A Case Study
The background
You admitted MB after a LIMA-LAD, SVG x2, initial vital signs
were stable – HR 75, BP 114/73, CVP of 5, Cardiac index was 2.1
after 250 ml of albumin index was up to 2.3, pulses are present
and easily palpable. There was good amount of urine in the OR
and is doing well since they have come back. Hgb was 10.7. You
have 3 blake drains to 2 pleuravacs, initial output was 70 out of
your single chest tube and 60 out of the y’d chest tubes, both
with good bubbling. Two hours later CI remains 2.3, you have
given two more albumins (for a total of 750 ml), BP if 102/70,
CVP 11, HR 82. Chest tubes put out 40 and 50 in the last hour,
intermittent bubbling is present, patient is just starting to wake
up, you are seeing some eye movement and random movement
of extremities. Two hours later your HR is 105, BP is 90/61, CVP
23, CI 1.9, pulses are present but weak, chest tube output for the
last hour is 5 and 5, and no bubbling is seen. You get your hgb
back and it is 8.2.
What do you think is happening?
 The patient is likely
experiencing a cardiac
tamponade
What is a test the physician might
order and what will it show?
 Sometimes a chest xray will
be ordered, to check for a
widened mediastinum.
What are some physical assessment findings that
support the diagnosis of cardiac tamponade?
 Distant heart tones, weak peripheral pulses,
restlessness/confusion (if awake), JVD
What do you expect the physician
to tell you?
 They will be on their way in, either to take patient back to
the OR or open their chest at bedside depending on stability
of the patient upon arrival (they will probably tell you before
heading in what their plans are). The goal will always be to
get them to the OR so they are in a sterile environment upon
opening the chest.
What do you need to do before
physician arrives?
 Notify the OR that the
physician is on the way in,
they either need to have OR
ready or have someone
assist at bedside). You can
attempt to strip/milk the
chest tubes to work clots
out, sometimes turning
patients side to side, or
sitting them straight up, or
making them cough helps
bring clots further down in
the tubes.
What could have prevented this?
 The best thing to do to
prevent tamponade is to
turn patients side to side
quickly, and always
monitor your chest tubes
and milk them as much as
possible. Sometimes due to
positioning of tubes,
amount of blood loss, &
status of coags there is just
not much that is able to be
done.
What signs help show that this is a
tamponade?
 Narrowing pulse pressure (normal 30-40), all of your heart
pressures are starting to move towards ‘one’ number,
decreasing urine, decreasing pulses.
What will happen to this patient if
no interventions occur and why?
 Patient will eventually go into multisystem failure (no urine,
liver shock, etc) and code, leading to death. The heart is
being squeezed from the outside so that minimal blood is
actually being circulated.
How is the presentation of this patient different than a
patient that walks into the ER with a pericardial effusion
with tamponade and why are the situations different?
 Typically a patient that comes into the ER with a cardiac
tamponade, unless it is from trauma, shows similar symptoms,
however that patient has had time to compensate for the
decreased flow and it is not quite as an emergent situations. This
is not saying that that patient is not critical, but there is usually a
little more time before that patient is going to code. Typically you
can rely on neuro symptoms more reliably with someone who has
NOT just had surgery – after surgery you don’t know whether
they are restless/confused because of anesthesia and pain
medications or because of decreased flow.
The Nurses Role
 The majority of items in the nurses role are in prevention of this
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happening: moving the patient and working with the chest tubes
in order to prevent clotting.
Once this has occurred the nurses role shifts into organizing the
patient and preparing them for a trip to the OR.
As this is occurring it is important to be monitoring the patient,
checking frequent cardiac outputs, managing vasoactive drips,
giving fluid (per orders)calling those who need called (OR team,
Supervisor, Perfusionist)
If the patient happens to code before surgeon arrival – minimize
compressions as much as possible. If compressions are required
make sure to use bed pan/bath basin – something to distribute
pressure across chest as much as possible
Often will look at the CXR – Radiologist often won’t look at
mediastinum
Stay Calm!
Any Questions?
Pictures Obtained from:
 Cardiac tamponade picture: http://medical-
dictionary.thefreedictionary.com/cardiac+tamponade
 Widened Mediastinum:
http://casereports.bmj.com/content/2011/bcr.03.2011.3
956.abstract
 Normal Chest X-ray:
http://www.meddean.luc.edu/lumen/meded/medicin
e/pulmonar/cxr/atlas/cxratlas_f.htm
 Chest tube striping/clogging :
http://www.pleuraflow.com/clogging/