EMERGENCY THORACOTOMY

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KIRUB 2008
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EDT Emergency Department Thoracotomy Thoracic
trauma Katastrofmedicinsk Centrum Universitetss
jukhuset Linköping Tore Vikström
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Theodore Billroth 1883
The Surgeon who should attempt to suture a wound
of the heart would lose the respect of his
colleagues
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Life-threatening Thoracic trauma

• (Airway obstruction)
• Tension pneumothorax
• Open pneumothorax
• Flail chest
• Massive hemothorax
• Cardiac tamponade

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EDT Emergency Hurry Go ahead Hurray
! Finnish at the OR
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Thoracic trauma

• 25-50 of deaths
• Penetrating lt 30 require operation
• Blunt lt10 require operation
• Majority simple procedures

Hunt PA, Greaves I, Owens WA.Department of
Academic Emergency Medicine, James Cook
University Hospital, Marton Road, Middlesbrough,
Cleveland TS4 3BW, UK Thoracic Trauma and
Critical Care (textbook)
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EDT

• Indications
• Penetrating thoracic injury
• PEA
• Contraindications
• Blunt trauma in multitrauma

Corsi PR, Prado Pde A, Rasslan S. Department of
Surgery, Faculdade de Ciencias Medicas da Santa
Casa de Sao Paulo, Brazil. Thoracic Trauma and
Critical Care (textbook)
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Who benefits from EDT ?

• The value of EDT in resuscitation of the patient
  in profound shock but not yet dead is
  unquestionable

Cothren CC, Moore EE.
Department of Surgery, Denver Health Medical
Center and the University of Colorado Health
Sciences Center, Denver, CO, USA.
clay.cothren_at_dhha.org. World J Emerg Surg. 2006
Mar 2414 Sheppard FR, Cothren CC, Moore EE,
Orfanakis A, Ciesla DJ, Johnson JL, Burch JM.
Department of Surgery, Denver Health Medical
Center, Denver, CO 80204, USA. 1 Surgery. 2006
Apr139(4)574-6.
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Who benefits from EDT ?

• That is half dead and new dead

Cothren CC, Moore EE.
Department of Surgery, Denver Health Medical
Center and the University of Colorado Health
Sciences Center, Denver, CO, USA.
clay.cothren_at_dhha.org. World J Emerg Surg. 2006
Mar 2414 Sheppard FR, Cothren CC, Moore EE,
Orfanakis A, Ciesla DJ, Johnson JL, Burch JM.
Department of Surgery, Denver Health Medical
Center, Denver, CO 80204, USA. 1 Surgery. 2006
Apr139(4)574-6.
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EDT

• Survival rates P/B (n4 620)
• Overall 7,4 (range 1,8-27,5)
• MOI 8,8 P 1,8 B
• Stab 16,8
• Gunshot 4,3
• Normal neurology 92,4
• Peter M Rhee J Am Coll Surg2000

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Survival rate correlates to

• Signs Of Life (SOL)
• Cardiac electrical activity
• Respiratory effort
• Pupillary response
• Mechanism Of Injury (MOI)
• Location Of Major Injury (LOMI)

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MOI

• Trubbigt våld 1.4
• Skottskada 4.3
• Stickskada 16.8

LOMI

• Multitrauma 0.7
• Buk 4.5
• Thorax 10.7
• Hjärta 19.4

SOL

• Saknas på skadeplats 1.2
• Finns under transport 8.9
• Saknas vid ankomst till sjukhus 2.6
• Finns vid ankomst till sjukhus 11.5

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Best survival rates

• EDT for stab injuries who arrive with SOL
• Low survival rates
• Blunt trauma/multitrauma
• No SOL in the field

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Time is of essense

• Scoop and run !
• 10 min av CPR

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• VOMIT

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• Victim Of Modern ImaginTechnology

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Choose the right track

• ATLS
• Airway
• Breathing
• Circulation
• Disability
• Exposure

• CTLS
• Airway
• Breathing
• CT scan
• Death
• Eternity

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Pitfalls

• Delay
• Too small incision
• Peroperative heart injury
• Suture over coronary artery
• Peroperative lung injury
• Peroperative oesophagus injury
• Indication ?

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...in the ED

• Thoracotomi equipment
• Prepared personell
• Resuscitation area

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Summary EDT

• Indications
• Stab wounds
• Deep shock (BPlt70 mmHg)
• Non responder
• Cardiac arrest in the ED
• 10 min CPR
• Emergency procedure now !
• 1 out of 4 can be saved
• EDT is part of damage control

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References

• Hunt PA, Greaves I, Owens WA.Department of
  Academic Emergency Medicine, James Cook
  University Hospital, Marton Road, Middlesbrough,
  Cleveland TS4 3BW, UK. paulantonyhunt_at_doctors.org.
  uk Emergency thoracotomy in thoracic trauma-a
• Kiss L, Lapadatu E, Balint I. Sectia chirurgie
  de urgenta, Spitalul Municipal Petrosani.
• The incidence of emergency thoracotomy in
  thoracic trauma. 7000 cases of thoracic trauma
  (T.T.) treated in the period of 1978-1995
• Grove CA, Lemmon G, Anderson G, McCarthy M
  Emergency thoracotomy appropriate use in the
  resuscitation of trauma patients. Am Surg. 2002
  Apr68(4)313-6 discussion 316-7.
• Jahangiri M, Hyde J, Griffin S, Magee P, Youhana
  A, Lewis T, Wood A.Emergency thoracotomy for
  thoracic trauma in the accident and emergency
  department indications and outcome. Ann R Coll
  Surg Engl. 1996 May78(3 ( Pt 1))221-4 Mansour
  MA, Moore EE, Moore FA, Read RR.Exigent
  postinjury thoracotomy analysis of blunt versus
  penetrating trauma. Surg Gynecol Obstet. 1992
  Aug175(2)97-101 Washington B, Wilson RF,
  Steiger Z, Bassett JS.Ann Thorac Surg. 1985
  Aug40(2)188-91.
• Emergency thoracotomy a four-year review.
• Frezza EE, Mezghebe H. J Cardiovasc Surg
  (Torino). 1999 Feb40(1)147-51.
• Bodai BI, Smith JP, Ward RE, O'Neill MB, Auborg
  R. JAMA. 1983 Apr 8249(14)1891-6.
• Emergency thoracotomy in the management of
  trauma.Mazzorana V, Smith RS, Morabito DJ, Brar
  HS. Am Surg. 1994 Jul60(7)516-20 discussion
  520-1. Brown SE, Gomez GA,
  Jacobson LE, Scherer T 3rd, McMillan RA Am Surg.
  1996 Jul62(7)530-3 discussion 533-4.
• Penetrating chest trauma should indications for
  emergency room thoracotomy be limited
• Bodai BI, Smith JP, Blaisdell FW. J Trauma. 1982
  Jun22(6)487-91
• The role of emergency thoracotomy in blunt
  trauma.
• Lorenz HP, Steinmetz B, Lieberman J, Schecoter
  WP, Macho JR. J Trauma. 1992 Jun32(6)780-5
  discussion 785-8. Emergency thoracotomy
  survival correlates with physiologic status.
• Beltrami V, Bertagni A, Gallinaro L, Montesano
  G, Prece V. Ann Ital Chir. 2000
  Jul-Aug71(4)425-30.
• Major surgery in thoracic injuries.
• Karmy-Jones R, Nathens A, Jurkovich GJ, Shatz
  DV, Brundage S, Wall MJ Jr, Engelhardt S, Hoyt
  DB, Holcroft J, Knudson MM, Michaels A, Long W.J
  Trauma. 2004 Mar56(3)664-8 discussion 668-9.
  
• Urgent and emergent thoracotomy for penetrating
  chest trauma. Lewis G, Knottenbelt JD Injury.
  1991 Jan22(1)5-6.
• Should emergency room thoracotomy be reserved
  for cases of cardiac tamponade?
• Fialka C, Sebok C, Kemetzhofer P, Kwasny O,
  Sterz F, Vecsei V. J Trauma. 2004
  Oct57(4)809-14