ED Thoracotomy

1
ED Thoracotomy

• Scott Nguyen, MD
• Elmhurst Hospital Center
• July 27, 2005

2
ED Thoractomy

• Definition Thoracotomy performed in the
  Emergency Department for resuscitation of
  patients arriving in extremis.

3
Procedure Left Anterolateral Thoracotomy
4
Clamshell Thoracotomy
5

• Purpose

6
Release Pericardial Tamponade
7
Control Intrathoracic Hemorrhage
8
Eliminate massive air embolism or bronchopleural
fistula

• Post intubation positive pressure ventilation
• Get air transfer across traumatic alveolovenous
  channels
• Pulmonary hilar cross clamping
• Air aspirated from L ventricular apex and aortic
  root
• Cardiac massage

9
Perform Open Cardiac Massage

• Bimanual internal massage with hands in a hinged
  clapping motion
• Ventricular compression proceeding from apex to
  base of heart

10
Occlude Descending Thoracic Aorta
11
Futile?

• Overall survival 4-5
• Little to Lose
• Exists a risk to Health care workers
• Risk blood contact
• 26 trauma pts HIV or Hepatitis
• Health care costs
• J Trauma. 1998 Jul45(1)87-94

12
Selective Application of ED Thoracotomy

• Mechanism of Injury
• Presence of Vital Signs
• Location of Injury
• Other Signs of Life

13
Survival based on mechanism
J Trauma. 1998 Jul45(1)87-94
14
Presence of vital signs
J Trauma. 1998 Jul45(1)87-94
15
Survival based on organ injured
JACS 2000 Mar190(3)288-98.
16
Conclusions

• ER thoracotomy considered in pts w/
• Presence of vital signs in field or hospital
• Better results in penetrating cardiac injury
• Results w/ Blunt trauma poor, but survivors exist
• Contraindicated in pts w/
• No vital signs, Asystole

17
But what about Pulseless Electrical Activity
(PEA)?
18
Other Signs of Life (SOL)
JACS 2000 Mar190(3)288-98.
19
What about PEA?
26/62 (42) ED Thoracotomy survivors had PEA
requiring CPR
JACS 199211-215, 2004
20
PEA?

• ED Thoracotomy Indicated
• PEA after penetrating trauma from stabs
• Up to 70 good outcomes
• PEA after blunt trauma
• Typically poor outcome, but occasionally will
  have a survivor
• If CPR gt 5 min, contraindicated

JACS 199211-215, 2004
21
Algorithm Penetrating Trauma
Thoracotomy
J Trauma. 1998 Jul45(1)87-94
22
Algorithm Blunt Trauma
Thoracotomy
J Trauma. 1998 Jul45(1)87-94