Tampanode Precautions after pulling epicardial pacer wires

Specialties CCU

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Specializes in CT ICU, OR, Orthopedic.

After pulling epicardial pacemaker wires, the patient is always placed on tamponade precautions. I was recently told that they do not need tamponade precautions if they have chest tubes....this doesn't make sense to me. Tamponade is caused by an excess of fluid in the pericardial sac... since the CT are MS and/or plueral...any one else ever heard of this?

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Specializes in Cardiology.

Can you tell me what "tamponade precautions" is, exactly? Not sure what you would do? Take BPs more often? Check on the patient Q15min to assess heart tones?

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Specializes in CT ICU, OR, Orthopedic.
Can you tell me what "tamponade precautions" is, exactly? Not sure what you would do? Take BPs more often? Check on the patient Q15min to assess heart tones?

Basically, VS q 15 min, for 1 hour, then q 30 min for one hour, and auscultate heart tones on the hour...yeah, nothing too exciting...watch for hypotension, tachycardia, arrhythmias etc. Younasically stick by the of for an hour or two to make sure he's ok.....

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Specializes in ICU.

Um, chest tubes go into the lung. Tamponade occurs around the heart. I don't see how a chest tube does a bit of good for tamponade. Unless it's a unique chest tube that somehow got put into the pleural sac. And I doubt that's ever happened.

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Specializes in CT ICU, OR, Orthopedic.
Um, chest tubes go into the lung. Tamponade occurs around the heart. I don't see how a chest tube does a bit of good for tamponade. Unless it's a unique chest tube that somehow got put into the pleural sac. And I doubt that's ever happened.

that was exactly what I said, but the nurse had 30 years experience compared to my 3 years...she said something about releiving the pressure in the chest (MS)...so I didn't want to tell her she was wrong, so I asked here!

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Specializes in CT ICU, OR, Orthopedic.
Um, chest tubes go into the lung. Tamponade occurs around the heart. I don't see how a chest tube does a bit of good for tamponade. Unless it's a unique chest tube that somehow got put into the pleural sac. And I doubt that's ever happened.

Well they do go into the plueral cavity, not the lung... Or the mediastinum...

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Specializes in Telemetry, CCU.

Maybe she meant mediastinal tube? Although I'm not even sure a mediastinal tube would drain the fluid between the heart and the pericardial sac unless the little hole in the sac was big enough to drain the fluid. In that case it would help, but it still wouldn't hurt to have the pt on precautions.

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Specializes in CT ICU, OR, Orthopedic.
Maybe she meant mediastinal tube? Although I'm not even sure a mediastinal tube would drain the fluid between the heart and the pericardial sac unless the little hole in the sac was big enough to drain the fluid. In that case it would help, but it still wouldn't hurt to have the pt on precautions.

Yeah that was what I figured she meant the MS ones, but it still does Not make sence anatomically! Thanks for your responses! I am going to continue with my usual practice.

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Specializes in CVICU, ICU, RRT, CVPACU.

DNPStudent........the more experienced nurse was possible right or wrong depending on what she was referring to as the method of tamponade. There are different types of chest tubes and drains. Pleural chest tubes sit in between the pleural space, Mediastinal Chest tubes sit in the mediastinum. MS chest tubes prevent cardiac tamponade by releasing a buildup of blood volume in the mediastinum after cardiac surgery or in the even that you caused enough bleeding to somehow fill up the mediastinum upon pulling the epicardial wires. As far as causing a tamponade in the PERICARDIUM......thats a different story. You must be trained to remove them and know what to look for prior to pulling them. It only takes around 100 ml's of blood in the pericardium to cause problems. Checking to make sure your INR isnt 2-3 before pulling them, electrolytes, bed rest for an hour or so, ect.........are good things to practice. Pericardial Tamponade is rare. I have seen multiple Mediastinal tamponades from clotted off chest tubes several hours after surgery.

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Specializes in ICU.
Well they do go into the plueral cavity, not the lung... Or the mediastinum...

I stated myself incorrectly. CT's go into the pleural space, yes, but the pleural space is not the same thing as the pericardial sac. It would still be a different anatomical space.

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Specializes in Critical care.

Epicardial wires exist post OHS (open heart surgery) exclusively. An intact pericardium is not an absolute assumption in this setting because some surgeons do not close (or only losely approximate) the pericardial sac post OHS. Thus, the pericardial space communicates with the pleural space. A pleural CT could then drain both medi and pleural spaces.

I feel that your collegue's description could lead certain others to a false assumption that a CT effectively prevents tamponade. To split hairs, I feel it's necessary to closely watch any pt with freshly pulled epicardial wires. Tamponade can take less than 50 ml of blood in just the right place (compressing the right atrium alone could nearly shut down all cardiac output at it's worst, for one example) To negate this, some docs just cut the wires at the skin and leave the reminant in-situ.

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Specializes in CT ICU, OR, Orthopedic.
Epicardial wires exist post OHS (open heart surgery) exclusively. An intact pericardium is not an absolute assumption in this setting because some surgeons do not close (or only losely approximate) the pericardial sac post OHS. Thus, the pericardial space communicates with the pleural space. A pleural CT could then drain both medi and pleural spaces.

I feel that your collegue's description could lead certain others to a false assumption that a CT effectively prevents tamponade. To split hairs, I feel it's necessary to closely watch any pt with freshly pulled epicardial wires. Tamponade can take less than 50 ml of blood in just the right place (compressing the right atrium alone could nearly shut down all cardiac output at it's worst, for one example) To negate this, some docs just cut the wires at the skin and leave the reminant in-situ.

Thanks...I've seen one surgeon cut the wire at the skin, but we all (nurses, NPs, PAs, etc) all looked at him like he was totally nuts!! I've never worked in another ICU, so I am limited to what I've seen there...

I am going to continue my usual practice....

Thank you!

Amy

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