A Penetrating Injury

ED Thoracotomy

Dr Laura Attwood

EM Consultant, RVI

Aim

• Statistics• Case review• Discuss Pre-Hospital elements• Code Red• Roles within the Resus• Development of a Traumatic Cardiac Arrest

Protocol

Statistics

• TARN data• 3rd most common cause of trauma in North

East– 1st RTC– 2nd Fall

• Increasingly more common according to TARN• Often Interpersonal violence related

Statistics

• Home Office• In 2009-10

– North East rate for violent crime = 3rd highest in all regions of England & Wales at 560 incidents per 1000 persons

– 1st = London, 2nd = East Midlands• In 2012/13

– 5th highest– 725 offences

Statistics

• Daily Mail!

Case Review

Background

• RVI Emergency Department

• ~ 2100 hours

• x 1 Consultant• X 1 Reg• x 5 SHO’s• x 2 nurses in Resus.

Pre Hosp Info

• Young male• Stab wound to the back• ETA 5 mins• Respiratory arrest but now breathing

Team preparation

• Trauma Team call• ED Staff• Cardiothoracic surgeon contacted and set off

for hospital• Orange on call contacted ICU consultant• Thoracotomy kit moved next to bed • Team briefed on potential for Thoracotomy

Handover

• 30 mins on scene• Difficult to access due

to Police present and perpretator still on scene

• Respiratory arrest in ambulance

• Unable to get IV access

On arrival

• No external Catastrophic Haemorrhage

• A: Intubate/Ventilate– Establish etCO2

• Monitoring attached– ECG = asystole– Sats = not recordable

• Pulse check = no carotid/radial

On arrival

• X1 posterior chest stab wound

• = Thoracotomy Initiated

Thoracotomy Kit

VS

Landmarks

View inside

What next

• No wounds in the heart• No wounds in the lung• Aortic compression• With internal cardiac compressions

Moving on

• Unable to obtain large IV access– IO line establish in tibia– Blood pushed through with 20ml syringe

• Consultant General Surgeon arrives and extends the damage control trauma surgery to Laparotomy.

Laparotomy

• Evidence of splenic disruption• ?gone through descending abdominal aorta

also• Abdomen packed to control haemorrhage• Unable to regain output from patient

• Decision taken as a team to stop resuscitation and patient pronounced dead.

Post Mortem

• Verbal Report

• Concludes above findings

• Grade IV Splenic laceration

• Wound through descending abdominal aorta

Discussion Points

• Pre Hospital – stay and play vs scoop and run• Code Red call• Venous Access• How to get the MHP into the patient• Staffing• Development of a Traumatic Cardiac Arrest

Protocol

Pre Hospital

• Paramedics involved

• Training and Education issues

• Do the land paramedic crews understand what we want to do to the patients when they arrive and why it is so time critical?

• ? Scoop and Play

Code red call

• Who is alerted:– Blood transfusion for MHP to be activated– Porters to collect MHP form lab– Trauma Theatre– Trauma Team Personnel

• Would this have helped?• ?More staffing – possible resource from

ODP/Theatre Staff

Lines

• Trauma Subclavian Line/Peripheral Access = ideal

• If we can’t….

• Just lean towards IO’s– x2 yellow IO’s in humeral heads with Level1

attached– Significant success in Military Operations

MHP

• Use of Belmont and Level 1 infusers• Can use with IO’s• Ensure the blood is also warmed

Ideal Staffing

Ideal Staffing

Ideal staffing

• Level 1 = 1.5 nurses• Belmont = 1.5 nurses• ODP• Nurse 1: Monitoring/Trauma Kit• Nurse 2: Drug nurse

• TTL• Anaesthetist• B Doc• C Doc

• General Surgeon• Orthopaedic Surgeon

Traumatic Cardiac Arrest Protocol

Summary

• Trauma case that we may see more and more off

• Lets be prepared • Plan what resources we need• Implement some simple changes

• In hospital AND pre hospital