Emergency Room Thoracotomy and Laporotomy
Trent Cross
Outline
Emergency Room Thoracotomy and Laparotomy
The Why, When and the How
Trent Cross
Trauma Surgery Registrar
Auckland City Hospital
Background
- Over last 2 decades the number of patients arriving in extremis rather then dying in the pre hospital setting is increasing
- Believed to be due to maturation in regionalized trauma systems
- Emergency Department thoracotomy (EDT) and/or laparotomy can be an component of a complex resuscitation when used appropriately with an understanding of its indications, physiological objectives, technical manoeuvres and consequences
History
- EDT came into use in the US for Rx of heart wounds in late 1800’s and early 1900’s
- Began as a concept of open cardiac massage in 1874 and indications expanded to the Rx of penetrating chest trauma and heart lacerations around the turn of the century
- With improvement in Resus and demonstrated efficacy of closed chest compression by Kouwenhoven in 1960 and external defib in 1965 the used of EDT for medical reasons ceased
- In the late 1960’s the pendulum swung toward EDT again with refinements in cardiothoracic techniques and the use of temporary thoracic aortic occlusion in patients with exsanguinating abdominal haemorrhage
Background
- In the past 3 decades several groups have attempted to determine clinical guidelines for EDT
- Current Literature a little confusing – different definitions, experiences, pre-hospital treatments etc
- Overall survival: 4 – 33% for EDT
Who Does Well?
-Penetrating >> Blunt
-Isolated cardiac injury > Non-cardiac injury
-Stab wounds > GSW
-Vital signs (VS) present in ED > VS lost in ED > VS lost in-transit > No VS at scene
-BP response to cross-clamp >> No response
Why Not Everyone?
-Inherent dangers to medical staff
-Fine line between therapy and butchery
-High costs of care for severely neurologically impaired survivors
-Equipment costs
Indications
-Salvageable post-injury cardiac arrest:
-Pts sustaining witnessed penetrating trauma with <15min pre-hospital CPR
-Pts sustaining witnessed blunt trauma with <5min pre-hospital CPR
-Persistent severe post-injury hypotension (SBP<60mmHg) due to:
-Cardiac tamponade
-Haemorrhage – intra-thoracic, intra-abdominal, extremity, cervical
-Air Embolism
Contraindications
-Penetrating trauma: CPR > 15 min and no signs of life (pupillary response, respiratory effort, or motor activity)
-Blunt trauma: CPR > 5 min and no signs of life, or asystole
-Severe head injury, multi system injury, non-traumatic arrest, insufficient training or equipment
Take Home Message
-Indications and Contraindications hard to formalize, with the exception of some pillars
-Use local protocols
-Utilize decision-making experience of senior staff
Technical Issues
-Intubation
-Prep skin (Betadine, PPE)
-Left Anterolateral EDT- 5th IC space
-Sharply dissect through Skin and musculature, blunt dissection through pleura
-Right Anterolateral EDT if right sided injury
-Can extend incision across to either side to form clamshell (watch Int mam Art)
What can it Achieve?
-Pericardiotomy
-Hilar Cross Clamping
-Aortic Cross clamping
-Also Control of Great vessel lacerations, internal cardiac massage and internal defibrillation (if EDT done)
Technical Points
Pericardiotomy
-Allows release of tamponade, repair of heart, internal massage
-Parallel and anterior to left phrenic nerve
-Grasp with forceps and incise with scissors. Extend carefully with scissors or bluntly
-Visual inspection not sensitive to rule out tamponade – open and assess for retrocardiac blood
Technical Points
Cardiac repair
-Finger pressure
-Satinsky clamps for atrial wounds
-Interrupted sutures – nylon, prolene
-Care around coronary vessels – mattress sutures to pass underneath
-Use pledgets, especially right ventricle
-Foley catheter for control of larger wounds
-Skin staples
-Consider posterior wounds – care with elevation of heart
Technical points
Hilar cross-clamping
-Major pulmonary haemorrhage
-Air embolus
-May cause damage to pulmonary veins
-Not good for the right heart – partial or intermittent occlusion possible
Technical Points
-Aortic closs-clamping
-Reduces intra-abdominal haemorrhage
-Redistibutes blood flow to brain, lungs, and coronary vessels
-Can overload heart ( afterload) and precipitate failure
-Ischaemia of distal organs, including bowel and spinal cord – ideally 30 minutes or less – be wary of reperfusion issues following clamp removal
-Retract left lung to expose aorta
-Ideally, dissect mediastinal pleura to expose vessel
-Clamp with care, to avoid damage to posterior vessels
-Empty vessel difficult to discern from oesophagus
Technical Points
-Internal cardiac massage
-Use 2-handed technique
-More efficient then external massage, when performed correctly (55% baseline perfusion vs 20%)
-Great vessel injuries
-May require sternotomy for access
-Digital control
-Simple sutures
-Cardiopulmonary bypass
Finer Points
-NGT to help distinguish aorta from oesophagus
-Stop ventilation prior to incising pleura, to collapse lung and prevent injury
-Position retractor with handle downwards to allow extension to clamshell
EDT Complications
-Hypoperfusion related ischaemic damage to neurological structures – brain (up to 50% anoxic brain death in survivors), and spinal cord
-Damage to any of many neighbouring structures – oesophagus, coronary vessels
-Recurrent bleeding from chest wall or internal mammary arteries
-Transmission of blood-borne pathogens to surgical staff
Does EDT Work?
-Overall survival 4 –33%
-Penetrating thoracic 18 – 33%
-Isolated thoracic stab causing tamponade ~70%
-Blunt trauma 0 – 2.5%
-Vital signs
-Arrest at scene 0%
-Arrest in-transit 4%
-Arrest in ED 19%
-Deterioration in ED without arrest 27%
-Blunt trauma without signs of life 0%
-Penetrating trauma without signs of life 0 – 5%
Emergency Department Laparotomy
-Limited literature
-Suggests a limited role with poor results, some evidence for ED Thoracotomy and aortic cross clamping pre laparotomy
-Technically full Midline incision Sternum to PS
-Same exposure risks as EDT
-Risk of enterotomy, organ damage (damage in an effort to correct something else)
-Therapeutic options include Packing, Digital pressure, Pringle manouver, clamping bleeding
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Ministry of Health
