URGENT THORACOTOMY : Indications and how to do it URGENT THORACOTOMY : Indications and how to do it Peter Syarief - Dr.H.A.Rotinsulu Lung Hospital The 8 th Annual Indonesian Symposium and Workshop on Acute Care Surgery - Bandung 2018
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URGENT THORACOTOMY :Indications and how to do itURGENT THORACOTOMY :Indications and how to do it
Peter Syarief - Dr.H.A.Rotinsulu Lung Hospital
The 8th Annual Indonesian Symposium and Workshop on Acute Care Surgery - Bandung 2018
HISTORY
• The surgeon who should attempt to suture a wound of the heart would lose the respect of his surgical colleagues" - Theodore Bilroth, 1882
• The first successful 'prehospital' thoracotomy and cardiac repair was carried out by Hill on a kitchen table in Montgomery, Alabama in 1902
STATISTICS
• Thoracic trauma accounts for 20-25% deaths due to injury in US
• 16,000 deaths per year due to chest injury• Rate of thoracic injuries 12 per million population
per day (~30/day in Miami-Dade County)• About 50% fatalities of MVA have sustained
some chest injury• Ratio penetrating/non penetrating variable
usually about 75-85% blunt injuries
WHAT?
Emergency thoracotomy can be defined as thoracotomyoccurring either operating room as an
integral part of the initial resuscitation process
in the emergency department
immediately at the site of injury
Emergency thoracotomy in thoracic trauma—a review, Hunt, P.A. et al. Injury , Volume 37 , Issue 1 , 1 - 19
Ethical
Economic
Social
ScientificThe decision to
perform
emergency
thoracotomy
involves careful
evaluation of
DECISION
Emergency thoracotomy in thoracic trauma—a review, Hunt, P.A. et al. Injury , Volume 37 , Issue 1 , 1 - 19
SURVIVAL RATE
Survival Rate following emergency thoracotomy:
• The overall survival rates for penetrating thoracic trauma are around 9–12% but have been reported to be as high as 38%
• The survival rate for blunt trauma is approximately 1–2%
Emergency thoracotomy in thoracic trauma—a review, Hunt, P.A. et al. Injury , Volume 37 , Issue 1 , 1 - 19
SURVIVAL AFTER EMERGENCY DEPARTMENT THORACOTOMY
• EDT had an overall survival rate of 7.4%• Normal neurologic outcomes were noted in 92.4% of
surviving patients• Factors reported as influencing outcomes were the
mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL)
• The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department
Rhee, Peter M et al., Journal of the American College of Surgeons , Volume 190 , Issue 3 , 2000, 288 – 298
(Review of published data from the past 25 years)
ACCEPTED INDICATIONS
Penetrating thoracic injury• Traumatic arrest with previously witnessed
cardiac activity (pre-hospital or in-hospital)• Unresponsive hypotension (BP < 70mmHg)
Trauma.org
Blunt thoracic injury• Unresponsive hypotension (BP < 70mmHg)• Rapid exsanguination from chest tube
(>1500ml)
RELATIVE INDICATIONS
• Penetrating non-thoracic injuryTraumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
• Blunt thoracic injuriesTraumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
• Penetrating thoracic injuryTraumatic arrest without previously witnessed cardiac activity
CONTRAINDICATIONS
Blunt injuries
• Blunt thoracic injuries with no
witnessed cardiac activity
• Multiple blunt trauma
• Severe head injury
RATIONALE
• Overall survival of patients undergoing emergency thoracotomy is between 4 and 33% depending on the protocols used in individual departments.
• The main determinants for survivability of an emergency thoracotomy are the mechanism of injury (stab, gunshot or blunt), location of injury and the presence or absence of vital signs.
THE AIMS
The primary aims of emergency thoracotomy are:
• Release of cardiac tamponade• Control of haemorrhage• Allow access for internal cardiac
massageSecondary manouvers include cross-clamping of the descending thoracic aorta
Trauma.org
Vertical Pericardial Incision
LIMA
LIMA
Sub-xyphoid Trans-diaphragmatic Pericardial Window
LACERATION ADJACENT TO CORONARY ARTERY
VENTRICULAR LACERATIONS AND REPAIRS
ED Thoracotomy (EDT)
INTERNAL PADDLES FOR DIRECT CARDIOVERSION
APPLICATION OF AORTIC CROSS CLAMP
RATIONALE FOR EDT
• Resuscitate agonal patient with penetrating cardiothoracic injuries
• Evacuation of pericardial tamponade• Control intra-thoracic hemorrhage• Perform open CPR• Repair cardiac injuries• Apply x-clamp to thoracic aorta• Apply hilar x-clamp to lung• Aspirate air embolismAsensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-
Based Surgery 2003: 1(1) 11-21.
C Clay Cothren and Ernest E Moore Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA
World Journal of Emergency Surgery 2006, 1:4
INDICATIONS FOR EDT
1. Salvageable post-injury cardiac arrest:
Patients sustaining witnessed penetrating trauma with < 15 minutes of pre-hospital CPR
Patients sustaining witnessed blunt trauma with < 5 minutes of pre-hospital CPR
2. Persistent severe post-injury hypotension (SBP<60mmHg) due to:
Cardiac tamponade
Hemorrhage – intra-thoracic, intra-abdominal, extremity, cervical
Air embolism
C Clay Cothren and Ernest E Moore Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA
World Journal of Emergency Surgery 2006, 1:4
1. Penetrating trauma: CPR >15 minutes and no signs of life (pupillary response, respiratory effort, motor activity)
2. Blunt trauma: CPR > minutes and no signs of life or asystole
CONTRA-INDICATIONS FOR EDT
EMERGENCY DEPARTMENT THORACOTOMY: OUTCOMES
Survivors/ Total EDT
Survivors/ Penetrating
Trauma
Survivors/ Blunt
Trauma537/8744
(6.1%)500/8619
(5.8%)35/7945 (0.44%)
Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-Based Surgery 2003: 1(1) 11-21.
Review of 42 published series
Nontraumatic (urgent)
Thoracotomy ?
• Acute mediastinitis descending necrotizing
mediastinitis (DNM)
• Complication of odontogenic, peritonsilar, or other pharyngeal infections
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www.themegallery.com
COMMUNICATION PATHWAYS OF OROPHARYNGEAL INFECTIONS INTO THE MEDIASTINUM
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