BP drop in CABG

nursej22, MSN, RN · Mar 28, 2011

I am not quite sure I understand all your abbreviations and it would be helpful to know what the admitting diagnosis or chief complaint was.

What were the lung and heart sounds? Any jugular venous distention? CXR?

I am guessing your patient had cardiac tamponade, not a clot in the heart but in the sac surrounding the heart. The classic signs, referred to as Beck's Triad are hypotension, JVD, and muffled heart tones.

I am not sure that the Afib had any much to do with your symptoms except it may have lowered the BP if it was rapid.

Heart surgery is definitely a risk factor for tamponade.

In the future, I would recommend a more thorough assessment (perhaps you did this but you didn't give this info in the OP). Lung and heart sounds, jugular veins, blood glucose to r/o hypoglycemia, perhaps getting a portable CXR and/or echo.

You did mention an EKG which will help to r/o an acute infarct.

The hypotension and heart block would have made me suspicious of an RV infarct.

CCL RN, RN · Mar 28, 2011

Heart tones, heart tones, heart tones.

Refractory hypotension, rhythm changes, complete heart block!!! Eeks. As a cath lab nurse, even VT doesn't get much of a rise out of me, but CHB is always a scary story.

What you could have done better was a thorough assessment, which would have included heart tones. Also, don't wait for the tele tech to tell you about your pts monitor, frequently check yourself.

Sounds like this pt was giving all kinds of signs that they were in distress, and it's a shame it was missed.

Last pericardial taponade I had was a code--that died. It was also missed by the primary nurse.

Start your shift with a review of their past strips, in addition to your report. A thorough assessment for baseline reference, and frequent reassment when your pt status suddenly changes. This is, after all, why they are in tele. And check those strips yourself.

Kudos to you for seeking a way to prevent this in the future.

fabiusgile · Mar 30, 2011

Where to start. First off I Was in there every 15-20 min reassessing inbetween giving 4 units of blood. 2ndly her heart sounds did not change she was a very large women. I was looking for input. Not I failed to assess my pt. Her rhythms didn't change to the heart block until after we were actively transferring her. blood sugar fine. I was checking the monitor and asking my teletech if the rhythm had changed shift. I can't watch it the whole shift. She had no kneck distention and they had been drying her out her Lung sounds were clear. All I had was the symptomatic BP her Pulse was 80-100. I was asking what would you have done. I think I did the best I could with what I had presenting but IF I hadn't would you have done. Tests Assessments etc. Not I failed to assess my pt.

fabiusgile · Mar 30, 2011

My unit manager and the ICU/Tele manager said I did fine my documentation was all there etc. But I want to better myself and be prepared for those "Oh Crap" moments.

nursej22, MSN, RN · Mar 30, 2011

Tamponade: definitely an "oh crap" moment, and seriously, it's hard to pick up until it's really impacting cardiac output.

Pulsus paradoxus (decrease in BP with inspiration) is supposedly also indicative of tamponade and/or pericarditis, but is tricky to detect.

It sounds like you did every thing possible.

And I'll bet the next time you have an OHS patient with low BP not responsive to fluids or dopamine, you'll be thinking tamponade.

fabiusgile · Mar 30, 2011

she didn't get the dopamine until she was on the unit.. All the cardiologist gave me was boluses. When I read the md note it sounded like the clot was in the heart is that possible?

nursej22, MSN, RN · Mar 30, 2011

While I have seen patients with atrial and ventricular thrombi I have never heard the clot being removed, just anticoagulated. I think embolization would be too risky to attempt evacuation.

A pericardial window is performed for persistent pericardial effusion, so I think your patient's clot was outside of the heart.

fabiusgile · Mar 30, 2011

Hearts are just interesting. Maybe when it said evacuated 400ml it was in the pericardial sac. Mechanical electrical plumbing all in one

RNextraordinare · Mar 30, 2011

Post CABG patients are always at risk of tamponade after surgery and after pulling of epicardial pacing wires. It is possible for up to 1liter of fluid to be in the pericardium before a patient exhibits signs of tamponade. Needle pericardiocentesis can be done at the bedside preferablly with ultrasound as blindly carries a high mortality. hope I helped somewhat!

R*Star*RN, BSN, RN · Mar 30, 2011

I sometimes find it difficult to clearly hear heart sounds in very large patients. They always seem a little muffled. I've considered purchasing on of those electronic stethoscopes.

At my facility when someone goes into a-fib for any length of time we start the a-fib protocol. So if she was in and out of A-fib all day I'd question why she wasn't on the protocol.

A-fib can cause clots. Did the patient have a therapeutic PT/INR? Was the patient on some sort of anti-coagulant? Also don't forget that A-fib and stroke are linked.

You said they made a pericardial window so I'm assuming she had a pericardial effusion, but did was it labeled as tamponade?

Could have gotten a stat portable chest x-ray while giving the boluses.

edit: reread your original post that said the clot was evacuated. I agree this was most likely from the pericardial sac. In this situation as a fairly new cardiac nurse (1.5 years on the unit) I would have called my charge nurse to come in an assess my patient to make sure I wasn't missing anything.

fabiusgile · Mar 30, 2011

I had charge and 3 other nurses assess her. Would a port x-ray show it? The cardiologist was aware of the A-Fib. I think his thinking was that it wasn't sustained and because of the D/C of amniodorone would cause it? I'm not sure