CT surgery complications
  • No investigation is diagnostic for tamponade
  • Opening even the lower part of the wound and sucking a few clots can be life saving
  • A wire cutter must always be present in the surgical ICU
  • Explore early rather than late
  • Nothing is usually lost by a negative exploration but missing tamponade is fatal
  • Unexplained hypotension can be tamponade.
  • Hyperkalemia especially in children may be a prelude to tamponade.
  • Serum Lactate may rise in the presence of surgical bleeding and impending tamponade despite normal hemodynamics.
  • If you cannot understand what is going wrong with the patient - think tamponade.
  • Beware of sudden cessation in bleeding
  • A patient with an open sternum can still tamponade

See sections on bleeding and Medical management of Bleeding for basic principles!

When to re-open[]

  • Stable then bleeds >200ml/hr
  • 400 ml/hr for > 2 hours
  • Total loss in first 5 hours > 1 litre
  • Loss > 10% of circulating blood volume (use 80 ml/kg)
  • Do it early - then everyone is still around, the patient is not unstable.

Diagnosis of Tamponade[]

  • Usually clinical. Echo may not see clot on RA
  • Watch for falling urine output
  • May not see rise in CVP due to hypovolaemia
  • Otherwise unexplained increased need for inotropes
  • Bleeding that slows dramatically, then BP falls a few hours later

Diagnosis of bleeding.[]

Mostly this is revealed, but beware the slighty unstable patient (may even be hypertensive) who is bleeding into an open pleura. Several litres of blood can be hidden in there before it becomes apparent.

Problem Patients[]

Patients who have difficult blood groups or have religious objections to blood transfusion must be dealt with very promptly. Have a lower than what should be a low threshold for re-exploration.