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.
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.