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  Until 1960 – “medical” arrests –1960 – CPR –1965 – external defibrillation  Late 1960’s – resurgence in trauma  Currently – selective approach (Injury, physiologic status)

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

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

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)

ED Thoracotomy: Survival correlates with Injury pattern and status of patient Injury Pattern ShockNo V/SNo S.O.L Overall Cardiac35%19%3%16% Penetr.14%8%1%10% Blunt2%1%01.4%

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

ED Thoracotomy: Technical aspects  Pericardiotomy: –Hemorrhage control –Cardiac repair –Foley technique

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

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

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

10/5/ Chest Trauma: Pericardial Tamponade Intrapericardial Pressure (mm Hg)

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

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

10/5/ Chest Trauma NECK HYPOVOLEMIC SHOCK

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%

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