Coronial
VIChospital

Finding into death of Trevor Ronald McDonald

Deceased

Trevor Ronald McDonald

Demographics

43y, male

Date of death

2006-06-25

Finding date

2012-10-01

Cause of death

Hypoxic brain injury secondary to haemopericardium and tamponade complicating ruptured right coronary artery during coronary angioplasty

AI-generated summary

Mr Trevor McDonald, 43-year-old male, died from hypoxic brain injury following cardiac tamponade complicating coronary angioplasty. During elective PCI at Frankston Hospital, he sustained right coronary artery perforation causing pericardial bleeding and tamponade. Following initial pericardiocentesis, he likely suffered laceration of the right ventricular outflow tract (RVOT), possibly from the drainage needle inserted without ultrasound guidance. Despite resuscitation and emergency transfer to a tertiary cardiac centre, he suffered irreversible hypoxic brain injury. Key clinical lessons: (1) complications of PCI in regional facilities without on-site cardiac surgery incur significant time delays for definitive surgical management; (2) emergency pericardiocentesis carries risk of vessel injury, particularly when performed without imaging guidance; (3) prolonged cardiac tamponade causes incremental cerebral hypoxia; (4) all interventional cardiologists should maintain expertise in emergency tamponade management and have cross-accreditation with cardiac surgical centres; (5) robust inter-hospital transfer protocols are essential.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

cardiologycardiothoracic surgeryanaesthesiaintensive care

Error types

proceduralsystemdelay

Drugs involved

diazepampromethazineheparinabciximabmidazolamaramineatropineprotamineadrenalineaspirinclopidogrel

Clinical conditions

coronary_artery_diseasecoronary_artery_atherosclerosisacute_coronary_syndromecoronary_artery_occlusioncoronary_artery_perforationhypoxic_brain_injurycardiac_tamponadepericardial_effusionhaemopericardiummyocardial_ischaemiahypertensionhyperlipidaemia

Procedures

coronary_angiographypercutaneous_coronary_interventionballoon_angioplastystent_placementpericardiocentesispericardial_drain_insertionsternotomycoronary_artery_bypass_graftcardiopulmonary_bypass

Contributing factors

  • Perforation of right coronary artery during angioplasty
  • Laceration of right ventricular outflow tract during pericardiocentesis needle insertion
  • Pericardiocentesis performed without ultrasound guidance
  • Prolonged cardiac tamponade with inadequate initial relief
  • Delayed access to cardiothoracic surgical facilities
  • Significant delay in inter-hospital transfer (2 hours 45 minutes)
  • Delay in locating receiving hospital with available theatre and ICU bed
  • Extended period of cerebral hypoxia from approximately 3:35pm to 5:00pm
  • Patient moved and restless during pericardiocentesis, complicating needle placement

Coroner's recommendations

  1. Peninsula Health should ensure the Director of Frankston Hospital PCI Unit is an experienced interventional cardiologist who is cross-accredited to at least one tertiary cardiothoracic unit and practices interventional cardiology at Frankston
  2. Department of Health request the Intensive Care Advisory Committee to consider access to intensive care beds for emergency cardiac surgical patients in the context of overall intensive care bed supply in the State
  3. Department of Health seek advice from the Cardiac Clinical Network to integrate its role in emergency transfer of patients from stand-alone regional PCI units with services of the Intensive Care Advisory Committee and Adult Retrieval Victoria
  4. Cardiac Society of Australia and New Zealand consult with Department of Health and Cardiac Clinical Network to ensure guidelines for stand-alone regional PCI units account for local arrangements that reduce time for emergency transfer to tertiary cardiothoracic units
  5. Cardiac Society of Australia and New Zealand reconsider advice about transfer time from stand-alone regional PCI units to include time required to locate a bed in a receiving hospital and time for emergency transfer
  6. Cardiac Society of Australia and New Zealand review guidelines to require all interventional cardiologists performing angioplasties in regional stand-alone PCI Suites to be cross-credentialled to tertiary high-volume cardiothoracic units and work in such units for sufficient time to maintain exposure to emergency responses
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