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Ed Thoracotomy

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ED Thoracotomy: To Do or Not to Do?

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Case Presentation  Initial Trauma Management  Continued Trauma Management  ED Thoracotomy - Indications  ED Thoracotomy - Therapies  ED Thoracotomy – Technique  When is it Time to Quit?  Summary and Conclusion

Case Presentation - KA
History of Present Illness: EMS arrived at 8:07am to find 30 yo male supine on street. Pt found pulseless and apneic. No witnesses identified. Neighbors state they heard multiple shots fired and saw pt lying on ground without movement immediately prior to their arrival.

Past Medical History: Unknown

What do you want to do???

Initial Management Don’t Forget ABC’s First!
A = Airway


Pt was orally intubated in the field with size 8 ETT

B = Breathing


Pt was bagged via BVM and bilateral BS confirmed

C = Circulation


Pt was pulseless with NO BP! ECG monitor revealed a narrow complex rhythm at 100. A 14 gauge IV was placed in left AC.

Arrival to Hospital - TAA


Pt arrived in TAA at 8:22am, intubated and bagged, without pulses, with CPR in progress.

What do you want to do???




Reassess ABC’s first and LOOK at the patient!!! Physical Examination reveals a 1-2 cm circular entrance wound midline just below nipple line with profuse bleeding.

What do you want to do???

Management Continued
Exclude Correctible Causes of PEA
   

Severe Hypovolemia Cardiac Tamponade Tension Pneumothorax Rupture of the Ventricular Wall

What do you want to do???

Emergent Thoracotomy - Indications


A qualified surgeon must be present at the time of the patient’s arrival to determine the need and potential for success of an Emergency Department resuscitative thoracotomy. Patients with PENETRATING thoracic injuries who arrive pulseless, but with myocardial electrical activity, may be candidates for immediate resuscitative thoracotomy. Patients sustaining BLUNT injuries who arrive pulseless but with myocardial electrical activity are NOT candidates for resuscitative thoracotomy.





Emergent Thoracotomy - Therapies
   

Evacuation of pericardial blood causing tamponade Direct control of exsanguinating intrathoracic hemorrhage Open cardiac massage – closed heart massage for cardiac arrest or PEA is ineffective in a hypovolemic patient. Cross-clamping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart.

Emergent Thoracotomy - Technique



Minimal skin preparation with Betadine. A left anterolateral incision made from sternal border to the mid-axillary line in the fourth or fifth intercostal space.

Emergent Thoracotomy - Technique


Using a blade, the physician, with a double-gloved hand, carries the incision through the skin, subcutaneous tissue, and chest wall muscles.

Emergent Thoracotomy - Technique




A chest retractor is inserted and opened widely with the bar placed superior to the line of incision. If there is exsanguination from a great vessel injury, this is controlled by pressure.

Emergent Thoracotomy - Technique




The pericardium is opened anterior and parallel to the phrenic nerve. Hemopericardium is evacuated if present.

Emergent Thoracotomy - Technique


Small cardiac lacerations may be occluded using a finger while maintaining cardiac output with internal cardiac massage, using the other hand. Small cardiac lacerations may be occluded using a Foley catheter inserted through the laceration and inflating the balloon with normal saline.



Emergent Thoracotomy - Technique


The descending thoracic aorta can be occluded to improve diastolic coronary perfusion pressures or to slow intra-abdominal bleeding by: 1) Digital pressure 2) Pressing the aorta against the spine 3) Using an aortic or vascular clamp

When is it Time to Quit?
Discontinuing the Resuscitative Effort
 



There is discovery of irreparable injuries such as massive heart injury. There are NO signs of life (no pupillary reaction, no spontaneous heart beat, etc.) or sustained cardiac rhythm compatible with life after 15 minutes of vigorous resuscitation. There is inability to sustain a systolic pressure above 60 mm Hg after 30 minutes of vigorous resuscitation.

Summary and Conclusion
   



ED Thoracotomy is a skill that can be acquired but requires repeated practice and experience. Anatomic location, mode of injury, and condition of the patient are used to determine appropriateness of ED Thoracotomy. Ensure that you have adequate surgical backup before attempting this procedure! Know when to discontinue resuscitative efforts! Always maintain extreme personal caution when performing this procedure in the midst of heavy bleeding and sharp objects including broken ribs!

Don’t Forget ABC’s First!

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