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Difficulty: MediumCardiothoracic and Vascular Surgery

A 65-year-old woman is evaluated in the cardiovascular intensive care unit on postoperative day 4 following a coronary artery bypass grafting (CABG) procedure. Over the past 45 minutes, she has become increasingly restless, confused, and short of breath. Her temperature is 37.8°C (100.0°F), blood pressure is 82/50 mmHg, pulse is 122/min, and respirations are 26/min. On physical examination, her jugular veins are distended to the angle of the mandible while she is seated upright. Auscultation of the chest reveals clear lung fields bilaterally, but heart sounds are distant and muffled. Her extremities are cool and clammy, with a capillary refill time of 4 seconds. The sternal incision is intact without erythema or purulent discharge. Electrocardiography demonstrates sinus tachycardia with low-voltage QRS complexes. Which of the following is the most appropriate next step in the management of this patient?

  1. Bedside transthoracic echocardiographyAnswer
  2. B
    Computed tomography angiography of the chest
  3. C
    Intravenous administration of furosemide
  4. D
    Empiric administration of broad-spectrum antibiotics
  5. E
    Continued observation with aggressive intravenous fluid resuscitation

Answer

Bedside transthoracic echocardiography
The correct answer is bedside transthoracic echocardiography. This patient is exhibiting Beck's triad (hypotension, jugular venous distention, and muffled heart sounds) along with tachycardia and low-voltage QRS complexes, which is highly suggestive of cardiac tamponade. Cardiac tamponade is a life-threatening postoperative complication caused by the accumulation of blood or fluid in the pericardial space. This increases intrapericardial pressure, leading to impaired diastolic filling of the right ventricle and subsequent obstructive shock. The most appropriate next step is to confirm the diagnosis with bedside transthoracic echocardiography, which would demonstrate pericardial effusion and right atrial or ventricular diastolic collapse, followed by urgent surgical decompression.

Step-by-Step Solution

1
Evaluate the patient's vital signs and physical examination findings.
The patient is hypotensive, tachycardic, and has jugular venous distention with muffled heart sounds (Beck's triad).
To identify the physiological mechanism of shock.
2
Synthesize the clinical presentation with the postoperative timeline.
The recent CABG procedure combined with Beck's triad and low-voltage QRS strongly suggests postoperative cardiac tamponade.
Postoperative bleeding into the pericardial space can restrict cardiac filling, leading to obstructive shock.
3
Determine the most appropriate immediate diagnostic step.
Bedside transthoracic echocardiography is selected to confirm the presence of pericardial fluid and right heart collapse.
A rapid, non-invasive bedside test is required to definitively diagnose tamponade before proceeding with emergent surgical decompression.

Key Concept

Diagnosis and management of postoperative cardiac tamponade
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Topics

Cardiothoracic and Vascular Surgery

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