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Resuscitative Thoracotomy for Non-surgeons

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on 4 August 2015

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Transcript of Resuscitative Thoracotomy for Non-surgeons

Resuscitative Thoracotomy for Non-Surgeons
Glenn Ryan
Background
Controversial ?
Debated for 30+ years
Where should it be carried out
By whom
Which patient groups
Factors associated with survival
Likelihood of neurologically intact survival
What "constitutes signs of life"
Risks to operators
Quality of studies - never will be a PRCT
Traumatic Arrest
US Guidelines
Survival rates 0-3.7%
NAEMSP / ACSCOT 2003
Injuries non-compatible
Rigor
Trauma, apnoea, pulseless, no organised electrical activity, no SOL on arrival of EMS
Witnessed arrest and CPR for 15 minutes
Witnessed arrest and transport time > 15 mins to ED
Lockey et al 2006
68/909 patients
30 Px - anoxic insult
8 Px on-scene thotacotomy for penetrating chest
6 Px - TPTX
13 patients breached US guidelines
Definitions
Cardiac Arrest
Asystole
Circulatory Arrest
Low flow state?
ECG activity
Cardiac activity on FAST
Pulseless
+/- signs of life
Signs of Life
Respiratory effort
Pupillary response
Movement
Indications for Resuscitative Thoracotomy by Non-surgeons
1. Release tamponade
2. Control bleeding below diaphragm
Injury pattern
SOL
CPR
Points to Remember / Reassure!
The patient is dead or about to be

It can't get much worse for them

Ultimately, looking to correct one pathology
Human Factors Approach
Equipment

Approach to Incision

Incision
Human factors - Equipment
Human Factors - Approach to Incision
Books --> left lateral

No light

Anatomy - exposure

Dexterity
Steps to Perform a Clam Shell Thoracotomy
Bilateral Thoracostomies
5th IC space
Skin Incision
Swallow shaped, follow ICS down to intercostal muscle
Getting Started
Getting Through the Sternum
1-2 minutes to get into the chest
Open Pericardium
Divide the pericardium

Extend incision to base

Remove any clot with your hand

Aim to leave the heart in its bed as much as possible
What Now?
Heart starts

Heart needs re-starting

Manage the wound
Re-starting the Heart
Flick it

2 handed massage

Volume load

Adrenaline

Compress the aorta

Don't "deliver" the heart
Managing the Wound
Occlude with finger

Stitch it

Staple it

Foley cather
Extend incision to posterior axillary line
Other Procedures That Might be Considered
Aortic Compression

Hilar clamp

Hilar Twist

Staple lung

Lung compression
Keys to Success
Everything to gain situation
Early recognition - rapid decision making
Rapid access to the pericardium
Extend incision to posterior axillary line
Good quality massage
Aortic occlusion

Penetrating thoracic injury
Pulseless
SOL
i.e. "low flow" state

Penetrating thorax and shock - 33%
Isolated stab wound tamponade - 70%
additional 185 (92) / 1000
Mechanism
Penetrating
Blunt
Accepted Indications
Penetrating thoracic injury
Traumatic arrest
CPR < 15 min

All penetrating thoracic - 15%
Additional 81 (37) / 1000
Relative Indications
Penetrating Non-Thoracic
Haemorrhage control

Blunt
Pulseless
SOL
Witnessed loss of SOL
Contraindications
Blunt thoracic trauma without SOL
Polytrauma
Severe head injury
Davies et al 2011
71 stab wounds
Loss of vital signs
13 survivors
11 neurologically normal
18% survival rate from no signs of life

Blood-Borne Pathogen Exposure
Universal precautions
Double glove
Be aware of your sharps

Stop CPR!!
HIV - 0-4.3%

Hep B - 0.3-3.7%

Hep C - 2.8-12%
REBOA
Acknowledgments
Trauma.Org - photos

LAA and Dr Gareth Davies - some content from a prior presentation and photos
Full transcript