gotta do, which is get the dude on the table, put some monitors on, put a tube in his trachea.....

I've got 2 stellar CRNAs helping so I tell them what I need...

Dr R told me dude's BP was 60 systolic in the ICU....I can feel a carotid but not a radial so that sounds about right.

I'm gonna have a tube in, an A line in, and a central line before they're draped I tell myself.

Since this guys still with us and talking to us on planet earth, we can't cut his sub-xiphoid open without some kinda pharmacologic intervention....well, yeah, we could......

GIVE TOO MUCH OF ANYTHING AND HE'LL FLATLINE.

If you've ever got a crashing tamponade, friends, PLEASE REMEMBER THAT.

They become a DIRT PILLOW CDAZY FAST with justa bout anything!

I'm on the left side of the OR table as the herd of people are hurriedly readying to slide Dude over from his bed.

Jim the anesthesia tech is by my side.

Mary CRNA is at the head, Jenelle CRNA is available for whatever.

I hand the induction syringes to Jenelle.

"Jenelle, as soon as Marys got the monitors on, squirt these in CDAZY FAST!" I say.

Patient is rolled onto the OR table.

As soon as Dude's motion stops I grab his left arm and extend it onto the arm board. Jim the anesthesia tech reflexively places the rolled-up-and-taped OR towel underneath his wrist and wraps some one-inch tape around Dude's palm and underneath the arm board.

Mary is hastily putting on the monitors.

I can't feel a pulse but I can feel the artery....firm, annular..... skinny old dude....

I slam the Arrow art line needle where I feel the artery-sans-pulse and a little droppa blood appears in the art-line-plastic-chamber-thinghy....wire threads....twist and push... pull out the needle....

BINGO!!!! man I'm a lucky sonnofabitch

Transducer hooked up......I look up at the monitor....

BP 50/30😱

And this old dudes still kinda with us!

This all took literally about a minute.

Mary has the monitors on....Jenelle, as instructed, starts pushing the syringes.

Syringe number one: ketamine 30mg

Syringe number two: sux 100mg

Mary inserts the Miller 2 twenty seconds after the drugs are in and slams in the 8.0 ETT.

"Hey Bill, wouldja mind putting in a central line when this is over?" Dr R says as he walks out to the scrub sink.

"Sure", I say....knowing I'll have the line in before he returns.

OR staff tucks the arms....OR scrub starts prep...I had previously asked Jim the anesthesia tech to be ready for a central line as soon as he had secured the A line.....being the stellar professional he is, he's waiting for me....gloves, kits open, everything....man this job is fun when you've got premium help!

Head to the left, quick prep, gloves on, quick-drape, grab the needle,

BOOM.

Wire, scalpel, dilator, line.

Before the drape.

Stitching when Dr R walks back in.

Yeah, I couldda waited.

But this guys only got one peripheral with no good looking peripheral IV sites looking at me.....and if this goes to s hit I'd like access to his central circulation anyway and I like a challenge too!

Drapes up....Dr R hurrying....


The above, from throwing the guy on the table, monitors on, induced, tubed, lines in, prepped and draped, was probably seven minutes.

DUDE'S TAMPONADE IS PROGRESSING.....

Systolic 50.....40........39......over the next 30 seconds...

I push twenty mikes of epi thru the brown port of the new central line...

Dr R skillfully approaches the pericardium and lances it....

400mL blood rushes out.....

I was trying to wait and wait to push the epi cuz I knew Dude's BP would probably come up as soon as Dr R hit the pericardium with the steel....but when I saw the systolic hit DA THIRTIES I couldnt help myself....

Keep in mind the above scenerio is happening in seconds...

So now, concominantly, Dr R has relieved the pericardium of the near-two-units of pressure, and my twenty mikes of epi are hitting....

Systolic 60...70....90....110....130.....150...180 fuk me....

Stops at 180.

Decisions are what we get paid a low NFL draft pick salary for.

Was twenty mikes of epi too much? Geez I dunno....pressures in the 30s.....20 mikes with a pressure that low is a pretty reasonable dose....sometimes you'll give that, then double it...and double again...

..BP peaked at 180.....the flip side is hypoperfusion for a longer time if the pressure doesnt pop with the lancing-of-the-pericardium...

Heres a learning point...if you get a dramatic swing in hemodynamics, make small corrections initially cuz alotta times your small corrections will work.

This will prevent you from oscillating from really-high-to-really-low...

180 isnt the end of the world so I turn the sevo upto-max and hyperventilate the dude for 30 seconds....couldda reached for a big nitro stick but having been here before, I'm gonna wait...

pressure trends down.

Again, the above happened in minutes.

This was a twenty minute case, Folks.

All the above s hit happened in twenty minutes.😱

We go from talking to colleagues in the doctors lounge one minute....to a stat call the next minute...and a stressful, harrowing next twenty minutes.....all in

ONE HOUR OF AN ANESTHESIOLGIST'S LIFE AT WORK.

Dr R was complimentary of our premium CDAZY FAST action.

More importantly, I spoke with Tamponade Dude this morning.

He's extubated, doing well.

And he doesnt remember a thing.

Periodically in this biz ya gotta STEP UP TO THE MIKE WITH MICATIN (right Gern?) and earn the benjamins.

It's gratifying sometimes....this anesthesia biz.....being able to be a part of a critical case where another human's life hangs in the phase between life and death...and you're able to swing'em back to PLANET EARTH...

I'll drink to that.

Jet pops open an Isosceles cab...

CHEERS!

 

[epidural man]

I was late call yesterday, meaning I'm the doc backing up the on-call doc who arrives at 3PM.

I can leave when he can handle The Show, which usually translates to around 6-7 pm.

Sure enough, right at 3pm when the non-call docs are trying to get outta the hospital Dr R the heart surgeon comes sauntering into the OR.

"I NEED WANNA YOU GUYS TO HEAD TO ICU 17 AND GET THE GUY OVER HERE. HE'S TAMPONADING SO MAKE IT AS QUICK AS POSSIBLE, OK?"

Dr R's a pretty nice guy.....and if he injects urgency into a situation HE AIN'T BULLS HITTING.

Ten minutes later dudes in the OR.

He's conscious but barely.

About 8 people in the room.

I'm usually casual, talkative, but not now......I'm focused on what I've gotta do, which is get the dude on the table, put some monitors on, put a tube in his trachea.....

I've got 2 stellar CRNAs helping so I tell them what I need...

Dr R told me dude's BP was 60 systolic in the ICU....I can feel a carotid but not a radial so that sounds about right.

I'm gonna have a tube in, an A line in, and a central line before they're draped I tell myself.

Since this guys still with us and talking to us on planet earth, we can't cut his sub-xiphoid open without some kinda pharmacologic intervention.

BUT GIVE TOO MUCH OF ANYTHING AND HE'LL FLATLINE.

If you've ever got a crashing tamponade, friends, PLEASE REMEMBER THAT.

They become a DIRT PILLOW CDAZY FAST with justa bout anything!

I'm on the left side of the OR table as the herd of people are hurriedly readying to slide Dude over from his bed.

Jim the anesthesia tech is by my side.

Mary CRNA is at the head, Jenelle CRNA is available for whatever.

I hand the induction syringes to Jenelle.

"Jenelle, as soon as Marys got the monitors on, squirt these in CDAZY FAST!" I say.

Patient is rolled onto the OR table.

As soon as Dude's motion stops I grab his left arm and extend it onto the arm board. Jim the anesthesia tech reflexively places the rolled-up-and-taped OR towel underneath his wrist and wraps some one-inch tape around Dude's palm and underneath the arm board.

Mary is hastily putting on the monitors.

I can't feel a pulse but I can feel the artery....firm, annular..... skinny old dude....

I slam the Arrow art line needle where I feel the artery-sans-pulse and a little droppa blood appears in the art-line-plastic-chamber-thinghy....wire threads....twist and push... pull out the needle....

BINGO!!!! man I'm a lucky sonnofabitch

Transducer hooked up......I look up at the monitor....

BP 50/30😱

And this old dudes still kinda with us!

This all took literally about a minute.

Mary has the monitors on....Jenelle, as instructed, starts pushing the syringes.

Syringe number one: ketamine 30mg

Syringe number two: sux 100mg

Mary inserts the Miller 2 twenty seconds after the drugs are in and slams in the 8.0 ETT.

"Hey Bill, wouldja mind putting in a central line when this is over?" Dr R says as he walks out to the scrub sink.

"Sure", I say....knowing I'll have the line in before he returns.

OR staff tucks the arms....OR scrub starts prep...I had previously asked Jim the anesthesia tech to be ready for a central line as soon as he had secured the A line.....being the stellar professional he is, he's waiting for me....gloves, kits open, everything....man this job is fun when you've got premium help!

Head to the left, quick prep, gloves on, quick-drape, grab the needle,

BOOM.

Wire, scalpel, dilator, line.

Before the drape.

Stitching when Dr R walks back in.

Yeah, I couldda waited.

But this guys only got one peripheral with no good looking peripheral IV sites looking at me.....and if this goes to s hit I'd like access to his central circulation anyway and I like a challenge too!

Drapes up....Dr R hurrying....


The above, from throwing the guy on the table, monitors on, induced, tubed, lines in, prepped and draped, was probably seven minutes.

DUDE'S TAMPONADE IS PROGRESSING.....

Systolic 50.....40........39......over the next 30 seconds...

I push twenty mikes of epi thru the brown port of the new central line...

Dr R skillfully approaches the pericardium and lances it....

400mL blood rushes out.....

I was trying to wait and wait to push the epi cuz I knew Dude's BP would come up as soon as Dr R hit the pericardium with the steel....but when I saw the systolic hit DA THIRTIES I couldnt help myself....

Keep in mind the above scenerio is happening in seconds...

So now, concominantly, Dr R has relieved the pericardium of the near-two-units of pressure, and my twenty mikes of epi are hitting....

Systolic 60...70....90....110....130.....150...180 fuk me....

Stops at 180.

Decisions are what we get paid a low NFL draft pick salary for.

Was twenty mikes of epi too much? Geez I dunno....pressures in the 30s.....20 mikes with a pressure that low is a pretty reasonable dose...BP peaked at 180.....the flip side is hypoperfusion for a longer time if the pressure doesnt pop with the lancing-of-the-pericardium...

Heres a learning point...if you get a dramatic swing in hemodynamics, make small corrections initially cuz alotta times your small corrections will work.

This will prevent you from oscillating from really-high-to-really-low...

180 isnt the end of the world so I turn the sevo upto-max and hyperventilate the dude for 30 seconds....couldda reached for a big nitro stick but having been here before, I'm gonna wait...

pressure trends down.

Again, the above happened in minutes.

This was a twenty minute case, Folks.

All the above s hit happened in twenty minutes.😱

We go from talking to hottie surgeon girlfriend in the doctors lounge one minute....to a stat call the next minute...and a stressful, harrowing next twenty minutes.....all in

ONE HOUR OF AN ANESTHESIOLGIST'S LIFE AT WORK.

Dr R was complimentary of our premium CDAZY FAST action.

More importantly, I spoke with Tamponade Dude this morning.

He's extubated, doing well.

And he doesnt remember a thing.

Periodically in this biz ya gotta STEP UP TO THE MIKE WITH MICATIN (right Gern?) and earn the benjamins.

It's gratifying sometimes....this anesthesia biz.....being able to be a part of a critical case where another human's life hangs in the phase between life and death...and you're able to swing'em back to PLANET EARTH...

I'll drink to that.

Jet pops open an Isosceles cab...

CHEERS!

Jet,

Great post but I have to complain a little. It seems like about a year ago, you would have stopped at the

"Since this guys still with us and talking to us on planet earth, we can't cut his sub-xiphoid open without some kinda pharmacologic intervention."

and then asked what we would have done. Them there were some good discussion we had back then,

Then after people perseverated, argued, called each other stupid for their okay choices, you would have finished with your "this is what I did" post.

Anyway, cool post.

 

[dfk]

hey jet,
whenya gonna write that book?
best seller fo' sho' !!

 

[huktonfonix]

hey Jet,

Coupla questions as a new attending. Was there any consideration to keep him spontaneously breathing? Do you think it makes a difference. In the one true tamponade I've done, my attending who is a badass cardiac guy chose to put him down with succ too, so I've always wondered if the drop in pressure with PPV is overemphasized. Also, do you ever wait for the surgeon to be scrubbed and the patient to be prepped and draped before you induce for these cases?

 

[Planktonmd]

hey Jet,

Coupla questions as a new attending. Was there any consideration to keep him spontaneously breathing? Do you think it makes a difference. In the one true tamponade I've done, my attending who is a badass cardiac guy chose to put him down with succ too, so I've always wondered if the drop in pressure with PPV is overemphasized. Also, do you ever wait for the surgeon to be scrubbed and the patient to be prepped and draped before you induce for these cases?

I would definitely wait until they are ready to cut before inducing anesthesia and most likely intubate with Ketamine without SUX and maintain spontaneous ventilation.

 

[jetproppilot]

hey Jet,

Coupla questions as a new attending. Was there any consideration to keep him spontaneously breathing? Do you think it makes a difference. In the one true tamponade I've done, my attending who is a badass cardiac guy chose to put him down with succ too, so I've always wondered if the drop in pressure with PPV is overemphasized. Also, do you ever wait for the surgeon to be scrubbed and the patient to be prepped and draped before you induce for these cases?

Great points, Hukt.

I can't emphasize enough how much this case went thru like an orchestra.....hence emphasizing how TEAMWORK SAVES LIVES...

no ONE DUDE saved this dudes life.

Back to your comment about waiting for the surgeon to induce....sounds great but if youre waiting to induce you are wasting time.

With the (relatively) new scrub technique that takes a haffa second for a surgeon to scrub HER hands luv ya honey you dont need to wait.

Alotta stuff above, as with most emergencies, happens concominantly...

PREP AND DRAPE takes at leasta minute..even if you just pour betadine and throw on da drapes...

so don't wait if the surgeon is present.

She can be STEEL WIELDING cdazy fast.

 

[jetproppilot]

I would definitely wait until they are ready to cut before inducing anesthesia and most likely intubate with Ketamine without SUX and maintain spontaneous ventilation.

MAN PLANK, YA MAKE THAT SOUND REALLY EASY!!!!

Like youre gonna give justa little somethin-somethin with no relaxant, tamponade-dude's gonna vigilantly cooperate despite the Miller 2 lifting his skull off the table,

and he's gonna lie still there, even though he's still with us, letting you violate his oropharynx with a blade and a tube.

Sorry Dude, the RISKS OUTWEIGH THE BENEFITS HERE. YOU'RE SPOUTING ACADEMIC WORRYS.

I'd rather give relaxant and virtually guarantee my airway than risk fighting with a near-conscious-dude-sans-relaxant....

especially when the surgeon is thirty seconds away from cutting.

I don't see the benefit of keeping'em breathing! DA STEEL BLADE IS THIRTY SECONDS AWAY!

FLAG THROWN

REFEREE:"PERSONAL FOUL....NUMBER THIRTY SIX (plank)..."

"ACADEMIC DOGMA...FIFTEEN YARDS.."

"Repeat second down."

 

[Planktonmd]

Great points, Hukt.

I can't emphasize enough how much this case went thru like an orchestra.....hence emphasizing how TEAMWORK SAVES LIVES...

no ONE DUDE saved this dudes life.

Back to your comment about waiting for the surgeon to induce....sounds great but if youre waiting to induce you are wasting time.

With the (relatively) new scrub technique that takes a haffa second for a surgeon to scrub HER hands luv ya honey you dont need to wait.

Alotta stuff above, as with most emergencies, happens concominantly...

PREP AND DRAPE takes at leasta minute..even if you just pour betadine and throw on da drapes...

so don't wait if the surgeon is present.

She can be STEEL WIELDING cdazy fast.

Do you think if you made the time between induction and incision shorter and if you did not abolish spontaneous ventilation that the pressure might have not dropped to 30 and needed epi?

 

[jetproppilot]

Jet,

Great post but I have to complain a little. It seems like about a year ago, you would have stopped at the

"Since this guys still with us and talking to us on planet earth, we can't cut his sub-xiphoid open without some kinda pharmacologic intervention."

and then asked what we would have done. Them there were some good discussion we had back then,

Then after people perseverated, argued, called each other stupid for their okay choices, you would have finished with your "this is what I did" post.

Anyway, cool post.

YEAH, YOURE RIGHT, DUDE.

I shouldda played it out.

But I'm in the mood to test my writing skills.😀

My bad.

 

[Planktonmd]

Like youre gonna give justa little somethin-somethin with no relaxant, tamponade-dude's gonna vigilantly cooperate despite the Miller 2 lifting his skull off the table,

and he's gonna lie still there, even though he's still with us, letting you violate his oropharynx with a blade and a tube."

This is precisely how I intubate crashing people in the unit all the time.

 

[huktonfonix]

YEAH, YOURE RIGHT, DUDE.

I shouldda played it out.

But I'm in the mood to test my writing skills.😀

My bad.

It still seems to have stimulated some discussion

 

[jetproppilot]

Do you think if you made the time between induction and incision shorter and if you did not abolish spontaneous ventilation that the pressure might have not dropped to 30 and needed epi?

I see a drop from 50 to 38 insignificant in the realm of things, Dude.

If the Dudes pressure was 50 after the drape I wouldda still gone ahead with a little epi....

GIMME A BREAK DUDE.....FIFTY VERSES THIRTY EIGHT?

OK Plank, you've gotta sytolic of 50. Or 38.

EPIS COMMEN IN MY BOOK IF ITS NOT GETTEN BETTER CDAZY FAST.

So the answer to your question is no.

The induction was negligible in the whole scheme of things.

There was no shorter.

There was no wasted time.

 

[jetproppilot]

This is precisely how I intubate crashing people in the unit all the time.

Good for you.

A little finely-selected amnestic/paralytic isnt gonna hemodynamically swing things significantly one way or the other.

But a little finely-selected-amnestic will save the patient memory of the situation....and a little paralytic will ensure that you get the tube in.

The first time.

 

[Planktonmd]

I see a drop from 50 to 38 insignificant in the realm of things, Dude.

If the Dudes pressure was 50 after the drape I wouldda still gone ahead with a little epi....

GIMME A BREAK DUDE.....FIFTY VERSES THIRTY EIGHT?

OK Plank, you've gotta sytolic of 50. Or 38.

EPIS COMMEN IN MY BOOK IF ITS NOT GETTEN BETTER CDAZY FAST.

So the answer to your question is no.

The induction was negligible in the whole scheme of things.

There was no shorter.

There was no wasted time.

🙂
OK
Why not?
The outcome was good and this is what matters.
I Know that your patient was in good hands and he got the best shot at making it alive.
Strong work.

 

[jetproppilot]

🙂
OK
Why not?
The outcome was good and this is what matters.
I Know that your patient was in good hands and he got the best shot at making it alive.
Strong work.

OK.

Lets walk through this.

You've gotta dude dying because of an EVENT.

You've gotta INTUBATE before surgeon-dude can address da EVENT.

Surgeon dude is so close you could pull the drug rep pen outta his scrubs.

You virtually guarantee a snorkel thru da cords if Tamponade Dude will lay still for thirty seconds.

You may have a struggle if you attempt intubation without paralysis.

So....uhhhhhh......

Whats the beef with succinylcholine?

 

[OB1🤙]

P.S. This thread is awesome. Very strong work there, Jet.

 

[jetproppilot]

OK.

Lets walk through this.

You've gotta dude dying because of an EVENT.

You've gotta INTUBATE before surgeon-dude can address da EVENT.

Surgeon dude is so close you could pull the drug rep pen outta his scrubs.

You virtually guarantee a snorkel thru da cords if Tamponade Dude will lay still for thirty seconds.

You may have a struggle if you attempt intubation without paralysis.

So....uhhhhhh......

Whats the beef with succinylcholine?

Yeah, yeah, I know the academic concerns.

 

[Planktonmd]

OK.

Whats the beef with succinylcholine?

Hmmmm....

It abolishes spontaneous ventilation for a few minutes?

 

[Planktonmd]

Hmmmm....

It abolishes spontaneous ventilation for a few minutes?

I forgot to add: you don't have a few minutes 😀

 

[jetproppilot]

I forgot to add: you don't have a few minutes 😀

Yeah, I respect your stance. Its what our elders told us in residency.

What you're not realizing is ALL THE ABOVE happened in just a few minutes.

Surgeon Dude is ready as soon as the drapes are up.

Pressure 50, pressure 38, whatever...

but you HAVE TO GET THE TUBE IN BEFORE ANY OF THIS S HIT HAPPENS.

So I'm gonna paralyze the dude so I can be sure to do my part THE FIRST TIME.

Your worries, with a surgeon standing by, are purely ACADEMIC DOGMA that we diligently pass on to our resident colleagues...

FOR NOTHING.

Gotta surgeon ready (or almost ready) to cut?

GIVE DA SUX, RESIDENT COLLEAGUES. A HUNDRED MILLIGRAMS.

Make Tamponade Dude lay still for a minute.

So you can perform your crucial step with ease.... no need to struggle....for you or the patient....

 

[scotchnwater]

This is a rather ignorant question coming from someone who has...very little experience in such things, but:

Is it normal for someone who is POD #4 from a CABG and still requiring ICU status to have neither an A-line or central access?

 

[epidural man]

when did the guy get extubated?

I'm just curious because I have found that versed is a rock solid (hemodynamically) agent - much more than what the books seem to say, and I wonder how 15-20mg would have worked for an induction.

 

[epidural man]

This is a rather ignorant question coming from someone who has...very little experience in such things, but:

Is it normal for someone who is POD #4 from a CABG and still requiring ICU status to have neither an A-line or central access?

good question. my guess is he left the unit and probably was back in the unit because he was struggling on the floor.

Jet?

 

[urge]

If the surgeon was going in with just a needle I would have given ketamine only. No tube.

For an open I would have gotten an aline and a good IV first, then do the same as Jet did.

 

[Planktonmd]

Yeah, I respect your stance. Its what our elders told us in residency.

What you're not realizing is ALL THE ABOVE happened in just a few minutes.

Surgeon Dude is ready as soon as the drapes are up.

Pressure 50, pressure 38, whatever...

but you HAVE TO GET THE TUBE IN BEFORE ANY OF THIS S HIT HAPPENS.

So I'm gonna paralyze the dude so I can be sure to do my part THE FIRST TIME.

Your worries, with a surgeon standing by, are purely ACADEMIC DOGMA that we diligently pass on to our resident colleagues...

FOR NOTHING.

Gotta surgeon ready (or almost ready) to cut?

GIVE DA SUX, RESIDENT COLLEAGUES. A HUNDRED MILLIGRAMS.

Make Tamponade Dude lay still for a minute.

So you can perform your crucial step with ease.... no need to struggle....for you or the patient....

Your points are valid and I know for a fact that you did what you always do: great patient care.
That said, I understood that you induced GA, intubated, your surgeon went to scrub while you placed a central line.
This in my opinion is too long even if it was 5 minutes.
The few times I had to do a real tamponade case I let them prep drape have the surgeon standing there knife in hand ready to cut then induce GA and If the BP is really bad skip the Sux and just intubate with ketamine.
This doesn't mean my way is the only way or the best way.

 

[jetproppilot]

This is a rather ignorant question coming from someone who has...very little experience in such things, but:

Is it normal for someone who is POD #4 from a CABG and still requiring ICU status to have neither an A-line or central access?

Not an ignorant question at all, my friend.

Tamponade Dude was doing fairly well.....to the point where A line and central line had been DCed....don't know the specifics of why he was still in the ICU.....

good question though.

All I know is we had to go get the mo fo from the ICU, he was several days post CABG, and he didnt have an A line or a central line.

So this tamponade s hit was very unexpected, to say the least.

Thanks for posing a question to the obvious.

 

[jetproppilot]

Your points are valid and I know for a fact that you did what you always do: great patient care.
That said, I understood that you induced GA, intubated, your surgeon went to scrub while you placed a central line.
This in my opinion is too long even if it was 5 minutes.
The few times I had to do a real tamponade case I let them prep drape have the surgeon standing there knife in hand ready to cut then induce GA and If the BP is really bad skip the Sux and just intubate with ketamine.
This doesn't mean my way is the only way or the best way.

And I respect your position.

 

[jetproppilot]

And I respect your position.

I'm still paralyzing the sonnofabitch.😆

 

[Gern Blansten]

Good case Jet. Thanks for posting it.

 

[elwademd]

jet, to follow on planktonmd's line of thought... do you think the intubation (time he was intubated before the surgeon got going) played a role in the drop in blood pressure? intubation and the "positive" pressure decreased venous return... the heart's already compromised by the tamponade event... bp continues to drop as there are two forces pushing against the heart (the blood, and the increasing intrathoracic pressure)... just curious.

edit: great case btw. pericardial tamponade is definitely something to respect (fear's too strong of a word) to say the least, and i feel that residents in anesthesia/ct surgery/im should know about it.

 

[jetproppilot]

.

 

[mille125]

for the youngsters out there:


if you are sitting in from of the american board of anesthesiology you must follow plankton's advice...however in practice many excellent anesthesiologist would do what jet did (i think that i would as well)....


good job..

 

[kraphtymac]

This is a rather ignorant question coming from someone who has...very little experience in such things, but:

Is it normal for someone who is POD #4 from a CABG and still requiring ICU status to have neither an A-line or central access?

Agreed... and can you say... pericardiocentesis needle to bedside?

 

[OB1🤙]

What did this dude's airway look like? If he was a micrognathic dwarf (or maybe a gravid fire-ant), I'd understand this whole argument, but I gotta admit I don't really get the "academic contraindication" (if you will) to sux in this spot.

I mean, if there is concern about the airway and you're gonna throw another cowpie onto an already saturated $hit sandwich by paralyzing, fine. But if the dude looks easily snorkelable, I just don't see what you lose with sux.

Since there must be some fundamental thing I'm not understanding here about what exactly makes the no sux point of view the ABA-approved one, can someone enlighten a lowly CA-1? Thanks.

 

[Consigliere]

What the hell is CDAZY FAST? Probably the most idiotic thing I have heard in a long time.

 

[jetproppilot]

What the hell is CDAZY FAST? Probably the most idiotic thing I have heard in a long time.

Thats OK.

Its a line out of a commercial.

Mastercard I think.

 

[Planktonmd]

What did this dude's airway look like? If he was a micrognathic dwarf (or maybe a gravid fire-ant), I'd understand this whole argument, but I gotta admit I don't really get the "academic contraindication" (if you will) to sux in this spot.

I mean, if there is concern about the airway and you're gonna throw another cowpie onto an already saturated $hit sandwich by paralyzing, fine. But if the dude looks easily snorkelable, I just don't see what you lose with sux.

Since there must be some fundamental thing I'm not understanding here about what exactly makes the no sux point of view the ABA-approved one, can someone enlighten a lowly CA-1? Thanks.

If you give Sux (or any muscle relaxant) you have to use positive pressure ventilation.
PPV might be all you need to drop the cardiac output to zero in this guy.

 

[OB1🤙]

If you give Sux (or any muscle relaxant) you have to use positive pressure ventilation.
PPV might be all you need to drop the cardiac output to zero in this guy.

Gotcha. Thanks.

"Cdazy fast" is from those Volkswagon commercials with the weird German dudes.

 

[elwademd]

Agreed... and can you say... pericardiocentesis needle to bedside?

a few days post cabg... the heart's been manipulated, and part of the pericardium has been removed, and therefore the heart may not be in the "normal" position (i.e. it shifts rightward)... some people wouldn't be comfortable in a blind procedure period... others wouldn't want to do it even with echo/us at bedside because of the anatomic distortion mentioned above... and in the time waiting for the echo/us tech to come or for someone to find the echo/us equipment, have the appropriate needle, etc. the patient could be dead.

as jet pointed out, the whole case took 20 minutes. remember, a pericardial effusion is different than cardiac/pericardial tamponade. with an effusion, you have time. with tamponade, you probably don't.

i watched a cardiologist attempt a pericardiocentesis on a large pericardial effusion... in a matter of 20 seconds, he developed tamponade physiology- bp went from 130s to 50s/60s systolic, guy became lethargic, ashen... being internal medicine, i was a bit freaked, called the ct surgeon and the or, pumped him with fluids (thank the er nurses he had 2 lines) and i think dopamine (was on hand) to get his pressure up, and got him safely to the or where anesthesiologist and ct surgeon could do their thing.

i thought about tubing him, but was reminded that the increased intrathoracic pressure may drop his venous return (but again, i'm not an anesthesiologist, and the surgeon wasn't there; so my time factor was much different than jet's).

like jet's, the case was short (mine was a bit longer, as the ct surgeon was not in house at the time).

again, respect tamponade. when you see it, everything can happen very very fast.

 

[Noyac]

when did the guy get extubated?

I'm just curious because I have found that versed is a rock solid (hemodynamically) agent - much more than what the books seem to say, and I wonder how 15-20mg would have worked for an induction.

Yes versed is very stable, BUT
In this case I believe 15mg of versed would have killed this guy. **** look what 30 mg of ketamine did 50 to 38.

As far as paralyzing this guy, I'd do it fo sho.

I've done a few of these cases as well. I did some this way and others I did with ketamine sedation only and a mask with the surgeon doing a needle aspiration through an incision under local first while the pt is sitting upright somewhat, maybe 45degrees. The BP comes up and then we proceed with GA and pericardial window.

 

[radslooking]

MAN PLANK, YA MAKE THAT SOUND REALLY EASY!!!!

Like youre gonna give justa little somethin-somethin with no relaxant, tamponade-dude's gonna vigilantly cooperate despite the Miller 2 lifting his skull off the table,

and he's gonna lie still there, even though he's still with us, letting you violate his oropharynx with a blade and a tube.

Sorry Dude, the RISKS OUTWEIGH THE BENEFITS HERE. YOU'RE SPOUTING ACADEMIC WORRYS.

I'd rather give relaxant and virtually guarantee my airway than risk fighting with a near-conscious-dude-sans-relaxant....

especially when the surgeon is thirty seconds away from cutting.

I don't see the benefit of keeping'em breathing! DA STEEL BLADE IS THIRTY SECONDS AWAY!

FLAG THROWN

REFEREE:"PERSONAL FOUL....NUMBER THIRTY SIX (plank)..."

"ACADEMIC DOGMA...FIFTEEN YARDS.."

"Repeat second down."

lol, one of my personal favorites. i also like it when you talk about squats not counting unless your scrotum touches the floor.

 

[milrisome]

Same case. Same set up. Only I don't give sux, right? Pt is stable (as stable as pre-op anyway) and ventilating spontaneously. No drop in BP with induction. But surgeon steps up to the plate and complains about the pt breathing. I try to explain my rationale. He's still whining about how it's not what he's seen done in the past and the chest is moving way too much and blah blah blah. I'm thinking cut the pericardium open and this will all be moot.

Result: bigger delay with spont resps than with paralytics.

 

[videolectures]

Awesome case

Reading through it makes your catecholamine level surge abit...at least for a resident. Curious if this patient is crashing and hardly 'here nor there' ...amnesia is covered

requirements...amnesia, analgesia and hemodynamic stability

amnesia covered...unforunately via lack of cerebral perfusion...hopefully once the tamponade is resolved and cerebral perfusion re-established...MAP back in the 90's ...give the guy some nice amnesia...tons of versed and even alil analgesia is your inclined

analgesia...local in a crashing patient

hemodynamic stability...FAST FORWARD AND FULL

FAST...keep all his catecholamines surgining...(his own epi,norepi and cortisol and RAAS) will keep his HR up..

FORWARD...so our best to promote foward flow

FULL...try to distend his LV as much as possible despite the damn pericardial fluid compressing the LV...hence preload

---PPV going to knock out your preload hence not keeping his as full as we would want.

Everything you explained (vividly) in 20 mins is hardcore...not many can perform to that level that effeciently

patient is alive and well...anesthesia performance...PERFECT!