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Emergency Department Thoracotomy in the management of Chest Trauma. Sudhir Sundaresan, MD FRCS(C) Division of Thoracic Surgery May 28, 2009. ED Thoracotomy: Historical. Late 1800’s – cardiac wounds, anesthesia-induced arrest 1874 – Schiff – open cardiac massage
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Emergency Department Thoracotomy in the management of Chest Trauma Sudhir Sundaresan, MD FRCS(C) Division of Thoracic Surgery May 28, 2009
ED Thoracotomy: Historical Late 1800’s – cardiac wounds, anesthesia-induced arrest 1874 – Schiff – open cardiac massage Until 1960 – “medical” arrests 1960 – CPR 1965 – external defibrillation Late 1960’s – resurgence in trauma Currently – selective approach (Injury, physiologic status)
Definitions No V/S = No blood pressure - vs - No “signs of life” (SOL) No BP No resp effort No motor effort No cardiac electrical activity Fixed / non-reactive pupils
ED Thoracotomy: When? Post-injury Cardiac arrest Penetrating: witnessed; < 15mins CPR Blunt: witnessed; < 5 mins CPR Persistent shock (SBP<60) Hemorrhage Tamponade Air embolism
ED Thoracotomy: When NOT? Post-injury Cardiac arrest Penetrating: > 15mins CPR and NO SOL Blunt: > 5 mins CPR and NO SOL Prior chest surgery (sternotomy, thoracotomy)
ED Thoracotomy: Survival correlates with Injury pattern and status of patient
ED Thoracotomy: Technical aspects • Supine, Left arm out of the way • Incision: left submammary; clamshell • Pericardiotomy
ED Thoracotomy: Technical aspects Pericardiotomy: Hemorrhage control Cardiac repair Foley technique
ED Thoracotomy: Technical aspects Open massage and resuscitation: 2-hand technique Intracardiac epinephrine Internal defibrillation
ED Thoracotomy: Technical aspects Occlude thoracic aorta: Retract lung superiorly, suction Dissect out aorta just above diaphragm
ED Thoracotomy: Purpose Release tamponade Control exsanguinating intrathoracic hemorrhage Open cardiac massage Closed chest CPR: 25% CO, 20% cerebral perfusion – OK for 15 mins at normothermia Clamp aorta Deal with broncho-venous air embolism
Chest Trauma: Pericardial Tamponade Intrapericardial Pressure (mm Hg)
ED Thoracotomy: Aortic clamping Redistribute blood flow (brain,heart) Address intra-abdominal hemorrhage Extremity injuries Downside (limit to < 30 mins) Paraplegia Anaerobic gut metabolism massive ischemia/reperfusion injury
ED Thoracotomy: Air embolism Pulmonary broncho-venous air emolism Penetrating > blunt injuries Scenario: hypotension/arrest after intubation/PPV Management: ED thoracotomy Hilar clamping Pericardiotomy, de-air the heart
Chest Trauma NECK HYPOVOLEMIC SHOCK
ED Thoracotomy: Downside Injury to intrathoracic structures Consequences of anaerobic metabolism Massive ischemia-reperfusion injury Post-pericardiotomy syndrome Exposure of HCW’s to blood-borne pathogens HIV – 4% Hepatitis C – 14%
Reference Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes World J Emerg Surg. 2006; 1: 4.