Acute tamponade after AF ablation69-year-old woman, 60 kg, in the cath lab after AF ablation

The patient

The examiner asks

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1. Consider

   What's the diagnosis, and your priorities?

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   • A 69-year-old with tamponade from bleeding after ablation, still heparinised and on aspirin, in a remote cath lab. Patient
   • At 69, heparinised and on aspirin, she will tolerate both bleeding and induction poorly.
   • She has Beck's triad: low BP, raised JVP and distant heart sounds. Disease
   • RV diastolic collapse confirms tamponade; I'd look for pulsus paradoxus over 10 mmHg.
   • Cath lab is remote: I call for senior help and plan theatre transfer early. Surgery

2. Plan

   How will you manage her?

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   • Needle drainage under local by the cardiologist, before any anaesthetic. Disease
   • Reverse her heparin with protamine, 1 mg per 100 units, given slowly over 5–10 minutes. Crisis
   • Goals: full, fast and contracting; no vasodilation, no bradycardia, no myocardial depression. Disease
   • Large-bore access, arterial line, blood crossmatched and massive transfusion ready.
   • If GA is needed, the surgeon is scrubbed and she is draped before induction.
   • Ketamine induction, keeping her breathing spontaneously if possible.
   • If ventilated: low inspiratory pressures and no PEEP until drained. Airway

3. Crisis

   Drainage fails and she goes to theatre. At induction the ECG shows sinus rhythm at 130 but there is no arterial trace or pulse. What do you do?

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   • Adult arrest, non-shockable: PEA, sinus at 130 with no pulse, from her tamponade. (Crisis)
   • Call for help; start CPR and tell the surgeon to open now.
   • Adrenaline 1 mg early in this non-shockable arrest, repeated every 3–5 minutes.
   • Her reversible cause is tamponade: surgical release comes first, even if it interrupts compressions.
   • Fluid and blood running fast to support filling.

4. Crisis

   The pericardium is opened and blood pours out; BP 60/30 and suction is overflowing. What now?

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   • Massive haemorrhage: pericardium open, suction overflowing, BP 60/30; massive transfusion protocol activated. Crisis
   • Red cells, plasma and platelets close to 1:1:1, warmed.
   • Surgeon controls the bleeding point while I resuscitate.
   • Her heparin: complete the protamine, 1 mg per 100 units, given slowly.
   • Her aspirin: platelets even if the count looks adequate.
   • Ionised calcium checked as citrated blood runs; keep her warm.
   • ICU afterwards, watching for sudden failure once the heart is freed. After surgery