1. James Regan 03.17.16 Trauma M&M

2. Situation Admitting Dx: MVC Procedure: Resuscitative thoracotomy, exploratory laparotomy Complication: Death

3. Background FF, 32 yo M, involved in MVC Prolonged extrication Air ambulance unable to takeoff No PMH/PSH Taken to OSH for stabilization Hypotensive Received 9L x Crystaloid, and 8 units RBC prior to arrival

4. FF OSH: Hypotensive: SBP 80-90 Intubated due to being combative ABG: 6.70/67/124/8 Hgb:11.4 2x Large bore IV access R femoral introducer

5. FF Trauma Bay PE: Initial Vitals: BP 59/34 HR 74 Sats100% on vent GCS 3T – paralyzed/sedated Pupils 5mm, ?reactive Posterior scalp lac Blood from L ear canal L Open radius fracture L open femur fracture, L open Tib/Fib fracture R thigh swelling/eccyhmosis

6. CC Labs Hgb 7.4 INR2.9 ABG 6.94/45/200/10.4 Resuscitated with blood products: Total 10x RBC, 7x FFP, 3x Plts FAST – Negative

7. FF Pulse lost: Code: PEA/V.fib Shocked 1x, Epi 1x Thoracotomy Cross clamp aorta Cardiac massage Shocked 3x, multiple epi, Ca2+, Bicarb ROSC x 2, SBP 85/45

8. FF OR from exploratory laparotomy + retroperitoneal blood Approx 2 L intraperitoneal blood Pt lost pulses Cardiac massage with no ROSC Code called approx 1hr 10 mins after arrival

9. Post-Mortem

10. Assessment Significant Trauma Delay getting to Level 1 Center Extrication/No Air ambulance Pre-Hospital Resusc 9x NS, 8x RBC Pre-hospital Bleeding control Tourniquet

11. Assessment Trauma Bay Splint, tourniquet Better transfusion ratio Thoracotomy? Exploratory laparotomy

12. Procedure: Thoracotomy, Exploratory laparotomy Complication: Death Attending: Dr Garfinkel Resident: Regan Grade:IV Classification: patient disease, management

13. Literature An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma Journal of Trauma and Acute Care Surgery, 2015 Whether EDT improves outcomes in patients who present pulseless after critical injuries – primary outcomes were survival and neurologically intact survival Population: Patients presenting pulseless with or without signs of life oFor thoracic penetrating, extrathoracic penetrating or blunt

14. Literature Literature review Survival With signs of lifeWithout signs of Life Thoracic Penetrating21.3% (11.7% neuro intact) 8.3% (3.9% neuro intact) Extra-thoracic Penetrating 15.6% (16.5% neuro intact) 2.9% (5% nuero intact) Blunt4.5 % (2.4% neuro intact) 0.7% (0.1%)

15. Recommendations Strong recommendation EDT with signs of life thoracic penetrating trauma Conditional EDT without sign of life thoracic penetrating EDT with/without signs of life extra-thoracic penetrating EDT with sign of life blunt Recommend against EDT without signs of life for blunt