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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.<\/p>\n
Article <\/a><\/p>\n In April 2001, the ACS-COT Subcommittee on Outcomes gave their final recommendations regarding EDT.24,26(See Table 2.) <\/em>As expected there was insufficient evidence to support a Level I recommendation for this practice guideline.\u00a0Their Level II recommendations are as follows:<\/p>\n The above Level II recommendations also are applicable to the pediatric trauma population.<\/p>\n 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<\/p>\n 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 <\/p>\n Azygos vein on R<\/p>\n Can cut ligaments on bottom of hilium and then clamp it.<\/p>\n <\/p>\n Ladd AP, Gomez GA, Jacobsen LE, et al., Emergency room thoracotomy: updated guidelines for a level I trauma center. Am Surgeon<\/em>2002;68:421\u00964.<\/p>\n 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\u0092 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.<\/p>\n <\/p>\n 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<\/p>\n 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.\u00a0\u00a0 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.\u00a0\u00a0 Works every time.\u00a0\u00a0 Hemostatic.\u00a0\u00a0 I use this same technique when I need to crash onto the pump in the OR with the atrial catheter connected to the pump.\u00a0\u00a0\u00a0 I can place a purse string later if necessary.\u00a0\u00a0\u00a0 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.\u00a0\u00a0\u00a0 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.\u00a0 (Mattox)<\/p>\n <\/p>\n 3-0 prolene with large curved MH needle to repair cardiac injuries. consider teflon pledgets<\/p>\n can use 6 mm staples place 5 mm apart<\/p>\n can staple around foley 3 staples on either side then deflate<\/p>\n never put finger in, only on<\/p>\n put 14 F foley in 3 cm and fill balloon with saline, pull back 1 cm if no output<\/p>\n vent all air out before clamping<\/p>\n pull on it only enough to slow bleeding to an ooze<\/p>\n <\/p>\n Four Uses of ED Thoracotomy<\/p>\n 1 Relief of Tamponade<\/p>\n 2 Hemorrhage from Intrathoracic Source<\/p>\n 3 Cross Clamping of Pulmoanry Hilum after suspected air embolism<\/p>\n 4 Cross Clamping of Aorta as last ditch adjunct to CPR<\/p>\n <\/p>\n Asystole is contraindication, but what of PEA (J AM Coll Surg 2004;199:211)<\/p>\n Blunt trauma=5 minutes of CPR, bilat chest tubes. If no signs of life call code; if signs then open chest<\/p>\n <\/p>\n Factors suggesting discontinuation of resuscitation during thoracotomy<\/p>\n Systolic blood pressure remains <70 mmHg after 15\u00a0min despite fluid volume resuscitation Self-sustaining rhythm is not achieved within 15\u00a0min 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<\/p><\/blockquote>\n :<\/p>\n <\/p>\n D. Lockey, K. Crewdsen and G.E. Davies, Traumatic cardiac arrest: who are the survivors?, Ann Emerg Med<\/em> 48<\/strong> (3) (2006), pp. 240\u0096244.<\/p>\n <\/p>\n Recent article on thoracotomy for abd exsanguin, 16% of the group survived neuro intact (J Trauma 2008;64:1)<\/p>\n <\/p>\n 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.<\/p>\n <\/p>\n Following anterolateral thoracotomy, opening and evacuation of the pericardial cavity,2<\/a>,3<\/a>the 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\u00965 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.<\/p>\n <\/p>\n May be worth doing to increase organs for donation as well (J Am Coll Surg 2010;211:450)<\/p>\n Western Trauma published multi-center trial (J Trauma 2011;70(2):334)<\/p>\n 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.<\/p>\n When is ED Thoractomy Futile?<\/strong><\/p>\n Resuscitative thoracotomy in the ED is a resource-intense procedure<\/p>\n that is quite stressful and demands accurate evidence-based guidelines<\/p>\n for its cost effective application; there has been an ongoing search to<\/p>\n define when this heroic resuscitative effort is futile.<\/p>\n The Western Trauma Association recently published a multi-center<\/p>\n study to identify injury patterns and physiologic profiles at ED arrival<\/p>\n that are compatible with survival. During the 6 year study period, 56<\/p>\n patients survived to hospital discharge. Specifically, the purpose of<\/p>\n the study was to define the limits of resuscitative ED thoracotomy to<\/p>\n enable the development of rational guidelines to withhold or terminate<\/p>\n resuscitative efforts.<\/p>\n Contrary to some recommendations, the study found that with the<\/p>\n exception of an overtly devastating head injury, blunt trauma does not<\/p>\n preclude meaningful survival after ED thoracotomy. In addition, the<\/p>\n study documented survival of 7 patients with asystole found at the time<\/p>\n of thoracotomy.<\/p>\n The study concluded that resuscitative thoracotomy in the ED can be<\/p>\n considered futile care when (a) prehospital CPR exceeds 10 minutes after<\/p>\n blunt trauma without a response, (b) prehospital CPR exceeds 15<\/p>\n minutes after penetrating trauma without a response, and (c) asystole<\/p>\n is the presenting rhythm and there is no pericardial tamponade.<\/p>\n Clinical Pearl Suggested by Dr. Michael Winters, Univ of Maryland, Dept. of EM<\/em><\/p>\n Reference: <\/em>Moore EE, et al. Defining the<\/p>\n limits of resuscitative emergency department thoracotomy: a<\/p>\n contemporary Western Trauma Association perspective J Trauma <\/em>2011;70:334-9.<\/p>\n Cardiopulmonary Arrest<\/p>\n these signs are present, the patient should have resuscitation performed and be transported to the nearest emergency<\/p>\n department or trauma center. If these signs of life are absent, resuscitation efforts may be withheld.<\/li>\n validated in this study ((J Trauma. 2011;71: 997\u20131002)<\/p>\n 20 J for the first shock, 40 J subsequent<\/p>\n 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<\/p>\n Patients with Abdominal or Extremity Injuries may benefit as well (J Trauma. 2004;57:809 \u2013814.) and (Surgery 2006;139:574)<\/p>\n<\/a><\/a><\/a><\/a><\/a><\/a><\/a><\/a><\/a><\/a><\/p>\n<\/p>\n\n
<\/span>NAEMSP\/ACS-COT Guidelines for Withholding or Termination of Resuscitation in Prehospital Traumatic<\/span><\/h3>\n
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<\/span>Internal Defibrillation<\/span><\/h2>\n
<\/span>Partial Pericardotomy<\/span><\/h2>\n
<\/span>Non-Chest Injuries<\/span><\/h2>\n
<\/span>On-Scene Throacotomy<\/span><\/h2>\n