Answer 1

The first clip is a ME 5-chamber view. There is a pericardial collection visible around the RV, LA and LV. There is early systolic collapse of the LA, consistent with tamponade physiology. In the TG SAX view the effusion is seen surrounding the heart, but it is largest inferiorly / posteriorly to the RV and LV. The LV is small, consistent with poor filling due to tamponade. Tamponade is one of the complications of type A dissection, when dissection occurs back into the pericardium.

When you are treating the hemodynamics you need to immediately communicate what you see with the surgeon; they need to urgently open the chest and the pericardium given that the patient is peri-arrest. Management until they can do this is to have the patient “full, fast and tight”.

So you need to optimize pre-load, which would involve a fluid bolus, and taking measures to avoid any decrease in venous return due to high intrathoracic pressure, (so avoid PEEP and high inflation pressures with ventilation). Vasoactive agents that will keep HR up, (stroke volume is relatively fixed due to extrinsic compression, so higher HR will mean more cardiac output), and keep SVR up (to provide perfusion pressure) are indicated. There has been little response to vasopressors, so an inotrope would be the next step; epinephrine will provide some chronotropy (increase in HR), as well as inotropy, and at higher doses will have some vasoconstrictor effect too. A bolus (10-20mcg), plus an infusion at a moderate dose would be a good start, with repeat, or larger bolus if necessary. You will probably also need a vasoconstrictor running.