Prehospital thoracotomy debate

www.resus.me/swan24

Prehospital resuscitative thoracotomy is a

prehospital autopsy

Prehospital = a location

Re (back) suscitare (raise). PATIENT IS DEAD

Thoracotomy = surgical procedure

LOCATION dictates access to life-saving intervention

PROCEDURE is speciality specific

SURGEON 1

SURGEON 3SURGEON 2

Cardiac Theatre 2 Tuesdays 8am to 6pm

No teleporters

NO TIME

TIME

Penetrating traumatic cardiac arrest

LOSS OF OUTPUT to THORACOTOMY <10min

Pericardiotomy in 2-3min AFTER KNIFE to SKIN

Option 1: Don’t do thoracotomy, send to morgue

Option 2: Do thoracotomy, may live.

ProcedureSimple Equipment

Simple to train

Simplified steps

Clear indications + contraindications

Targeted Rx:

specific purpose of relieving clotted CT

controlling a cardiac wound(s)

if necessary providing internal cardiac massage.

Clamshell thoracotomy

Indications

Contraindications

Clamshell Thoracotomy

NSW AE RO ME DI CAL & ME DICAL RETRIE V AL SE RV ICE

Authorised by: Director Aeromedical and Medical Retrieval Services Page 1 of 5

HELICOPTER OPERATING PROCEDURE

Traumatic Cardiac Arrest

HOP No: C/06 Issued: April 2013

Page: 1 of 5 Revision No: 2

TRIM No: 09/300 Document No: D13/5679

Distribution: Sydney Illawarra Orange !!! Helicopter Road Fixed Wing

1. Introduction

1.1. Cardiac arrest refers to the combination of pulselessness and the absence of signs of life 1.2. Survival rates from traumatic cardiac arrest are poor but comparable with published

survival rates for out-of-hospital cardiac arrest of any cause. Patients who arrest after hypoxic insults and those who undergo out-of-hospital thoracotomy after penetrating trauma have a higher chance of survival. Patients with hypovolemia as the primary cause of arrest rarely survive1.

2. Objectives

2.1. To optimise the approach to the management of pre-hospital traumatic cardiac arrest by pre-hospital critical care teams.

3. Scope

3.1. Clinical crew

4. Process 4.1. Airway Management 4.1.1 All cardiac arrest patients should be intubated without anaesthetic drugs, however if ROSC occurs anticipate the need for IV sedation and analgesia. 4.1.2 Quantitative capnometry should be used to confirm tracheal tube placement, to assess the effectiveness of resuscitation, and to inform prognosis2. 4.2 Respiratory Management 4.2.1 Unless the possibility of tension pneumothorax can be reliably excluded, bilateral open thoracostomies should be made3. Needle thoracocentesis may be performed initially for reasons of access or expediency but these should not be considered to provide definitive pleural decompression.

X X X

X X

VLE -life and limb saving procedures

Thoracotomy workshop

Pig lab procedural skills

Simulation assessment + training

Governance

100% mortality if not performed

Meaningful survivors if performed

WTF?

WTF?

WTF?

The Skeptics

competency in the face of rarity

competency of non-surgeons

Surgeons: RT, craniotomy competency for non-surgeons

Radiology- FAST, REBOA

Anaesthesia: RSI

“Not survivable”. literature doesn’t support the nihilism

Ethics: beneficence/non-maleficence are met.

benefit:harm approaches infinity

RT

@pulmcrit

Cowboys/adrenaline junkies

Patients not dead- pseudoPEA

FAILURE to build a system that can access the central circulation and control it in the next 10

years is a trauma system that needs resuscitation