ED Thoracotomy

2012 WTA Guidelines

(J Trauma 73(6), December 2012, p 1359–1363)

 

Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

Article

In April 2001, the ACS-COT Subcommittee on Outcomes gave their final recommendations regarding EDT.24,26(See Table 2.) As expected there was insufficient evidence to support a Level I recommendation for this practice guideline. Their Level II recommendations are as follows:

The above Level II recommendations also are applicable to the pediatric trauma population.

What is the true survival rate of this procedure? Of studies reporting EDT, 7035 procedures were performed with a survival rate of 7.83%. These procedures were stratified by the mechanism of injury. The survival rate for EDT based on penetrating trauma was 11.16%. The survival rate for EDT based on blunt trauma was 1.6%. The survival rate for EDT based on penetrating cardiac injury was 31.1%22,25,26,29Four series included pediatric trauma patients. The overall survival rate for 142 patients who required an EDT was 6.3%. When stratified by the mechanism of injury, the survival rate for penetrating trauma was 12.2% vs. 2.3% for blunt trauma. There was no reliable data reporting penetrating cardiac injuries in the pediatric population.How may survivors succumb to severe neurologic impairment? Of the series reporting neurologic outcomes, 4520 patients were subjected to EDT. There was a 5% overall survival rate. Of these survivors, 15% survived with severe neurologic impairment.What are the valuable physiologic predictors of favorable outcomes? Physiologic predictors of outcomes for EDT have been identified. In 1983, Cogbill and associates determined four statistically significant indicators that portend a dismal outcome. They are: 1) no signs of life at the scene; 2) no signs of life in the ED; 3) no cardiac activity at the time of EDT; and 4) persistent hypotension (SBP < 70 mmHg) despite aortic occlusion. Five years later, Branney and his group determined that the absence of vital signs in the face of blunt trauma also led to a poor outcome.22,25,26,29

Accepted IndicationsPenetrating thoracic injury- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)- Unresponsive hypotension (BP < 70mmHg) Blunt thoracic injury- Unresponsive hypotension (BP < 70mmHg)- Rapid exsanguination from chest tube (>1500ml)Relative IndicationsPenetrating thoracic injury- Traumatic arrest without previously witnessed cardiac activityPenetrating non-thoracic injury- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)Blunt thoracic injuries- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)ContraindicationsBlunt injuries- Blunt thoracic injuries with no witnessed cardiac activity- Multiple blunt trauma- Severe head injury

 

Azygos vein on R

Can cut ligaments on bottom of hilium and then clamp it.

 

Ladd AP, Gomez GA, Jacobsen LE, et al., Emergency room thoracotomy: updated guidelines for a level I trauma center. Am Surgeon2002;68:421–4.

This group from the Indiana University School of Medicine developed and published a protocol for Emergency Room Thoracotomy (ERT) in 1995, after reviewing their own experience with 160 patients undergoing ERT. The present study was undertaken to evaluate this protocol, reviewing the records of all patients undergoing ERT over the next 5 years. Of the 79 patients, 65 had suffered gunshot wounds and 14 stab wounds. The authors’ protocol divided patients into 4 physiologic classes. Class I patients had no signs of life: full arrest, absent reflexes, and no ECG activity. Class II were agonal: and electrical activity on ECG but no pulse. Class III were in profound shock, with BP < 60 torr, and Class IV were in mild shock, BP > 60 but < 90 torr. The authors found that there were no survivors among patients who were Class I or II at the scene, or Class I on ED arrival, and they therefore recommend that ERT not be performed henceforth for these groups.

 

I put into the right atrium whatever catheter is available and has a connector to be allowed to have a connection to venous fluids being administered

Then I place a right angled clamp, curved Glover vascular clamp, Satinsky clamp, or whatever I have across the atral appendage even occluding the catheter for a secord or two.   I then ask for a large silk suture – 0 or 00 will do and I just tie it secure around the atrium, but not occluding the catheter.   Works every time.   Hemostatic.   I use this same technique when I need to crash onto the pump in the OR with the atrial catheter connected to the pump.    I can place a purse string later if necessary.    If there are lots of people around, I will tie the knot on the silk suture, and then NOT cut the suture, but wrap it Roman sandle style around the catheter, so as to secure it so that none of the many people in the room or during transport can inadvertently pull it out.    I then leave the silk ends long and un cut in case I need to use the loos ends for something else , but it someone cuts then at the second knot on the catheter, then I dont say anything, and just get moving with the resuscitation or move to the OR.  (Mattox)

 

3-0 prolene with large curved MH needle to repair cardiac injuries. consider teflon pledgets

can use 6 mm staples place 5 mm apart

can staple around foley 3 staples on either side then deflate

never put finger in, only on

put 14 F foley in 3 cm and fill balloon with saline, pull back 1 cm if no output

vent all air out before clamping

pull on it only enough to slow bleeding to an ooze

 

Four Uses of ED Thoracotomy

1 Relief of Tamponade

2 Hemorrhage from Intrathoracic Source

3 Cross Clamping of Pulmoanry Hilum after suspected air embolism

4 Cross Clamping of Aorta as last ditch adjunct to CPR

 

Asystole is contraindication, but what of PEA (J AM Coll Surg 2004;199:211)

Blunt trauma=5 minutes of CPR, bilat chest tubes. If no signs of life call code; if signs then open chest

 

Factors suggesting discontinuation of resuscitation during thoracotomy

Systolic blood pressure remains <70 mmHg after 15 min despite fluid volume resuscitation Self-sustaining rhythm is not achieved within 15 min of start of thoracotomy Need for aortic cross-clamping in an attempt to restore myocardial and cerebral perfusion Absence of a pericardial effusion without cardiac activity on opening of the chest Emergence of signs of secondary devastating injuries with an independently poor outcome

:

 

D. Lockey, K. Crewdsen and G.E. Davies, Traumatic cardiac arrest: who are the survivors?, Ann Emerg Med 48 (3) (2006), pp. 240–244.

 

Recent article on thoracotomy for abd exsanguin, 16% of the group survived neuro intact (J Trauma 2008;64:1)

 

Rhee PM, Acosta J, Cridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg 2000;190:288-98.

 

Following anterolateral thoracotomy, opening and evacuation of the pericardial cavity,2,3the wound is controlled by digital compression or with the use of clamps if the laceration is atrial. The laceration may then be closed with a standard skin stapler using wide (6 mm) staples. The staples are placed at a 3–5 mm intervals with additional ones placed only if required to achieve haemostasis. Following stapling, the laceration may be safely oversewn using a 4/1 polypropylene suture in the operating theatre.

 

May be worth doing to increase organs for donation as well (J Am Coll Surg 2010;211:450)

Western Trauma published multi-center trial (J Trauma 2011;70(2):334)

States blunt trauma may not be an exclusion and even field cpr of 9 min for blunt and 15 min for penetrating. Asystole on arrival had neuro intact survivors.

• EDTs should be performed rarely in patients sustaining cardiopulmonary arrest secondary to blunt trauma due to the unacceptably low survival rate and poor neurologic outcomes;22
• EDT should be limited to those that arrive with vital signs at the trauma center and experience a witnessed cardiopulmonary arrest;16
• EDT is best applied to patients sustaining penetrating cardiac injuries who arrive at trauma centers after a short scene and transport time with witnessed signs of life;12,13
• EDT should be performed in patients sustaining penetrating non-cardiac thoracic injuries.12,13,15,16,22,23 They did acknowledge the difficulty in ascertaining whether the thoracic injury was cardiac or non-cardiac and promoted the use of EDT to establish the diagnosis; and
• EDT should be performed in patients sustaining exsanguinating abdominal vascular injuries although these patients experience a low survival rate.

When is ED Thoractomy Futile?

Resuscitative thoracotomy in the ED is a resource-intense procedure

that is quite stressful and demands accurate evidence-based guidelines

for its cost effective application; there has been an ongoing search to

define when this heroic resuscitative effort is futile.

The Western Trauma Association recently published a multi-center

study to identify injury patterns and physiologic profiles at ED arrival

that are compatible with survival. During the 6 year study period, 56

patients survived to hospital discharge. Specifically, the purpose of

the study was to define the limits of resuscitative ED thoracotomy to

enable the development of rational guidelines to withhold or terminate

resuscitative efforts.

Contrary to some recommendations, the study found that with the

exception of an overtly devastating head injury, blunt trauma does not

preclude meaningful survival after ED thoracotomy. In addition, the

study documented survival of 7 patients with asystole found at the time

of thoracotomy.

The study concluded that resuscitative thoracotomy in the ED can be

considered futile care when (a) prehospital CPR exceeds 10 minutes after

blunt trauma without a response, (b) prehospital CPR exceeds 15

minutes after penetrating trauma without a response, and (c) asystole

is the presenting rhythm and there is no pericardial tamponade.

Clinical Pearl Suggested by Dr. Michael Winters, Univ of Maryland, Dept. of EM

Reference: Moore EE, et al. Defining the

limits of resuscitative emergency department thoracotomy: a

contemporary Western Trauma Association perspective J Trauma 2011;70:334-9.

NAEMSP/ACS-COT Guidelines for Withholding or Termination of Resuscitation in Prehospital Traumatic

Cardiopulmonary Arrest

1. Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel’s thorough primarypatient assessment, is found apneic, pulseless, and without organized ECG activity upon the arrival of EMS at the scene.
2. Victims of penetrating trauma found apneic and pulseless by EMS, based on their patient assessment, should be rapidly assessed forthe presence of other signs of life, such as pupillary reflexes, spontaneous movement, or organized ECG activity. If any of

   these signs are present, the patient should have resuscitation performed and be transported to the nearest emergency

   department or trauma center. If these signs of life are absent, resuscitation efforts may be withheld.

3. Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with injuries obviously incompatible with life, suchas decapitation or hemicorporectomy.
4. Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with evidence of a significance time lapse sincepulselessness, including dependent lividity, rigor mortis, and decomposition.
5. Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with clinical condition, suggesting anontraumatic cause of the arrest, should have standard resuscitation initiated.
6. Termination of resuscitation efforts should be considered in trauma patients with EMS-witnessed cardiopulmonary arrest and 15 minof unsuccessful resuscitation and CPR.
7. Traumatic cardiopulmonary arrest patients with a transport time to an emergency department or trauma center of more than 15 minafter the arrest is identified may be considered nonsalvageable, and termination of resuscitation should be considered.
8. Guidelines and protocols for TCPA patients who should be transported must be individualized for each EMS system. Consideration should be given to factors such as the average transport time within the system, the scope of practice of the various EMS providers within the system, and the definitive care capabilities (i.e., trauma centers) within the system. Airway management and IV line placement should be accomplished during transport when possible.
9. Special consideration must be given to victims of drowning and lightning strike and in situations where significant hypothermiamay alter the prognosis.
10. EMS providers should be thoroughly familiar with the guidelines and protocols affecting the decision to withhold or terminateresuscitative efforts.
11. All termination protocols should be developed and implemented under the guidance of the system EMS medical director. On-line medical control may be necessary to determine the appropriateness of termination of resuscitation.
12. Policies and protocols for termination of resuscitation efforts must include notification of the appropriate law enforcement agenciesand notification of the medical examiner or coroner for final disposition of the body.
13. Families of the deceased should have access to resources, including clergy, social workers, and other counseling personnel, asneeded. EMS providers should have access to resources for debriefing and counseling as needed.
14. Adherence to policies and protocols governing termination of resuscitation should be monitored through a quality reviewsystem.

validated in this study ((J Trauma. 2011;71: 997–1002)

 

Internal Defibrillation

20 J for the first shock, 40 J subsequent

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Partial Pericardotomy

this report (Ann Emerg Med 2012;59(4):265) advocates leaving pericardium intact and just suctioning blood until surg involves. of course, the 3 L blood loss that ensued could be avoided by just opening the hole

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Non-Chest Injuries

Patients with Abdominal or Extremity Injuries may benefit as well (J Trauma. 2004;57:809 –814.) and (Surgery 2006;139:574)

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On-Scene Throacotomy

A technique involving an L-shaped incision and cutting through cartilage

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