Emergency ThoracotomyEmergency Thoracotomy in the ED in the ED

Mark CordenMark Corden

Sir Charles Gairdner EmergencySir Charles Gairdner Emergency

66thth March 2014 March 2014

Emergency ThoracotomyEmergency Thoracotomy

Definition:Definition: ““occurring either immediately at the site of

injury, or in the emergency department or operating room as an integral part of the initial resuscitation process”.

• P.A. Hunt, I. Greaves, W.A. Owens – 2005.

Thoracic TraumaThoracic Trauma

One of the leading causes of death in all age groups, accounts for 25-50% of all traumatic injuries.

The majority of patients with thoracic trauma can be managed non-operatively, with or without tube thoracostomy.

IntroductionIntroduction

Roberts and Hedges – 6Roberts and Hedges – 6thth Edition Edition Given the circumstances surrounding the Given the circumstances surrounding the

procedure and the associated injuries, few procedure and the associated injuries, few patients survive. patients survive.

The poor overall survival rates, however, The poor overall survival rates, however, should not discourage performance of the should not discourage performance of the procedure in the correct setting and when procedure in the correct setting and when appropriate surgical backup is available for appropriate surgical backup is available for definitive care.definitive care.

BackgroundBackground

Emergency Thoracotomy (ET) initially Emergency Thoracotomy (ET) initially proposed as treatment for penetrating proposed as treatment for penetrating cardiac injuries in 1966.cardiac injuries in 1966.

Approx. 16% survival in penetrating Approx. 16% survival in penetrating trauma but varying rates per institutions.trauma but varying rates per institutions.

~2% survival of patients with blunt trauma.~2% survival of patients with blunt trauma.

Might it work then?Might it work then?

Factors associated with increased chance of Factors associated with increased chance of success:success: Signs of Life – in ED.Signs of Life – in ED. Penetrating thoracic injury (vs. blunt)Penetrating thoracic injury (vs. blunt) Stab wounds (vs. gunshot or explosive wounds)Stab wounds (vs. gunshot or explosive wounds) Thoracic Injuries (vs. abdominal injuries)*.Thoracic Injuries (vs. abdominal injuries)*. Blunt injury WITH: <5 mins CPR + signs of life.Blunt injury WITH: <5 mins CPR + signs of life. Cardiac Rhythm: VF, VT or PEA vs. Asystole, severe Cardiac Rhythm: VF, VT or PEA vs. Asystole, severe

bradycardia.bradycardia.

Thus. Indications.Thus. Indications. Release of pericardial tamponade: Release of pericardial tamponade:

improves cardiac output and control of cardiac haemorrhage.improves cardiac output and control of cardiac haemorrhage. Control of intrathoracic vascular or cardiac haemorrhage:Control of intrathoracic vascular or cardiac haemorrhage:

Penetrating thoracic trauma withPenetrating thoracic trauma with• signs of life and CPR <15 minssigns of life and CPR <15 mins• Sys BP<70mmHg despite vigorous fluid resuscitation. Sys BP<70mmHg despite vigorous fluid resuscitation.

Blunt thoracic trauma withBlunt thoracic trauma with• signs of life and CPR <5mins.*signs of life and CPR <5mins.*• Post ICC with >1500mls rapid drainage/exsanguination.Post ICC with >1500mls rapid drainage/exsanguination.

Aorta cross clamping in blunt or penetrating abdominal Aorta cross clamping in blunt or penetrating abdominal trauma trauma

Those NOT in cardiac arrest.Those NOT in cardiac arrest. Open cardiac massageOpen cardiac massage

Witnessed, in-hospital arrest where CPR may be ineffective.Witnessed, in-hospital arrest where CPR may be ineffective. Air Embolus **Air Embolus **

Contraindications.Contraindications.

pre-hospital CPR performed for >15 minutes pre-hospital CPR performed for >15 minutes after penetrating chest injury without response after penetrating chest injury without response

pre-hospital CPR performed for >10 minutes pre-hospital CPR performed for >10 minutes after blunt chest injury without response after blunt chest injury without response

asystole is the presenting rhythm, no pericardial asystole is the presenting rhythm, no pericardial tamponadetamponade

Severe head injury Severe head injury Severe multisystem injury Severe multisystem injury Improperly trained team Improperly trained team Insufficient equipmentInsufficient equipment

ProcedureProcedure

LOOK for and treat:LOOK for and treat: Tension PTxTension PTx TamponadeTamponade Neurogenic ShockNeurogenic Shock Cardiogenic ShockCardiogenic Shock

RequirementsRequirements Patient Intubated.Patient Intubated. Paralysed and Sedated.Paralysed and Sedated. NG placed.NG placed.

Arrest or Shock with suspected correctable intrathoracic Arrest or Shock with suspected correctable intrathoracic pathology.pathology.

OROR Specific Diagnosis (tamponade, aortic injury, penetrating Specific Diagnosis (tamponade, aortic injury, penetrating

cardiac injury)cardiac injury)OROR Ongoing thoracic haemorrhaging.Ongoing thoracic haemorrhaging.

Thoracotomy Kit.Thoracotomy Kit.

Where is it?Where is it?

T2T2

Finochietto Retractor

BonneysForcep

Debakey Forceps

Mayo

MetzenbaumNelson

NeedleHolder

PottsClamp(s)

Satinsky Clamp

DebakeyAorticCalmp

TechniqueTechnique

‘‘traditional’ Left Anterolateral Thoracotomytraditional’ Left Anterolateral Thoracotomy VSVS

Clamshell Thoracotomy.Clamshell Thoracotomy.

addit.addit.

It may be difficult to definitively rule out It may be difficult to definitively rule out pericardial tamponade by visual inspection pericardial tamponade by visual inspection alone. If in doubt, use forceps to elevate a alone. If in doubt, use forceps to elevate a portion of pericardium and carefully incise portion of pericardium and carefully incise it to assess for haemopericardium.it to assess for haemopericardium.

Complications.Complications.

Significant and variable exist.Significant and variable exist. Most related to the primary injury.Most related to the primary injury. Left phrenic nerveLeft phrenic nerve and coronary arteries during and coronary arteries during

procedure.procedure. Bleeding.Bleeding. Infection. Infection.

Injury to or transmission of disease to staff. Cuts Injury to or transmission of disease to staff. Cuts from needle, scalpel, scissors or rib edge.from needle, scalpel, scissors or rib edge.

References:References:

http://lifeinthefastlane.com/ruling-the-http://lifeinthefastlane.com/ruling-the-resus-room-005-2/resus-room-005-2/

http://lifeinthefastlane.com/ed-http://lifeinthefastlane.com/ed-thoracotomy-is-it-just-the-first-part-of-the-thoracotomy-is-it-just-the-first-part-of-the-autopsy/autopsy/

Roberts and Hedges’ Clinical Roberts and Hedges’ Clinical Procedures in Emergency MedicineProcedures in Emergency Medicine, , Sixth Ed.Sixth Ed.

www.trauma.orgwww.trauma.org