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Emergency Department Thoracotomy in the management of Chest Trauma

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

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  1. Emergency Department Thoracotomy in the management of Chest Trauma Sudhir Sundaresan, MD FRCS(C) Division of Thoracic Surgery May 28, 2009

  2. 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)

  3. 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

  4. ED Thoracotomy: When? Post-injury Cardiac arrest Penetrating: witnessed; < 15mins CPR Blunt: witnessed; < 5 mins CPR Persistent shock (SBP<60) Hemorrhage Tamponade Air embolism

  5. 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)

  6. ED Thoracotomy: Survival correlates with Injury pattern and status of patient

  7. ED Thoracotomy: Technical aspects • Supine, Left arm out of the way • Incision: left submammary; clamshell • Pericardiotomy

  8. ED Thoracotomy: Technical aspects Pericardiotomy: Hemorrhage control Cardiac repair Foley technique

  9. ED Thoracotomy: Technical aspects Open massage and resuscitation: 2-hand technique Intracardiac epinephrine Internal defibrillation

  10. ED Thoracotomy: Technical aspects Occlude thoracic aorta: Retract lung superiorly, suction Dissect out aorta just above diaphragm

  11. 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

  12. Chest Trauma: Pericardial Tamponade Intrapericardial Pressure (mm Hg)

  13. 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

  14. 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

  15. Chest Trauma NECK HYPOVOLEMIC SHOCK

  16. 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%

  17. Reference Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes World J Emerg Surg. 2006; 1: 4.

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