Strategies for Action: Ways to Achieve Good Decisions

Abstract

On the pediatric cardiology ward, the on-call pediatric resident is called to evaluate a 6-year-old patient complaining of nausea and dizziness. The child is 5 days status post cardiac surgery. His symptoms had started about 2 h earlier and worsened gradually. By the time the resident arrives at the bedside, the patient’s clinical condition has deteriorated further, and he has signs of impaired consciousness. The pediatrician obtains vital signs and applies monitors. The blood pressure is 60/40 mmHg and the ECG shows sinus tachycardia with a heart rate of 130 bpm. The saturation fluctuates between 88 and 92 %. Knowing that the chest drain had been removed the day before, the physician next listens to the lungs, which reveals diminished breath sounds over the left lung and distant heart sounds. In addition, she notes marked distension of the child’s neck veins. At this point, she considers the most likely diagnoses to be either tension pneumothorax status post removal of the chest drain or pericardial tamponade. Supplemental oxygen via facial mask and a fluid bolus of 250-ml crystalloid solution are administered, but the child remains unstable. The resident considers intubation, but is concerned about the detrimental effects of positive pressure ventilation on hemodynamic parameters. She decides to optimize the patient’s status first. An epinephrine infusion is started and the blood pressure improves. The patient is now stable enough for transfer to the pediatric intensive care unit. There, transthoracic echocardiography shows a large circumferential pericardial fluid collection and right ventricular diastolic collapse. With the diagnosis of pericardial tamponade, the patient is immediately taken to the operating room for an exploratory thoracotomy.