急診緊急開胸術 How / When / Why ?

1. 急診緊急開胸術How / When / Why ? 陳昭文 醫師 高雄醫學大學附設醫院外傷科

2. 急診緊急開胸術 • Emergent room thoracotomy (ERT) • Emergency department thoracotomy (EDT) • ER Resuscitative thoracotmy (ERRT) • Open-chest cardiac message Trauma Service / KMUH

3. 急診緊急開胸術 • The term “emergency room resuscitative thoracotomy” (ERRT) should be restricted to a thoracotomy that is performed on a patient in extremis (impending death) outside the operating room… Trauma Service / KMUH

4. Patient in extremisOpen Abdomen + Open Chest Trauma Service / KMUH

5. 急診緊急開胸術Why? Trauma Service / KMUH

6. Time! • 外傷病患愈早得到終極而適切之照護其生存機會愈高 • 出血控制 • 復甦治療 Trauma Service / KMUH

7. Trauma Service / KMUH

8. 急診緊急開胸術When? Trauma Service / KMUH

9. Clear indication for EDTTrauma 5th ed (2004) • Salvageable postinjury cardiac arrest • Sustain witnessed cardiac arrest with high likelihood of isolated intrathoracic injury, particularly penetrating cardiac wounds • Persistent severe post-injury hypotension (Sys Bp < 60mmHg) • Cardiac tamponade • Intrathoracic hemorrhage • Air embolism • Active intra-abdominal hemorrhage Trauma Service / KMUH

10. Relative indication for EDTTrauma 5th ed (2004) • Refractory moderate post-injury hypotension (Sys Bp < 60mmHg) due to • Cardiac tamponade • Intrathoracic hemorrhage • Air embolism • Active intra-abdominal hemorrhage Trauma Service / KMUH

11. EDT IndicationUSC guidelines 2004 • Liberal Use Criteria • Some lives may be saved • Some patients may become organ donors • Excellent resident staff education • Strict use • Cost • Infective diseases Actual cause of death - Autopsy? Trauma Service / KMUH

12. EDT contraindicationUSC guidelines 2004 • Blunt multiple trauma • Head trauma • No vital signs > 20 mins Trauma Service / KMUH

13. EDT indicationRosen’s Textbook of Emergency Medicine • Penetrating Trauma • Cardiac arrest at any point with initial signs of life in the field • Blood pressure < 50 mm Hg systolic after fluid resuscitation • Severe shock with clinical signs of cardiac tamponade • Blunt Trauma • Cardiac arrest in the ED • Miscellaneous • Suspected air embolus Trauma Service / KMUH

14. 急診緊急開胸術How? Trauma Service / KMUH

15. EDT technical aspects • ED thoracotomy tray - Keep it simple! Trauma Service / KMUH

16. EDT technical aspects • Get everything ready! • Prepare instruments • Sutures (Prolene 2-0) • Assign duties Trauma Service / KMUH

17. EDT technical aspects • Incision • Left antero-lateral thoracotomy • 4th or 5th intercostal space • Below nipple in males • Infra-mammary crease in females • Left sternal border to anterior axillary line • Clam-Shell incision • Trap-door incision Trauma Service / KMUH

18. Incisions Trauma Service / KMUH

19. Incisions Trauma Service / KMUH

20. Trauma Service / KMUH

21. EDT technical aspects • Incision – Common mistakes • Too low! • Injury to diaphragm • Do not follow intercostal space • Hard to open chest • Messy! • Injury to lung • Miss injury to IMA Trauma Service / KMUH

22. EDT technical aspects • Procedures • Enter chest • Evacuate blood • Control any extracardial bleeding • Open pericardium • Cardiac message • Thoracic aortic cross-clamping Trauma Service / KMUH

23. EDT technical aspects • Cardiac injury • “Finger of 8” or “Continuous suture” • Staples!? • Avoid coronary vessels • Foley’s catheter in appropriate cases Trauma Service / KMUH

24. EDT technical aspects • Cardiac injury • Common mistakes • Pledgets! • Cut the phrenic nerve • Foley’s catheter in atrial wounds • Failure to examine posterior aspect • Not prepared! ”Give me a 2-0 suture!” Trauma Service / KMUH

25. EDT technical aspects • Aortic cross-clamping • Redistribute limited volume of blood to heart and brain • Decrease subdiaphragmatic bleeding • 2-3 cm above diaphragm • Sharp dissection Trauma Service / KMUH

26. EDT technical aspects • Aortic cross-clamping • Common mistakes • Clamp the esophagus! • Injury to the esophagus • Tear intercostal vessels • Try to clamp a “collapsed” aorta without dissection Trauma Service / KMUH

27. EDT technical aspects • Cardiac resuscitation • Fluid resuscitation (Level 1 infuser!?) • Cardiac message • Epinephrine, defibrillation • Cardiac aspiration for air embolism • Rewarm heart • Remove aortic clamp ASAP • Cardiac pacer? Trauma Service / KMUH

28. EDT technical aspects • Air embolism • Source • Lung injuries • Low-pressure heart chambers • Major venous injuries • Often air in coronary vein • Aspirate ventricles Trauma Service / KMUH

29. EDT technical aspects • Cardiac resuscitation – common mistakes • Defibrillate an empty heart • Forget the air embolism • Massive fluid administration in cardiac tamponade without major blood loss Trauma Service / KMUH

30. Outcome • Survival rate varies • Threshold - Indications of EDT • Mechanism • Anatomical site of injury • Vital signs – Field ,Transport, ER Trauma Service / KMUH

31. Outcome 2% 16% Hopson et al. 2003 Trauma Service / KMUH

32. Outcome Trauma Service / KMUH

33. Some facts we have to know… • The greatest mistake in ED Thoractomy is not doing it early enough! …be brave! • Thoracotomy in the ED should only be performed by an appropriately trained surgeon… Poor experience we have! • A trauma patient who loses vital signs in the ED may be saved by immediate thoracotomy, especially those with penetrating injury… be aware of it! Trauma Service / KMUH

34. 10 思考外傷救護目標 • Control bleeding! • Grasp every opportunity! • Time is of essence! Trauma Service / KMUH

35. THANK YOU! Trauma Service / KMUH