Emergency Thoracotomy

Emergency Thoracotomy

1. ED Thoracotomy Indications & Procedure Jeremy Mason 6 th November 2015

2. 25% – 50% all traumatic injuries involve thorax Thoracotomy is an integral part of resuscitation in selected patients Need to decide quickly if thoracotomy is indicated to increase chance of survival Patients may deteriorate prehospital or in the ED and this may be the only option to restore life Thoracic trauma

3. Release cardiac tamponade Control haemorrhage Perform open cardiac massage Cross clamp the descending thoracic aorta Control air embolism Aims of thoracotomy

4. Penetrating thoracic injury Haemodynamic instability (SPB <70mmHg despite vigorous fluid resuscitation) Traumatic arrest with previously witnessed cardiac activity ( prehospital or ED) Indications;

5. Blunt thoracic injury Cardiac tamponade diagnosed rapidly on USS with no obvious non survivable injury Unresponsive hypotension (SPB < 70mmHg ) >1500ml from chest tube immediately returned Indications;

6. Penetrating chest injury – traumatic arrest without witnessed cardiac activity Penetrating non thoracic injury (abdominal or peripheral) with previously witnessed cardiac activity Blunt thoracic injuries with traumatic arrest with previously witnessed cardiac activity Relative indications

7. Penetrating injuries Patient has no signs of life at injury scene Asystole with no pericardial tamponade Prolonged pulselessness (>15 mins ) Other massive nonsurvivable injuries have occurred Poor outcome measures;

8. Blunt injury Patient requires >10 minutes prehospital CPR Patient has no signs of life at scene of injury Patient has other massive non survivable injuries Poor outcome measures

9. Non traumatic cardiac arrest Severe head or multisystem injury Improperly trained team Insufficient equipment Contraindications

10. Eastern Association for the Surgery of Trauma USA - Journal of Acute Care Surgery – 2015 Reviewed 72 studies – 10,238 ED Thoracotomies Patients presenting pulseless to the ED – ED Thoracotomy vs Resus without EDT Measured signs of life as Pupillary response Spontaneous ventilation Palpable carotid pulse Measurable BP Moving extremities Cardiac electrical activity Guidelines

11. Best outcome in patients presenting pulseless with penetrating thoracic injury With signs of life – strongly recommend EDT 21.3% survival (8x higher) 11.7% neurologically intact survival (5x higher) Without signs of life – conditionally recommend EDT 8.3% survival (41 x higher) 3.9% neurologically intact survival (20 x higher) Guidelines

12. Penetrating extrathoracic injury Signs of life – Conditionally recommend EDT Survival 15.6% (9x higher) Neurologically intact survival 16.5% (11 x higher) No signs of life – Conditionally recommend EDT Survival 2.9% (29 x higher) Neurologically intact survival 5% (56 x higher) Guidelines

13. Pulseless Blunt Injury With signs of life – Conditionally recommend EDT Survival 4.6% (9x higher) Neurologically intact survival 2.4% (8x higher) Without signs of life – Recommend against EDT Survival 0.7% Neurologically intact survival 0.1% Guidelines

14. Anatomy www.instantanatomy.net Moore Anatomy

15. https://calsprogram.org/manual/volume2/Section7_Circulation%20Skills/05-CirSk4EmergThoracotomy13.html

16. Located in T2 Ribspreaders in tray Scalpel + Blade – need to get from FT cupboard Tuffcut scissors mounted on wall of T2 SCGH ED Thoracotomy Kit

17. Scalpel + Blade Retractor – Finochietto’s rib spreader or Balfour abdominal retractor Gigli Saw / Tuffcut Scissors Curved Mayos Scissors Toothed forceps DeBakey Aortic Clamp Mosquito artery forceps Foley catheter Satinsky large vascular clamps Needle holders Internal defibrillator clamps Sutures, sternal wires Thoracotomy Kit

18. All you really need

19. Trauma Call Universal precautions Intubate and ventilate patient Intubate right main bronchus to collapse left lung Fluid resucitation + Blood Products / Massive Transfusion Protocol 15 degree headup Surgically prep the area Antibiotic prophylaxis Preparation

20. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study Simms ER, Flaris AN, Franchino X, et al.. World J Surg 2013; 37:1277. Looked at 6 different thoracotomy incisions on cadavers Left and Right Anterolateral , Left 2 nd intercostal incision, Left 3 rd Intercostal incision, median sternotomy & Clamshell Clamshell fastest for access and best for control of thoracic structures in Emergency Thoracotomy Research

21. Procedure “Clamshell Incision” A – 5 th intercostal space thoracostomy bilaterally midaxillary line B – Incise skin and subcut fat C & D – Extend to sternum E – Cut sternum F – Finochietto retractor (Bar on right) Simms et al 2013

22. https://www.youtube.com/watch?v=8BlPxQI2C90

23. Penetrating cardiac injury Direct digital pressure Staple cardiac defect closed Suture closure of injury Pass Foley catheter through defect, inflate balloon, apply traction Abdominal Haemorrhage / Hypoperfusion Cross clamp thoracic aorta to redistribute blood to myocardium and brain (Doubles MAP and Cardiac Output) Pass NG Tube to help identify Oesophagus vs Descending Aorta Ideally clamp just above diaphragm – maximize spinal cord perfusion Haemorrhage from pulmonary parenchyma or major pulmonary vasculature Clamp pulmonary Hilum / Injured tissue / Bleeding vessel Hilar twist Once in the chest

24. Pericardiotomy If no other obvious injuries and cannot see myocardium through pericardium Identify phrenic nerve anterolateral surface of pericardium Grasp pericardium anterior to phrenic nerve with tooth forceps – extend incision parallel to phrenic nerve Evacuate blood clots / Pericardial fluid Deliver heart from pericardial sac to inspect or fix defects Air Embolism Air in coronary vessels, heart or aorta is diagnostic Clamp hilum of affected lung Ventilate unaffected lung only Once in the chest

25. Open cardiac massage Start open cardiac massage immediately after placing thoracic aorta clamp 2 Hand “clapping” technique – wrists together at apex Internal massage better at maintaining Cardiac Output + Cerebral perfusion in animal studies that external compressions Internal Defibrillation VF – Shock 10J, repeat up to 50J (AP Paddles) Once in the chest

26. https://youtu.be/A57ZB_J4FuY

27. SMACC Chicago 2015 John Hinds https://www.youtube.com/watch?v=GFX_tocJShA

28. Intention to perform procedure should be quick Give a lead in – state from the outset the plan so everyone knows what is coming Rules in the sick obtunded trauma patient 1) Dont dick about with a duff anaesthetic 2) If they do arrest - dont dick about with a duff resuscitation attempt Learn indications and evidence as you wont have time to look these up when you need to perform the procedure! “Crack the Chest; Get Crucified”

29. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study Simms ER, Flaris AN, Franchino X, et al.. World J Surg 2013; 37:1277. An evidenced based approach to patient selection for emergency department thoracotomy : A practice management guideline for the Eastern Association for the Surgery of Trauma Seamon et al. Journal of Trauma Acute Care Surgery. 2015, Volume 79, Number 1 159:173 Emergency thoracotomy in thoracic trauma-a review. Hunt et al. Injury. 2006 Jan;37(1):1-19. Epub 2005 Apr 20 Western Trauma Association Critical Decisions in Trauma: Resuscitative thoracotomy , Cburlew et al, 2012 Guideline http://lifeinthefastlane.com/ed-thoracotomy-is-it-just-the-first-part-of-the-autopsy/, Kane Guthrie http://www.uptodate.com/contents/resuscitative-thoracotomy-technique SMACC Chicago, June 2015, “Crack The Chest; Get Crucified”, John Hinds References