Tag Archives: resuscitation

Resuscitative Thoracotomy

17 Sep

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:

  1. Hemodynamically unstable on arrival AND after appropriate fluid resuscitation.
  2. Pulseless patients, receiving CPR for less than 15 minutes, and if appropriate resources (eg, appropriately-trained surgeon, operating room) are available [4].

Blunt Thoracic injury — controversial.  According to the American College of Surgeons the sector of patients who may benefit include:

  1. Cardiac arrest in a trauma patient occurring prior to ED arrival, during resuscitation or observation
  2. 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.

General Approach

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.

References:

  1. http://www.trauma.org/index.php/main/article/361/
  2. http://www.uptodate.com/contents/resuscitative-thoracotomy-technique?source=search_result&search=thoracotomy+adult&selectedTitle=1%7E150#H536270528
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. Photo credit via < http://www.trauma.org/index.php/main/article/361/
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Humeral IO

28 Jul

back from vacation with some quick procedural tips via a recent EM Resident article:

HUMERAL INTRAOSSEOUS (IO) ACCESS:

Basics:

  • proximal humerus
  • higher flow rates vs. tibia (~ 2x)
  • closer proximity to central circulation

 

Contraindications (to any IO site):

  • unhealed fracture
  • active soft tissue infection
  • previous IO attempt within 48 hrs
  • inability to find landmarks
  • joint replacement/prosthetic

 

The Procedure:

  • Positioning (3 possibilities):
    • palm over the umbilicus
    • flexed arm behind back (i.e. palm “under” the umbilicus) — useful during CPR
    • elbow extended, adducted, hyperpronated (i.e. straight arm by side, hyperprone)

  •  Placement:
    • palpate greater tubercle
    • feel surgical neck
    • pick site 1 cm above surgical neck
    • aim 45 degree angle towards contralateral hip

There you go.  Add it to the toolbox.

 

References: EM Resident article + picture; humerus picture

 

 

quick & dirty epinephrine drip

2 Jun

great post from ALiEM covers this handy tip:

10-SECOND RECAP:

In a pinch, here’s a quick way to get an IV epi drip started until the pharmacy/PYXIS/IV pump setup catches up to your need.

  • Grab the code cart epi (its 1 mg)
  • Inject the whole 1 mg into a 1 Liter NS bag 
  • Hang your new Liter bag of 1 mcg/mL concentration epi
  • Run wide open until desired initial stabilization/BP
  • Titrate to effect

 

TO MAKE YOU FEEL MORE COMFORTABLE ABOUT THIS:

ANAPHYLAXIS:

  • starting drip is 1-4 mcg/min IV
  • a wide-open 18-gauge IV will deliver ~20-30 mL/min (or 20-30 mcg/min) of epinephrine
  • recommended push-dose epi is 0.1 mg (or 100 mcg) over 5 minutes, which is 20 mcg/min avg.

 

RESUSCITATION/PRESSOR DOSING:

  • dose is 2-10 mcg/min IV   (or 2-20 mcg/min, depending on your source)

 

There you go.  Good to have in your back pocket.

 

References: ALiEM post; Epocrates; uptodate.com; picture

visual aid: quick pressor reference

14 Apr

good refresher aid from March’s Emergency Medicine mag below.  The article goes through each pressor a bit more in depth, but the table here is a nice quick reminder of receptor activity and dosing, particularly with dopamine, which can have different effects at lower or higher doses.

pressors

 

References: article including table.

resuscitation in pregnancy

27 Feb

via a nice recent post at emDocs.  Click through for the whole read, but if you only have 30 seconds to spare…

QUICK PEARLS:

put your IV above the diaphragm (uterus compresses IVC)

 

remove fetal monitoring equipment prior to defib

 

if you need to RSI, etomidate + succinylcholine is safe

  • (Epocrates lists both as pregnancy “C”, though if you need an airway, benefit probably outweighs risk)
  • “Etomidate will cross the placental barrier, but causes less fetal respiratory suppression than other medications, and succinylcholine does not cross the placental membrane.”

 

peri-mortem c-section: by 4 MINUTES INTO CODE

 

IF YOU HAVE ANOTHER 30 SECONDS:

extra-thinking mnemonic for pregnant code: BEAU-CHOPS

B=Bleeding/DIC

E=Emboli: coronary, pulmonary, amniotic fluid

A=Anesthetic Complications (aspiration, local anesthetic toxicity)

U=Uterine Atony

C=Cardiac Disease i.e. cardiomyopathy, aortic dissection

H=Hypertensive disease i.e. preeclampsia-eclampsia

O=Other-think about the Hs and Ts

P=Placental abruption, previa

S=Sepsis

References: emDocs post, peri-mortem c-section refresher; picture

anaphylaxis quick hits

3 Feb

tying into a recent anaphylaxis theme, via a recent review in AAEM’s Common Sense mag (work a quick read, if you’ve got time):

 

10-second quick hits on ANAPHYLAXIS:

IM epi(nephrine) better than SC — higher plasma concentrations with IM

  • remember, for patient teaching, LATERAL thigh (away from big vessels)

 

in refractory cases, consider atropine and/or vasopressin

 

H2 blockers might be helpful to toss in with your H1 (e.g. diphenhydramine)

 

biphasic reactions are rare (also covered a bit here).

 

There you go.

 

References: AAEM article (pg 45-46); picture

 

 

how good is your precordial thump?

7 Nov

HOW STRONG IS YOUR THUMP?

tough finding data on this (if you find more, please send it my way):

one study with 2 cardiologists:

  • cardiologist 1: 6.3–7.1 J
  • cardiologist 2: 8.8–10.4 J
  • ventricular arrhythmia terminated in only 2/155 patients

defib-thump

The Good:

deliver mechanical force to attempt defib (see mechanism below)

you can’t kill dead (little downside, aside from possible trauma, depending on strength)

 

The Bad:

if its not v-fib, and you induce it with an R-on-T

rarely successful (0/180 successful thumps with fist or 30-40mph lacrosse balls in one study)

The Mechanism (theory):

  • conversion of mechanical energy to electrical current (mechanoelectric coupling)
  • initiated by chest impact with a rapid, transient rise in left ventricular pressure.
  • Increased pressure results in myocardial stretch
  • stretch-activated ionic channels including the K+ATP channels are activated and open, resulting in an inward current and subsequent depolarization.

In commodio cordis, this depolarization induces a premature ventricular beat which, if precisely timed during the upstroke of the T wave in the P-QRS-T electrical cycle, can result in ventricular fibrillation—in essence, the R-on-T phenomenon.

In intentional precordial thump, this depolarization can indeed defibrillate the myocardium and thus interrupting the ventricular dysrhythmia.

References: cardiologist thumps; lacrosse ball thumps + picture;  mechanism