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ED Thoracotomy

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ED THORACOTOMY
Hey guys! Here’s the latest overview of ED thoracotomies from LITFL.com posted on March 11, 2016.  I’ve only seen 3 of these during my medical career, two of them were last week. One was my patient and the other was Jenny’s. While both didn’t survive their hospital course, my patient did regain a pulse and make it through several hours of surgery. If you haven’t encountered this scenario yet, I’m sure you aren’t alone. Still, it’s important to know not only how to perform it, but when.
Interesting articles to review:

  • #1 To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis.

    Slessor D1, Hunter S2.

    Author information

    Abstract

    STUDY OBJECTIVE:

    The role of emergency department (ED) thoracotomy after blunt trauma is controversial. The objective of this review is to determine whether patients treated with an ED thoracotomy after blunt trauma survive and whether survivors have a good neurologic outcome.

    METHODS:

    A structured search was performed with MEDLINE, EMBASE, CINAHL, and PubMed. Inclusion criteria were ED thoracotomy or out-of-hospital thoracotomy, cardiac arrest or periarrest, and blunt trauma. Outcomes assessed were mortality and neurologic result. The articles were appraised with the system designed by the Institute of Health Economics of Canada. A fixed-effects model was used to meta-analyze the data. Heterogeneity was assessed with the I(2) statistic.

    RESULTS:

    Twenty-seven articles were included in the review. All were case series. Of 1,369 patients who underwent an ED thoracotomy, 21 (1.5%) survived with a good neurologic outcome. All 21 patients had vital signs present on scene or in the ED and a maximum duration of cardiopulmonary resuscitation of 11 to 15 minutes. Thirteen studies were included in the meta-analysis. If there were either vital signs or signs of life present in the ED, the probability of a poor outcome was 99.2% (95% confidence interval 96.4% to 99.7%).

    CONCLUSION:

    There may be a role for ED thoracotomy after blunt trauma, but only in a limited group of patients. Good outcomes have been achieved for patients who had vital signs on admission and for patients who received an ED thoracotomy within 15 minutes of cardiac arrest. The proposed guideline should be used to determine which patients should be considered for an ED thoracotomy, according to level 4 evidence.

    #2 Inaba K et al. FAST Ultrasound Examination as a Predictor of outcomes After Resuscitative Thoracotomy: A Resuscitative Thoracotomy. Ann Surg 2015; 262 (3): 512 – 8. (Inaba et al. 2015)*

    • Background #1: In patients who suffer a traumatic cardiac arrest, a final salvage maneuver that is performed in the Emergency Department (ED) is a resuscitative thoracotomy (RT). There are two lines of thought about RT that are on opposite sides of the spectrum. The first line of thought is that if RT is not performed the patient is going to die anyways, so why not try it as a last ditch effort. The second line of thought is that due to the low yield in survival with RT, why expend resources and create a potential risk of harm to providers. The Focused Assessment Using Sonography for Trauma (FAST) has a high sensitivity and specificity for identifying hemopericardium and cardiac activity in a matter of seconds. Since there is really no good way to discriminate between which patients with traumatic cardiac arrest would benefit from RT, maybe adding a bedside FAST could help make this distinction.
    • This was a prospective, observational trial in 1 Trauma center in California
      • Patients undergoing RT in the ED
        • All penetrating trauma patients with absent vital signs
        • All blunt trauma patients with loss of vital signs en route or in the resuscitation bay
      • FAST performed just before or concurrently with RT
    • Bottom Line #1: ALL survivors and organ donors had visible cardiac motion on FAST. If no cardiac motion or pericardial effusion was seen on FAST, then survival was zero.

These are useful especially when you’re looking at who to perform this on. End goal is for the patient to survive the hospital course or in the case of possible organ donation.

Due to the large regional and facility variation in practice of who/when to perform this procedure, it will be very important for you to know what your facility’s policy is or your trauma team’s stance is as well.

Quick ED thoracotomy video. ..no instructional audio, so go over the steps prior to watching this. Otherwise, you may be lost. ..

Below is LITFL’s most recent post from 03/11/16:
ED Thoracotomy

Resuscitative Thoracotomy

OVERVIEW

  • resuscitative thoracotomy is a thoracotomy performed prehospital, in the emergency department or elsewhere that is an integral part of the initial resuscitation of a patient
  • an alternate term is emergency thoractomy
  • survival 4-33%
  • determinants of survival include mechanism of injury, the location of injury and the presence or absence of vital signs
  • best outcomes in:

-> penetrating chest
-> those exsaunginating from chest tube
-> isolated chest trauma
-> cardiac injuries
-> abdominal trauma that benefits from aortic clamping
-> time since loss of vitals

REQUIREMENTS

  • ETT
  • shock or arrest with a suspected correctable intrathoracic lesion
  • specific diagnosis (cardiac tamponade, penetrating cardiac lesion or aortic injury)
  • evidence of ongoing thoracic haemorrhage

INDICATIONS

Accepted

  • penetrating injury + arrest + previous signs of life
  • blunt injury + arrest + previous signs of life

Relative

  • penetrating injury + no signs of life and CPR < 15min – blunt injury + signs of life in field or during transport -> arrest 15 min
  • blunt injury + no signs of life
  • multiple blunt trauma
  • severe head injury

RESUSCITATION IN TRAUMATIC ARREST

  • 1. Intubate (reverses hypoxia)
  • 2. Insert bilateral chest drains (or thoracostomies)
  • 3. Resuscitative Thoracotomy
  • 4. Limit fluid as this worsens outcome in penetrating thoracic trauma unless haemorrhage controlled
  • 5. Limit inotropes and pressors until circulation restored (will need once defect repaired)

TECHNIQUE

Goals

  • relieve cardiac tamponade
  • perform open cardiac massage
  • occlude aorta to increase blood flow to heart and brain
  • control life threatening thoracic bleeding
  • control bronchovenous air embolism

1. Full aseptic technique*** –> This was recently an issue where the Trauma attending cited both his team and ours in Rm9 for lack of full prep –> masks, surgical gloves, gowns, etc. should be worn when performing this procedure.
2. Scalpel through skin and intercostal muscles to mid axillary line.
3. Insert heavy duty scissors into thoracostomy incisions.
4. Cut through sternum.
5. Lift up (clam shell)

-> relieve tamponade (longitudinal incision through pericardium)
-> repair cardiac wounds (non-absorbable sutures, 3.0)
-> stop massive lung or hilar bleeding with finger (partial or intermittent occlusion may be performed to avoid right heart failure)
-> identify aortic injuries (repair with 3.0 non-absorbable sutures or use finger)
-> consider aortic cross clamping at level of diaphragm (limits spinal cord ischemia)

Emergency Escharotomy

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Case: 57 yo M who presents via EMS found with circumferential burns on bilateral lower extremities, left upper extremity, lower pelvis, and left side of chest after being trapped in a burning tent. Unknown time of incident.

VS: HR: 128, RR: 24, BP: 112/64, SpO2 96% on 4L O2

Alert, oriented x 2. SEVERELY DISTRESSED. Singed nares bilaterally. Bilateral wheezes, tachypneic. Tachycardic, RR. Abd S/NT/ND. Once again, 3rd degree burns circumferential burns from lower pelvis, extending to groin, and down to bilateral lower extremities. The 3rd degree burn covered the left side of his chest and his RUE. No pulses were palpated in his LUE or BLE. Though burned, BLE and RUE appeared blanched with poor cap refill and cool to touch. 72% estimated burn coverage total. Pt stated he was unable to feel or move bilateral lower extremities.

During the process of IV, O2, monitor, and moving the pt over. I called for pain medication, intubation meds, and got the equipment ready for intubation.

Trauma, Plastics, Urology – paged. Don’t wait to get consults on board in a case where you are preparing to do this procedure.

On physical exam, remember Wallace rule of nines (see total body surface area): 9% for each arm, 18% for each leg, 18% for the front of the torso, 18% for the back of the torso, and 9% for the head and 1% for the perineum. At the same time, think Lactated Ringers at 4 mL x kg x percentage burn = total fluids needed for replacement in initial 24hrs. First half of amount in first 8 hours with the second half over 16hrs{{Parkland}}.

But, first, intubate to secure the airway, provide pain control, and facilitate further exam. Needless to say, burns are extremely painful.. . so are escharotomies.

Trauma wedge took the RLE, and I had the LLE. In the race to get pulses back, I succeeded and was rewarded with getting to do the LUE as well.

How did I perform the procedure you ask? Well, it was with the Trauma fellow standing at the foot of the bed giving instructions and guidance . .. I had never seen anything like this except for textbook cases of a circumferential burn to the chest/trunk. This procedure is not on our sign off list, required list, or on anything that I had seen in cadaver lab.

While these procedures are as rare as a Trauma fellow eager to teach at 2 am, you may be faced with the same in a rural ED or with a wedge stuck in the OR, etc.

Advice: Be nice to your colleagues. And, more importantly, prepare.

Here are some very informative links that would’ve been great to have seen or reviewed prior.

Step 1: Read the Overview

Video 1: Robot voice explanation: Best display of lines for incision, but more from a surgical perspective

Video 2: Australian Escharotomy How-to

FYI:

Suprapubic catheter was also placed in the ED prior to the pt going to the OR. Another rare procedure, not required, but useful to know.

PEM Chronicles: Rasburicase

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     A case I saw  last month led me to utilizing a drug I’d never heard of before in the ED: Rasburicase.

     The drug: a recombinant urate oxidase enzyme, which converts existing uric acid to allantoin. This is key due to the higher solubility of allantoin in urine. Patients with Tumor Lysis Syndrome are at risk of acute renal failure due to precipitation of uric acid crystals in renal tubules and collecting ducts.

The case: a 12 yo F with no PMHx who was transferred from an urgent care center for multiple tender, enlarged lymph nodes and a WBC count of 98.

As we worked her up for a new presentation of a hematologic malignancy, it became evident she fit into the parameters for TLS. Initial uric acid level – 14.5 along with hyperkalemia, elevated serum LDH, and hyperphosphatemia. When Hem/Onc came on board, once labs were back, the first recommendations were hydration and Rasburicase.

Provided below is the article I found that informed me on the treatment and a few key points picked up when using it.

For kids only – The drug hasn’t been approved in the US for adults.

G6PD deficiency – Yes, from the depths of med school knowledge, this condition is a contraindication to using Rasburicase. The hydrogen peroxide it produces as a byproduct can lead to hemolysis. Ask if there is a family history.

Coordinating with pharmacy – Due to the preparation of rasburicase, it should be administered immediately after it has been prepared. IV access should be obtained well in advance.

Type of IV access – In our case, hem/onc was considering emergent dialysis. It may be prudent to discuss this with your consultants to get a head-start on what they’ll need once going upstairs.

Not at your medical facility, a specialized pediatric hospital, or somewhere with this in stock??? As you transfer, consider:

1.) Aggressive IV Hydration. Easy to start getting this started, especially if transporting to the next hospital will require hours instead of blocks.

2.) Allopurinol. Though it isn’t required when Rasburicase is given, allopurinol can’t decrease what is already present, but it can help prevent the formation of more uric acid.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200736/