You are working as an ICU specialist in a small regional hospital. You are called to give urgent assistance to a 65-year-old male who has presented to the Emergency Department with increasing shortness of breath, one week after discharge from a metropolitan hospital following apparently uncomplicated cardiac surgery.
Post-intubation, he has rapidly deteriorated and is now unresponsive with no recordable blood pressure. The cardiac monitor shows sinus tachycardia.
a) Outline your response to this crisis. (40% marks)
b) Other than cardiac tamponade ,what additional diagnoses need to be considered? (25% marks)
c) List the clinical signs indicating cardiac tamponade that may have been present prior to the cardiac arrest. (15% marks)
d) Describe how you would perform blind pericardiocentesis. (20% marks)
Confirm cardiac arrest
Good BLS i.e.:
Call for additional help
Local surgical team may be able to re-open sternotomy
Confirm IV access/intraosseous if needed
Adrenaline 1 mg IV immediately and then with alternate cycles
Bolus i.v. fluid as PEA
Continue CPR for 2 min
Rhythm check at 2 min – continue chest compressions, other responders stand clear, charge defibrillator to 200J, pause compressions, all clear, check rhythm and if non-shockable dump charge Immediately continue CPR for further 2 min
Look for and treat reversible causes (needle thoracostomy / pericardiostomy etc – 4Hs and 4Ts)
Additional Examiners‟ Comments:
A substantial number of candidates failed to recognise a cardiac arrest. Many of the answers were at a junior level e.g. listing the causes of cardiac arrest (Hs and Ts) without reference to this clinical scenario. The question on the technique of blind pericardiocentesis was also badly answered.
This question is in many ways identical to Question 15 from the first paper of 2011.The discussion section was copy-pasted below to simplify revision. Interestingly, though some of the candidates failed to identify cardiac arrest, the pass rate suggests that this was not essential.
As for the signs of cardiac tamponade - these are universally recognised as "Beck's Triad":
It is universally acknowledged that these features are observed only in a minority of patients. Other, more common features include the following:
The approach is as follows:
The college answer also suggests one connect an ECG lead (one of the chest leads) to the base of the needle and watch the ECG to look for a change in the QRS morphology, or ST elevation if the needle contacts the myocardium.
Jacobs, Ian, et al. "Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries.: A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa)."Resuscitation 63.3 (2004): 233-249.
Cikes, I. "A new millennium without blind pericardiocentesis?." European Journal of Echocardiography 1.1 (2000): 5-7.
Fitch, Michael T., et al. "Emergency pericardiocentesis." New England Journal of Medicine 366.12 (2012).
Sternbach, George. "Claude Beck: cardiac compression triads." The Journal of emergency medicine 6.5 (1988): 417-419.
Spodick, David H. "Acute cardiac tamponade." New England Journal of Medicine 349.7 (2003): 684-690.
Reddy, P. SUDHAKAR, et al. "Cardiac tamponade: hemodynamic observations in man." Circulation 58.2 (1978): 265-272.