ED Thoracotomy Scott Nguyen, MD Elmhurst Hospital Center

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ED Thoracotomy

• Scott Nguyen, MD
• Elmhurst Hospital Center
• July 27, 2005

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ED Thoractomy

• Definition Thoracotomy performed in the
  Emergency Department for resuscitation of
  patients arriving in extremis.

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Procedure Left Anterolateral Thoracotomy
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Clamshell Thoracotomy
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• Purpose

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Release Pericardial Tamponade
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Control Intrathoracic Hemorrhage
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Eliminate massive air embolism or bronchopleural
fistula

• Post intubation positive pressure ventilation
• Get air transfer across traumatic alveolovenous
  channels
• Pulmonary hilar cross clamping
• Air aspirated from L ventricular apex and aortic
  root
• Cardiac massage

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Perform Open Cardiac Massage

• Bimanual internal massage with hands in a hinged
  clapping motion
• Ventricular compression proceeding from apex to
  base of heart

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Occlude Descending Thoracic Aorta
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Futile?

• Overall survival 4-5
• Little to Lose
• Exists a risk to Health care workers
• Risk blood contact
• 26 trauma pts HIV or Hepatitis
• Health care costs
• J Trauma. 1998 Jul45(1)87-94

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Selective Application of ED Thoracotomy

• Mechanism of Injury
• Presence of Vital Signs
• Location of Injury
• Other Signs of Life

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Survival based on mechanism
J Trauma. 1998 Jul45(1)87-94
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Presence of vital signs
J Trauma. 1998 Jul45(1)87-94
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Survival based on organ injured
JACS 2000 Mar190(3)288-98.
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Conclusions

• ER thoracotomy considered in pts w/
• Presence of vital signs in field or hospital
• Better results in penetrating cardiac injury
• Results w/ Blunt trauma poor, but survivors exist
• Contraindicated in pts w/
• No vital signs, Asystole

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But what about Pulseless Electrical Activity
(PEA)?
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Other Signs of Life (SOL)
JACS 2000 Mar190(3)288-98.
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What about PEA?
26/62 (42) ED Thoracotomy survivors had PEA
requiring CPR
JACS 199211-215, 2004
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PEA?

• ED Thoracotomy Indicated
• PEA after penetrating trauma from stabs
• Up to 70 good outcomes
• PEA after blunt trauma
• Typically poor outcome, but occasionally will
  have a survivor
• If CPR gt 5 min, contraindicated

JACS 199211-215, 2004
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Algorithm Penetrating Trauma
Thoracotomy
J Trauma. 1998 Jul45(1)87-94
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Algorithm Blunt Trauma
Thoracotomy
J Trauma. 1998 Jul45(1)87-94