Podcast 83 – Crack to Cure – ED Thoracotomy

Crack to Cure

All the way back at podcast 36, I discussed traumatic arrest in the ED. In that episode, I laid out a general approach to patients coding from trauma, in this one I discuss only the performance of the procedure of ED thoracotomy.

This lecture was given at the 2012 ALLNYC EM Conference.

Here are the videos from the lecture:

Survivor Story

Our ultrasound fellow, Dan Lakoff, sent me this survivor story from a thoracotomy

Need the audio-only version? Right click here and choose save-as

Now on to the Vodcast…

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Comments

  1. Great post Scott. Wish I’d had it a couple of months ago!:
    (Except we do a clamshell)
    http://emergencymedicineireland.com/2012/08/learning-points-from-a-first-time-emergency-thoracotomy/

    DM

  2. I really enjoyed that lecture. Straight, to the point, and a nice review. Keep up the good work!

  3. Minh Le Cong says:

    you raise the bar yet again! this anexcellent resource and like your cricothyroidotomy teachings, will likely allow someone out there to save a life. the power of #FOAMEd!

  4. Michael Toolis says:

    Love it. What a gift EMCrit is!

  5. Damon Tedford says:

    Awesome. Thanks for posting.

  6. Chris Wearmouth says:

    Hi Scott, love the podcast! As a medical student in London I’ve seen some ED thoracotomies done, but over here we use the clamshell technique. It seems to me that it would give you much better access to the chest and need not take much longer. What are your thoughts on the two different approaches? Thanks!

  7. Karel Habig says:

    Hi Scott, as always I very much enjoyed your presentation. The hardest part of the procedure, like many “Life, Limb and Sight Saving Procedures” is the mental preparation to perform it when it is needed!
    I have seen both Left Lateral and Clamshell approaches and am convinced that clamshell offers significant advantages. Non-surgeons, like me, need all the help they can get! Clamshell is IMHO simpler, quicker and gives much better exposure (and can even be done prehospital). I live in Australia where penetrating trauma remains thankfully very rare. The guys worth speaking to are my colleagues at London HEMS. They have unparalleled experience training non-surgeon critical care physicians to perform prehospital thoracotomies and were responsible for clamshell supplanting left lateral approach in the UK and Australia.
    Cheers.

    • Karel,

      I can’t disagree with you on this one. Here is what it comes down to–there will be patients you open, see a beating heart, nothing in the chest, transfuse a unit or two and they are back (these are the ones that code in front of you). In these patients, a clamshell is a really morbid incision. We both agree if you find an injury in the chest, get the maximal exposure with a clamshell. The questions is whether you want to start with it or extend when you find the injury. I would not argue against either approach.

  8. RustedFox says:

    Video no workie ?

  9. Great video and lecture, Scott. When I was full time in the ED, our guys used to do a lateral approach like you describe and then extend it if needed. Most times, the lateral was enough. Rarely saw a patient survive an ED thoracotomy, never saw one survive a clamshell. I suspect that had more to do with delay than anything. This was years ago when we used to do CPR for a while and the decision to open was always a hesitant one when made by the ED docs. I like what you say about that narrow window of decision. The literature certainly seems to support rapid opening in any kind of mechanical source of arrest (i.e. tamponade). I think most people wait too long in the hopes they won’t have to do it.

    I did have a problem with the video as well, it just stops for me with around 10 minutes to go. Though it might be me, but saw the previous comment about having trouble, don’t know if its the same issue or not.

    Keep up the great work!

    • Yep, same with the cric. People don’t want to cut. Need a little devil on there shoulder shouting, “It is OK, use the friggin knife!”

  10. Thanks for the video Scott. Regarding technical problems the embedded video wouldn’t play for me using Chrome, opening in a new window worked fine though.

    Could you explain a little more about non-thoracic penetrating trauma? I presume for abdominal trauma the indications and technique are similar as it’s difficult to rule out an injury extending into the chest and you can’t directly control intra-abdominal haemorrhage. How about say a stab injury to the leg or groin arresting in the department? Is your approach going to differ?

    • Same approach for any penetrating. If I suspect the belly or leg, aortic cross-clamp makes more sense.

      Here are two articles:
      Patients with Abdominal or Extremity Injuries may benefit as well (J Trauma. 2004;57:809 –814.) and (Surgery 2006;139:574)

  11. Jean Marc Benoit says:

    Thanks for the great vodcast Scott! A question from Canada – in acute tamponade is subxiphoid ultrasound going to pick these up?

  12. Hi Scott
    Wonderful lecture! I live and practise in Denmark, where there are only 4 major trauma centres that have CT surgery. I’m an anesthesiologist and in Denmark it’s the responsibility of anesthesiologists to go in the ambulance or helicopter and transport critically ill patients between centres. I’m wondering how one should handle the transfer of a patient who actually survives the thoracotomy and has an injury that needs emergency CT surgery and there is a transportation time of at least 1-2 h to a centre that has CT surgery. I haven’t done one, but it seems to me that it would be difficult to keep the patient just marginally stable without some sort of hemostasis in the thoracic cavity. Is there some way of ensuring some sort of hemostasis if you are a non-CT surgeon or would one just have to rely on blood products to keep perfusion up and fentanyl to keep blood pressure down, while manually compressing whatever injury that’s causing the bleeding? I think one would come up shorthanded in that situation.

    Thanks Andre

  13. Valerio P.B. says:

    Great lecture Scott…now i wish to learn to do it..as Army doctor would be useful!!!!!

  14. Great posting! In Romania , we did it once with the help of a general surgeon but the patient died…
    Thanks for the post with cric, I’ve did it 2 wks ago! My first one alone, it was great!

  15. Hey Scott. Love your stuff. I’m a junior ED/ICU dual trainee from Oz. you continue to have a big impact down here. Just for interest, we have a show here called “Kings Cross ER” which follows our colleagues at St Vincent’s hospital in Sydney, Australia. They just had an hour long ep following an ED thoracotomy and LV repair. Quite interesting. I’m not sure how you’d get your hands on it – maybe contact them directly? (But I’m not advocating all your subscribers to start spamming them!)

    Ryan

  16. Ron Coe says:

    Why couldn’t you just pull the lower portion of the lung cephalad and tear the pulmonary ligament instead of cutting it. It pulls apart very easily. Difficult to cut with scissors because of location and limitation of space, and too dangerous of a location to use a scapal due to proximity to aorta. Can pulling the ligament apart be the best way to “cut” it and then twist the lung?

    • There are well developed ones and crappy, insignificant ones. The latter don’t require anything and you can just push them out of the way. The former, I have never tried tearing. If you tell me they tear easily I’ll give it a shot on the next one.

  17. Patrick Burkhardt says:

    Hey Scott-
    I found an interesting addendum in the rather obscure croatian journal “Collegium Anthropologicum”, may be of interest: http://collegium.hrvatsko-antropolosko-drustvo.hr/_doc/Coll.Antropol.34(2010)4_1449-1452.pdf

    Cheers, Patrick

  18. Found a good real world ED Thoracotomy video from Dr. Larry Mellick’s youTube channel of EM teaching videos.

Trackbacks

  1. […] CLICK THROUGH THIS LINK. Scroll to the bottom of the post for audio/video links. […]

  2. […] is Scott on ED thoracotomy in NYC last year.  It is a biggish video so you will need a decent […]

  3. […] procedure: “Slow is smooth, and smooth is fast” is a mantra from Scott’s Crack to Cure talk that I use all the time, at home and at work. What you think is slow in these settings, is […]

  4. […] but a great video by Scott Wiengart, ~35 min, with awesome visuals and some great tips. watched it again myself […]

  5. […] Crack to cure – ED thoracotomy […]

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