Admitting an open chest pt

CVmursenary · Jul 18, 2012

Do not turn them; you could puncture their heart with the ribs.

Editorial Team / Admin · Jul 18, 2012

Be ready to run your butt off and have the crash cart very, very close, as usually the reason the chest is open is that they are unstable hemodynamically. The last patient I took to ICU with an open chest bottomed out when we tried to wire his sternum. We had to open him back up, and he was on levophed, dobutrex, epi, and neo.

umcRN, BSN, RN · Jul 19, 2012

Well, I work in a pediatric cardiac ICU and I would say about 60% of infants return with open chests (small chest cavities do not accommodate swelling well). Be prepared for a LOT of bleeding and to be giving a lot of fluid. In an adult I suppose you would want the rapid infuser primed and ready. When your patient first comes up get a good look at their "window", the dressing area over the open chest, keep an eye on this, increased buldging of the window can be a sign that your patient is about to tamponade. Have your code drugs drawn and ready before your patient gets there, I like to think that the more drugs you have prepped to more bad "juju" you can ward off (doesn't always work that way but hey, at least you're prepared). We actually do turn our little ones with open chests but they are a lot easier to move than those adults

IHeartDukeCTICU · Jul 21, 2012

Just look at the bright side... if they code, their chest is already open :)

umcRN, BSN, RN · Jul 21, 2012

Just look at the bright side... if they code, their chest is already open :)

Haha I remember when I was on orientation and someone asked if they coded how do you do chest compression?

Instructors answer: Preferably with gloves! :yeah:

Biffbradford · Jul 26, 2012

Well, just because they have an open chest, doesn't mean you have to have the code cart in the room. You may have to work hard to get 'em stable (fluids, blood, drips, correct any coag. problems), but then you should be okay. From there it's either diurese to get the swelling down, or crank up the 'ol CVVH to pull the fluids off.

NO TURNING! Not even if they poop. On rare occation you may have to 'levitate' 'em to change the blood soaked linens so you don't get skin break down (or if someone zeroes the bed scale by mistake - DOH!), that's always a good team buiding exercise.

Chest compressions??? Not on your life. It's direct heart massage, and I ain't doing that! Call the surgeon in for that one.

Often that's a 2:1 nurse to patient staffing ratio until they're stable.

Good times.

umcRN, BSN, RN · Jul 27, 2012

hmmm in my unit if they code someone better get their hands in their chest soon and massage, sure the surgeon will be there soon to put them on ecmo but till then someone better be doing something other than standing around starting at a coding kid!

and yes, I have seen both bedside RN, fellow or attending doing cardiac massage on our babies...of course on tiny little hearts its more of a gentle squeeze, but when the question was asked in my orientation our instructor wasted no time in making sure we knew that open chest or not compressions need to be done if a kid is coding

volunteerpioneer · Jul 27, 2012

Everyone thanks for the input.

Perhaps I jinxed myself because at yesterday's shift I got my first open chest-patient. start of shift the surgeons did a wash out at bedside and decided to keep the chest open since they were planning to do it again the next day :/ .. first time I ever smelled burnt human flesh.. anyway he was a 2:1, but not because of his open chest, but because he had a BiVAD. He was also on CRRT, had a IABP, Nitric with his Vent.. MAN! Anyway..

didn't turn him ( how could I).. and kept my eye on the cart :/

Biffbradford · Jul 27, 2012

Being the 'mechanic' can be fun on those paitients. Interesting to see you write 'nitric'. The big hosp. here stopped using nitric because of the $$,$$$ cost they weren't getting re-imbursed for. Went to Flolan instead. I guess if you gotta glove up and grab some heart, then you do ... but I'd be on the horn with the cutter on call long before then tellin' him/her that things ain't looking good and don't expect to get any sleep tonight! :yeah: Fortunately where I work now, they don't do VADs. All that kind of excitement is behind me. :lol2: :w00t:

umcRN, BSN, RN · Jul 27, 2012

When I heard how much nitric cost I almost stroked because we have kiddos that LIVE on it for weeks to months at a time. With infants and children we try not to whip out the big guns (flolan, romodulin) until everything else has been tried. For the most part we are able to wean them off it pretty easily so.e kiddos just latch on tho and don't want to let it go

IHeartDukeCTICU · Jul 29, 2012

We just started using the CALS protocol (Cardiac Surgery Adv Life Support) which is a modified version of ACLS specific to CV/CTICU pts. Basically, if pt's meet certain criteria and they code, after 3 stacked shocks, we already start prepping the chest, the house officer (usually NP or PA) can open and either the other HO or the bedside nurse assists, all without a surgeon there.

It was presented at NTI a few years ago by another hospital in CA and adapted by our CTICU. Of course alot of training was involved and an open chest cart was developed. But there are a few studies out there (mainly from the UK) that have shown that in post-heart sx pt's that code, getting into the chest earlier has better outcomes.

Just think about regular ACLS: Do you really want to pound on a person who just had their sternum closed? Think RV puncture from ribs or sternal wires. Or what if they are actively tamponading? Opening the chest and evacuating while doing internal massage sounds much better :)

Also some of the drug doses are modified, i.e. no longer 1mg of epi... think about giving that to a fresh cabg who v-fib arrests... you get a rhythm back and then they blow a graft :)