TRAUMA

Emergency physician credentialing forresuscitative thoracotomy for traumaemm_1303 332..336

Mark Fitzgerald,1,2 Gim Tan,3 Russell Gruen,1,2 De Villiers Smit,2,3 Kate Martin,1,2 Emma Newton-Brown,3

Carl Luckhoff3 and Amit Maini31Trauma Service and 3Emergency & Trauma Centre, The Alfred Hospital, and 2National Trauma ResearchInstitute, Melbourne, Victoria, Australia

Abstract

Objective: A low case incidence and variable skill level prompted the development of a credentialingprogramme and specific surgical training in resuscitative thoracotomy for emergencyphysicians at The Alfred, a Level 1 Adult Victorian Major Trauma Service.

Methods: A review of the incidence of traumatic pericardial tamponade and the objectives of resus-citative thoracotomy were undertaken.

Results: A training programme involving pre-reading of a 17 page teaching manual, a 40 mindidactic lecture and a 2 h surgical skills station using anaesthetized pigs were developed.The specific indication for resuscitative thoracotomy for this programme is ultrasounddemonstrated cardiac tamponade secondary to blunt or penetrating truncal trauma in ahaemodynamically unstable patient with a systolic blood pressure of less than 70 mmHgdespite pleural decompression and intravenous volume replacement. Cardiac electricalactivity must be present. The primary aims of resuscitative thoracotomy taught are releaseof cardiac tamponade, control of haemorrhage and access for internal cardiac massage.

Conclusion: Emergency physicians working in high-volume Trauma Centres are expected to diagnosecardiac tamponade and on occasion decompress the pericardium. Specific training in theprocedure should be undertaken.

Key words: cardiac tamponade, credentialing, focused assessment with sonography in trauma, resuscitativethoracotomy.

Introduction

Most fatalities from blunt or penetrating cardiac injuriesoccur prior to hospital arrival. The main physiologicaldeterminant for survival to hospital is acute cardiac

tamponade – which might be present without externalsigns of injury, abnormal clinical signs or ECG abnor-malities. The cause of the tamponade is usually a lac-eration to a low pressure cavity. In recent years thewidespread availability and use of ultrasound for the

Correspondence: Associate Professor Mark Fitzgerald, Director of Trauma Services,The Alfred Hospital, Commercial Road, Melbourne,Vic. 3004, Australia. Email: m.fitzgerald@alfred.org.au

Mark Fitzgerald, MB BS, MRACMA, FACEM, Director of Trauma Services; Gim Tan, MB BS, MRACMA, FACEM, Director Emergency MedicineTraining; Russell Gruen, MB BS, PhD, FRACS, Director National Trauma Research Institute; De Villiers Smit, MB ChB, FACEM, DirectorEmergency & Trauma Centre, Kate Martin, MB BS, BMedSci, FRACS; Emma Newton-Brown, B Nursing, Crit Care Cert, Clinical Nurse Specialist;Carl Luckhoff, MB ChB, Emergency Registrar; Amit Maini, BSc, MB BS, Emergency Registrar.

doi: 10.1111/j.1742-6723.2010.01303.xEmergency Medicine Australasia (2010) 22, 332–336

© 2010 The AuthorsJournal compilation © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

initial assessment of severely injured patients has facili-tated the early diagnosis of cardiac tamponade andassociated cardiac injuries. Resuscitative thoracotomyis a life-saving intervention for haemodynamicallyunstable patients in extremis and with proven cardiactamponade on ultrasound.1,2

Background

The establishment of the Victorian State TraumaSystem – with associated improvements in prehospitalcare and transportation – has resulted in an increasednumber of patients with cardiac tamponade secondaryto blunt or penetrating cardiac injury presenting to theAlfred Trauma Centre. In 2008 there were 1025 patientswith an Injury Severity Score >15 admitted through TheAlfred Trauma Centre. The Alfred Trauma Registry2001–2008 data indicated a diagnosis of cardiac tam-ponade 6–12 times annually. A total of 38 resuscitativethoracotomies for trauma (9 penetrating, 29 blunt) wereperformed in the Trauma Centre Resuscitation Baysduring the 8 years 2002–2009 with 10 (4 penetrating, 6blunt) neurologically intact and independent survivors(26.3% overall, 44.4% penetrating, 20.7% blunt).

The initial trauma reception and resuscitation is ledby emergency physicians and registrars. Focusedassessment with sonography for trauma (FAST) is per-formed by these staff trained and credentialed in its use.We have found that FAST screening in the haemody-namically unstable population has a higher sensitivityand specificity when compared with the stable popula-tion. At The Alfred 4.7% of trauma callout patients areshocked, not responding to volume resuscitation and‘unstable’ (a systolic blood pressure of less than or equalto 90 mmHg, despite an intravenous fluid challenge of40 mL/kg of crystalloid and 4 units of blood). FASTinterpretation in this group involves several members ofthe trauma team. The specificity for FAST in this groupis 100% and the sensitivity 83.3%. The Likelihood Ratiofor presence of haemorrhage given a positive FAST is11.92 (P = 0.01).

Focused assessment with sonography for trauma isparticularly valuable when used for the early detectionof haemopericardium in trauma patients without overtsigns of pericardial tamponade or external signs ofchest injury. The early use of FAST has increased theearly diagnosis of haemopericardium. Once haemoperi-cardium is demonstrated, the operator should screen forsonographic evidence of tamponade – specifically rightatrial and right ventricular collapse

If tamponade is demonstrated, thoracotomy withpericardial decompression and repair of the cardiacinjury is indicated. The subsequent management ofthe patient prior to thoracotomy becomes critical. Thepatients’ appearance at presentation does not predictthe severity of injury. The time course of the patients’circulatory status cannot be predicted because of thenon-linear course of the pericardial pressure–volumerelationship.3 Patients might rapidly lose cardiac outputduring the transport phase from the Trauma Centreto the operating theatre. Aggressive intravenous fluidadministration might precipitate a loss of cardiac outputby increasing the rate of development of the tamponadeand the associated reduction in stroke volume. Also,careful consideration should be given to when mechani-cal ventilation is instituted. For the non-intubatedpatient, rapid sequence intubation should coincidewith the ability to undertake immediate thoracotomy.Hypotension and cardiac arrest is common followinginduction of general anaesthesia in patients with cardiactamponade. This is as a result of the drop in venousreturn associated with the institution of intermittentpositive pressure ventilation, myocardial depressionfrom anaesthetic agents and the sympatholysis associ-ated with general anaesthesia and the associated reduc-tion in heart rate. Induction agent dosing should be veryconservative and the use of ketamine for inductionshould be considered.

For patients not requiring immediate resuscitativethoracotomy, the receiving trauma team should accom-pany the patient to the operating theatre – because ofthe real risk of sudden decompensation prior to and atthe time of anaesthetic induction. For similar reasons,the surgeon should be scrubbed and the patient preppedand draped prior to induction of anaesthesia.

However, transfer to the operating theatre takes time.Data extracted from the Alfred Trauma Registry forthe 12 m (October 2002–September 2003) revealed 5patients with cardiac tamponade (not requiring resusci-tative thoracotomy in the trauma centre) had a mediantime from arrival to operating theatre of 45 min. Morethan 1 h elapsed before initiation of repair in 59% ofpatients with haemopericardium in a North Americanseries published in 2000.4

Emergency physicians performing FAST shouldanticipate this delay and have a clear managementplan and the required skills in case the patient deterio-rates unexpectedly during this period. Unresponsivehypotension with a systolic blood pressure of lessthan 70 mmHg and a FAST positive for pericardial tam-ponade is a consensus-based indication for immediate

Resuscitative thoracotomy

333© 2010 The AuthorsJournal compilation © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

resuscitative thoracotomy. Immediate resuscitative tho-racotomy in the resuscitation bay should be undertakenif the patient is already ventilated and haemodynami-cally unstable on arrival. Pericardial aspiration can beused as a temporizing procedure if there is significanthypotension associated with any delay to thoracotomy,but thoracotomy remains the definitive procedure. Peri-cardial aspiration is an unreliable procedure and mightcause lacerations to the coronary arteries.

Emergency physicians employed at The Alfred, aLevel 1 Adult Victorian Major Trauma Service, hadinconsistent skill levels for resuscitative thoracotomy –with a case range from nil to over forty cases. This ledto an inconsistent approach to the agonal traumapatient with tamponade and variability in indicationsfor resuscitative thoracotomy. It prompted the develop-ment of a specific surgical training credentialing pro-gramme supervised by trauma surgeons. Specificindications for the procedure for Emergency physicianswere developed in conjunction with trauma and cardio-thoracic surgery. It is recognized that there are otherindications for resuscitative thoracotomy among spe-cialist surgical groups.5–7

Credentialing for resuscitativethoracotomy for trauma

In 2008 The Alfred Director of Medical Servicesarranged a formal review of the scope of practice ofmedical staff. Procedures that were considered torequire specific credentialing for Alfred emergencyphysicians were – FAST, resuscitative thoracotomyfor trauma, pelvic C-clamp application and fiberopticbronchoscopy. It was envisaged that this would stan-dardize certain skill sets of the emergency physiciansworking at this level 1 Trauma Centre. A specific cre-dentialing programme for resuscitative thoracotomywas then developed (Table 1) and commenced in 2009.Re-credentialing is expected to occur yearly.

The specific indication for resuscitative thoracotomyfor this programme is cardiac tamponade (as demon-strated on FAST) secondary to blunt or penetratingtruncal trauma in a haemodynamically unstable patient(a systolic BP of less than 70 mmHg despite pleuraldecompression and intravenous volume replacement).Cardiac electrical activity must be present.

The programme emphasizes that the initial key inter-ventions in thoracic trauma resuscitation are:• Oxygenation• Assisted ventilation

• Pleural decompression• Haemorrhage control• Release of cardiac tamponade

The primary aims of resuscitative thoracotomy inthis programme are:• Release of cardiac tamponade• Control of haemorrhage• Access for internal cardiac massage8

Patients with blunt trunk trauma and cardiac arrestafter haemorrhagic shock might benefit from open-chestcardiopulmonary resuscitation.9 Single and bimanualtechniques of open cardiac massage are taught at theconclusion of the surgical skill station. There is no clearevidence that aortic cross clamping improves outcomeand the technique is not taught.

A requirement of the credentialing programme is suc-cessfully completing a surgical practicum using anaes-thetized pigs. The skill stations are approved by theinstitutional ethics authority and are strictly supervisedby veterinary surgical staff. The instructor for eachstation is a trauma surgeon or an emergency physicianexperienced in the procedure. Specialist, critical caretrained trauma nurses assist. Candidates are instructedin performing a left anterolateral thoracotomy andpericardial incision10 (Fig. 1). The animals are loadedwith Amiodarone prior to cardiac handling. Ventricularand then atrial wounds are then created. Candidatesare required to sequentially demonstrate haemorrhagecontrol using digital pressure (Fig. 2) and then atrialappendage clamping. The emergency physicians arealso required to perform effective internal cardiacmassage while applying digital pressure to the cardiacwound.

Table 1. Alfred Trauma Centre resuscitative thoracotomycredentialing programme

Pre-reading17 page overview ‘Alfred Trauma Centre Resuscitative

Thoracotomy’40 min didactic lecture2 h surgical skills station using anaesthetized pigs

Preparation/positioning/approachLeft anterolateral thoracotomyPhrenic nerve identification and pericardial decompressionEvacuation of pericardial clotDigital control of right ventricular and left ventricular

woundsApplication of vascular clamps to both atrial appendagesOpen cardiac massageInternal defibrillation

Credentialing certificate signed by the director of trauma andthe director of emergency medicine training

M Fitzgerald et al.

334 © 2010 The AuthorsJournal compilation © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Although simple wound repair techniques are dem-onstrated, it is emphasized that pericardial decompres-sion and haemorrhage control is the primary goal – andthat definitive surgical repair should be performed byresponding surgical staff.

The Alfred Trauma Centre has four resuscitationbays all similarly staffed and equipped. As part of thecredentialing programme candidates are expected to befamiliar with thoracotomy set-up and instruments(Tables 2,3).

Following current practice, The Alfred Trauma Reg-istry collects data on all resuscitative thoracotomies andreports ad hoc along with annual activity and mortality.

All resuscitative thoracotomies undergo clinical audit atthe Trauma Service Audit, the Emergency DepartmentAudit and Cardiothoracic Unit Audit meetings. A com-prehensive multidisciplinary clinical audit is conductedwhen required. The impact and value of this credential-ing programme will be assessed over the next 5 years.

Conclusion

Emergency physicians working in high-volumeTrauma Centres are expected to diagnose cardiac tam-ponade and on occasion decompress the pericardium.The low case incidence and variable skill level has

Figure 1. Anterolateral thoracotomy with pericardium decom-pressed.

Figure 2. Digital control of right ventricular wound.

Table 2. Alfred Trauma Centre set-up for thoracotomy

Have the trauma bay set-up for thoracotomy when advised ofthe impending arrival of a hypotensive patient with thoracictrauma. In addition to the normal trauma bay set-up, thefollowing is required:

Ultrasound machine bedsideOverhead Theatre lights switched onOverhead suction gantry positionedRequest the Trauma Center RN to have the thoracotomy tray

unpacked/laid outSorensen suction unit availableDefibrillator with internal paddles availableEnsure all staff are wearing protective equipment including

eye shieldsEnsure all staff are wearing X-ray gownsPlastic aprons, sterile gowns and gloves lay out

Table 3. Alfred Trauma Centre thoracotomy tray

One tray in each of the 4 trauma baysThe Trauma Centre nurse leader is trained in thoracotomy trayinstrument recognition and set-up

Retractor Finochietto adultFinochietto child

Scissors Mayo curved 8”Mayo curved 6”

Forceps Gillies toothedNeedle holder Crilewood 6”Retractor Alison lung bladeRetractor Large FritschSatinsky vascular clamps 2Forceps Curved Artery 4”Light handleCrawford clamps 2

Scalpel, internal defibrillator paddles, skin stapler, sutures andsurgical ties

Resuscitative thoracotomy

335© 2010 The AuthorsJournal compilation © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

prompted the development of a credentialing pro-gramme with specific training in resuscitative thorac-otomy at The Alfred, a Level 1 Adult Victorian MajorTrauma Service.

Competing interests

None declared.

Accepted 18 May 2010

References

1. Fitzgerald M, Spencer J, Johnson F, Marasco S, Atkin C,Kossmann T. The definitive management of cardiac rupture andtamponade secondary to blunt trauma. Emerg. Med. Australas.2005; 17: 494–9.

2. Fitzgerald M, Basu A, Rahman F et al. Survival following resus-citative thoracotomy for combined left ventricle and left atriumruptures secondary to blunt trauma. Injury 2008; 39: 1089–92.

3. Zerkowski HR, Schmit-Neuerburg KP, Reidemeister JC. Interdis-ciplinary management of perforating heart injuries). LangenbecksArch. Chir. Suppl. Kongressbd. 1991; 550–6.

4. Tyburski JG, Astral L, Wilson RF et al. Factors affecting prog-nosis with penetrating wounds of the heart (annual meetingarticles). J. Trauma 2000; 48: 587–91.

5. Group PW. Ad hoc subcommittee on outcomes, AmericanCollege of Surgeons-Committee on Trauma. J. Am. Coll. Surg.2001; 193: 303–9.

6. Kortbeek JB, Al Turki SA, Ali J et al. Advanced trauma lifesupport, 8th edition, the evidence for change. J. Trauma 2008; 64:1638–50.

7. Pahle AS, Pedersen BL, Skaga NO, Pillgram-Larsen J.Emergency thoracotomy saves lives in a Scandinavian hospitalsetting. J. Trauma 2010; 68: 599–603.

8. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy inthoracic trauma – a review. Injury 2006; 37: 1–19.

9. Fialka C, Sebök C, Kemetzhofer P, Kwasny O, Sterz F, Vécsei V.Open-chest cardiopulmonary resuscitation after cardiac arrest incases of blunt chest or abdominal trauma: a consecutive series of38 cases. J. Trauma 2004; 57: 809–14.

10. Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A.Emergency thoracotomy: ‘how to do it’. [Cited 5 July 2010.] Avail-able from URL: http://emj.bmj.com/content/22/1/22.full.pdf?sid=3617b2db-8db5-4c12-8748-50b98e48f034

M Fitzgerald et al.

336 © 2010 The AuthorsJournal compilation © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine