A thoracotomy can be a life-saving procedure in a select group of patients. This specific subset of patients is stillcontroversial.
Resuscitative thoracotomy may be justified in trauma patients with shock. The beneficial aspects of the procedure include:
- decompressing cardiac tamponade
- cross-clamping the aorta
- controlling exsanguinating cardiac or large vascular injuries.
External chest compressions can provide a maximum of 30% of cardiac output and is dependent on venous return to the heart (1). Chest compressions in the trauma patient are ineffective, may increase cardiac trauma by causing blunt myocardial injury and obstruct access for performing definitive manoeuvers (1).
Penetrating Thoracic Injury — Resuscitative thoracotomy may be justified in patients with:
- Hemodynamically unstable on arrival AND after appropriate fluid resuscitation.
- Pulseless patients, receiving CPR for less than 15 minutes, and if appropriate resources (eg, appropriately-trained surgeon, operating room) are available .
Blunt Thoracic injury — controversial. According to the American College of Surgeons the sector of patients who may benefit include:
- Cardiac arrest in a trauma patient occurring prior to ED arrival, during resuscitation or observation
- Profound hypotension (BP<70mmHg) due to truncal wound in an unconscious patient or unavailable operating room.
Contraindications — Resuscitative thoracotomy is likely to be futile if:
- No signs of life at the scene of injury
- Asystole is presenting rhythm and no pericardial tamponade on U/S.
- Prolonged pulselessness (>15 minutes)
- The patient requires >10 minutes of prehospital CPR
- Multiple, massive non-survivable injuries.
- Severe head injury (1)
PREPARATION — One member of the trauma team should be designated to lead the ongoing resuscitation effort while an experienced member of the trauma team is performing the thoracotomy.
A left sided approach is used in all patients in traumatic arrest and with injuries to the left chest. Patients who are not arrested but with profound hypotension and right sided injuries have their right chest opened first (4)
- An anterior lateral incision is made, the chest is entered, and a retractor is placed. Left or right incision based on location of thoracic injury.
- If tamponade is present, perform pericardiotomy – The pericardial sac is opened and temporizing measures are used to control any cardiac injuries.
- The aorta is cross-clamped to allow filling of the heart and facilitate ongoing fluid resuscitation.
- Open cardiac massage using a two hand approach (operator’s thumb can perforate right ventricle) is initiated once the heart has filled sufficiently.
Outcomes — Clinical data evaluating the outcomes of resuscitative thoracotomies are derived primarily from retrospective cases (3-5). Much heterogeneity in the populations and outcomes were present.
COST — Resuscitative thoracotomy is expensive. Costs associated with other aspects of resuscitative thoracotomy include expenditures related to community EMS, hospital resources including supplies, personnel and transfusion services, and consequences of blood-borne pathogen exposures. Furthermore, the patient neurological outcome plays a critical role in the long-term outcome of patient population.
Submitted by Christina Brown.
- Seamon MJ, Shiroff AM, Franco M, et al. Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. J Trauma 2009; 67:1250.
- Karmy-Jones R, Namias N, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating chest trauma. J Trauma Acute Care Surg 2014; 77:994.
- Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med 2015; 65:297.
- Powell DW, Moore EE, Cothren CC, et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg 2004; 199:211.
- Photo credit via < http://www.trauma.org/index.php/main/article/361/>
Adapted from an old post, but a good refresher that came up again recently, with a new little table from a recent emed journal article that includes some recommendations for BP targets in stroke (ischemic or otherwise):
(and from a previous post):
IS SOMETHING BLEEDING (OR ABOUT TO)? MINIMIZE THE DAMAGE:
–lowering to SBP 140-160 probably safe
–theory: less/slower hematoma growth
–options: nicardipine (less cerebral vasospasm)
—SBP 100-120, HR <60
–theory: reduce shear forces
–options: beta blocker (labetolol push, esmolol drip), nitroprusside
–goal SBP 80-100
–theory: permissive hypotension; bleed slower, less likely to blow out the few clots they’re making
Reference(s): emed-journal article; uptodate.com: Ruptured abdominal aortic aneurysm, management of aortic dissection, Spontaneous intracerebral hemorrhage: Prognosis and treatment, Kodama K, et al. Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection, picture
for a quick sense of what is an equivalent dose across different opiates:
- morphine 10 mg IV
- hydromorphone 1.5 mg IV
- fentanyl 200 mcg IV
- hydromorphone 7.5 mg PO
- oxycodone 15-20 mg PO
- hydrocodone 30-45 mg PO
- codeine 180-200 mg PO
References: e-med journal article; emedicine; picture
Your next patient is a 70 yo M with neck swelling and syncopal episode, who said he “felt like couldn’t breathe” when bending forward, then passed out.
Vital Signs – WNL
Physical exam – Awake, ambulating male with chest wall venous distention, b/l neck swelling, facial plethora when leaning forward and trace peripheral, LE edema.
WHAT DOES THAT MEAN?
Superficial venous distention in superior vena cava syndrome —>
Imaging – In ED, CT chest and neck (w/ contrast) to evaluate for obstructing mass (e.g. something compressing the SVC)
Etiology – In the preantibiotic era, syphilitic thoracic aortic aneurysms, were frequent causes of the SVC syndrome. More recently, intrathoracic malignancy is responsible for 60 to 85 % of cases of SVC syndrome. Non-small cell lung cancer (NSCLC) is the most common, accounting for 50 % of all cases.
Clinical Manifestations – Interstitial edema of the head and neck is visually striking, but generally of little clinical consequence. However, edema may narrow the lumen of the nasal passages and larynx –> dyspnea, stridor, cough, hoarseness, and dysphagia. Cerebral edema can also occur (not awesome).
Cardiac output may be diminished transiently by acute SVC obstruction, but, within a few hours, blood return is reestablished by increased venous pressure and collaterals. Hemodynamic compromise, if present, more often results from mass effect on the heart than from SVC compression.
Submitted by Christina Brown.
quick hit review in July’s EP Monthly:
- as effective as oral NSAIDs for pain relief (NNT for 50% pain relief with topical gel = 11)
- adverse GI side effects less common
- risk of renal injury not clearly defined, but less systemic absorption (6-10% vs. 85% oral)
1% diclofenac gel (Voltaren):
- typically QID, up to 32 g/day
- 100g tube costs ~$45 (the 1.5% solution costs way more)
Worth knowing about, especially in those with significant GI issues taking NSAIDs, with focal musculoskeletal issues. Keep the cost in mind, though.
References: EPmonthly mag + picture
Some quick reminders and visual aids on which reflexes test which nerve roots:
C5 – Biceps
C6 – Biceps, Brachioradialis
C7 – Triceps
L4 – Patellar (knee jerk)
S1 – Achilles (ankle jerk)
This NYU site has some good pictures for each tendon reflex, but here’s a quick & dirty picture for those short on time:
There you go. Add it to the mental rolodex.
References: neuroexam.com, NYU neuro exam site, picture
nice idea from a recent JEM article:
- distal fingertip avulsions bleed, hard to dress
- variable efficacy/availability of bandaging/surgicel/lido+epi/etc
- gluing it is quick, cosmetic, and even a bit antimicrobial
- irrigate well, as usual
- digital block might help (for irrigation, and ’cause the adhesive will sting a bit)
- no ointments before or after (will break down the adhesive)
- tourniquet, direct pressure/milking, elevation — to staunch bleeding
- apply layer of tissue adhesive
- let dry, apply another layer
- let dry, apply another layer
Might consider this trick from a previous post to accelerate drying, especially if you didn’t quite stop the bleeding completely.
Boom, there you go.
References: JEM article; picture