1. 急診緊急開胸術 How / When / Why ?
陳昭文 醫師
高雄醫學大學附設醫院外傷科

2. 急診緊急開胸術 Emergent room thoracotomy (ERT)
Emergency department thoracotomy (EDT)
ER Resuscitative thoracotmy (ERRT)
Open-chest cardiac message
Trauma Service / KMUH

3. 急診緊急開胸術
The term “emergency room resuscitative thoracotomy” (ERRT) should be restricted to a thoracotomy that is performed on a patient in extremis (impending death) outside the operating room…
Trauma Service / KMUH

4. Patient in extremis Open Abdomen + Open Chest
Trauma Service / KMUH

5. 急診緊急開胸術 Why?
Trauma Service / KMUH

6. Time!
外傷病患愈早得到終極而適切之照護其生存機會愈高
出血控制
復甦治療
Trauma Service / KMUH

7. Trauma Service / KMUH

8. 急診緊急開胸術 When?
Trauma Service / KMUH

9. Clear indication for EDT Trauma 5th ed (2004)
Salvageable postinjury cardiac arrest
Sustain witnessed cardiac arrest with high likelihood of isolated intrathoracic injury, particularly penetrating cardiac wounds
Persistent severe post-injury hypotension (Sys Bp < 60mmHg)
Cardiac tamponade
Intrathoracic hemorrhage
Air embolism
Active intra-abdominal hemorrhage
Trauma Service / KMUH

10. Relative indication for EDT Trauma 5th ed (2004)
Refractory moderate post-injury hypotension (Sys Bp < 60mmHg) due to
Cardiac tamponade
Intrathoracic hemorrhage
Air embolism
Active intra-abdominal hemorrhage
Trauma Service / KMUH

11. EDT Indication USC guidelines 2004
Liberal Use Criteria
Some lives may be saved
Some patients may become organ donors
Excellent resident staff education
Strict use
Cost
Infective diseases
Actual cause of death - Autopsy?
Trauma Service / KMUH

12. EDT contraindication USC guidelines 2004
Blunt multiple trauma
Head trauma
No vital signs > 20 mins
Trauma Service / KMUH

13. EDT indication Rosen’s Textbook of Emergency Medicine
Penetrating Trauma
Cardiac arrest at any point with initial signs of life in the field
Blood pressure < 50 mm Hg systolic after fluid resuscitation
Severe shock with clinical signs of cardiac tamponade
Blunt Trauma
Cardiac arrest in the ED
Miscellaneous
Suspected air embolus
Box 38–4. Indications for Thoracotomy
Initial thoracostomy tube drainage is > 20 ml/kg of blood
Persistent bleeding at a rate > 7 ml/kg/hr
Increasing hemothorax seen on chest x-ray studies
Patient remains hypotensive despite adequate blood replacement, and other sites of blood loss have been ruled out
Patient decompensates after initial response to resuscitation
Trauma Service / KMUH

14. 急診緊急開胸術 How?
Trauma Service / KMUH

15. EDT technical aspects ED thoracotomy tray - Keep it simple!
Trauma Service / KMUH

16. EDT technical aspects Get everything ready! Prepare instruments
Sutures (Prolene 2-0)
Assign duties
Trauma Service / KMUH

17. EDT technical aspects Incision Left antero-lateral thoracotomy
4th or 5th intercostal space
Below nipple in males
Infra-mammary crease in females
Left sternal border to anterior axillary line
Clam-Shell incision
Trap-door incision
Trauma Service / KMUH

18. Incisions
Trauma Service / KMUH

19. Incisions
Trauma Service / KMUH

20. Trauma Service / KMUH

21. EDT technical aspects Incision – Common mistakes Too low!
Injury to diaphragm
Do not follow intercostal space
Hard to open chest
Messy!
Injury to lung
Miss injury to IMA
Trauma Service / KMUH

22. EDT technical aspects Procedures Enter chest Evacuate blood
Control any extracardial bleeding
Open pericardium
Cardiac message
Thoracic aortic cross-clamping
Trauma Service / KMUH

23. EDT technical aspects Cardiac injury
“Finger of 8” or “Continuous suture”
Staples!?
Avoid coronary vessels
Foley’s catheter in appropriate cases
Trauma Service / KMUH

24. EDT technical aspects Cardiac injury Common mistakes Pledgets!
Cut the phrenic nerve
Foley’s catheter in atrial wounds
Failure to examine posterior aspect
Not prepared!
”Give me a 2-0 suture!”
Trauma Service / KMUH

25. EDT technical aspects Aortic cross-clamping
Redistribute limited volume of blood to heart and brain
Decrease subdiaphragmatic bleeding
2-3 cm above diaphragm
Sharp dissection
Trauma Service / KMUH

26. EDT technical aspects Aortic cross-clamping Common mistakes
Clamp the esophagus!
Injury to the esophagus
Tear intercostal vessels
Try to clamp a “collapsed” aorta without dissection
Trauma Service / KMUH

27. EDT technical aspects Cardiac resuscitation
Fluid resuscitation (Level 1 infuser!?)
Cardiac message
Epinephrine, defibrillation
Cardiac aspiration for air embolism
Rewarm heart
Remove aortic clamp ASAP
Cardiac pacer?
Trauma Service / KMUH

28. EDT technical aspects Air embolism Source Lung injuries
Low-pressure heart chambers
Major venous injuries
Often air in coronary vein
Aspirate ventricles
Trauma Service / KMUH

29. EDT technical aspects Cardiac resuscitation – common mistakes
Defibrillate an empty heart
Forget the air embolism
Massive fluid administration in cardiac tamponade without major blood loss
Trauma Service / KMUH

30. Outcome Survival rate varies Threshold - Indications of EDT Mechanism
Anatomical site of injury
Vital signs – Field ,Transport, ER
Trauma Service / KMUH

31. Outcome 2%
16%
Hopson et al
Trauma Service / KMUH

32. Outcome
Trauma Service / KMUH

33. Some facts we have to know…
The greatest mistake in ED Thoractomy is not doing it early enough! …be brave!
Thoracotomy in the ED should only be performed by an appropriately trained surgeon… Poor experience we have!
A trauma patient who loses vital signs in the ED may be saved by immediate thoracotomy, especially those with penetrating injury… be aware of it!
Trauma Service / KMUH

34. Grasp every opportunity!
思考外傷救護目標 10
Control bleeding!
Grasp every opportunity!
Time is of essence!
Trauma Service / KMUH

35. THANK YOU!
Trauma Service / KMUH