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:
Articles to Read
- Why You Should Consider Empiric Clamshell
You Also Need to Watch
Nice Diagram
I quibble with some of this, but it is beautiful none-the-less
from @learnEDjon
Most Recent Guidelines from EAST
Full Text of EAST Resus Thoracotomy Guidelines
Strayer's Summary Slide
Additional New Information
- If cardiac wall motion or pericardial fluid, go forward–if not, don't. From Surgical Lit
- Review Article Paulich and Lockey (BJA Education 2020;20(7):242)
- Remember, if you are going to sew the heart–2-0 Prolene on a Tapered Needle (Non-Cutting)
More on EMCrit
EMCrit 287 – Thoracotomy Masterclass with Dennis Kim
Additional Resources
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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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
Saw your fantastic post when you first published it.
I really enjoyed that lecture. Straight, to the point, and a nice review. Keep up the good work!
Thanks Cory and Minh!
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!
Love it. What a gift EMCrit is!
Awesome. Thanks for posting.
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!
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.… Read more »
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.
Video no workie ?
workie just fine. let me know what you are trying and i’ll troubleshoot
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… Read more »
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!”
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)
Thanks for the great vodcast Scott! A question from Canada – in acute tamponade is subxiphoid ultrasound going to pick these up?
definitely, though i go straight for parasternal long as my first view
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… Read more »
Great lecture Scott…now i wish to learn to do it..as Army doctor would be useful!!!!!
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!
Thanks for the follow-up, lavinia
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
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.
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
totally badass!
Found a good real world ED Thoracotomy video from Dr. Larry Mellick’s youTube channel of EM teaching videos.
I would suspect that doing closed chest massage during open thoracotomy is not correct and makes it way more dangerous. Also, shouldn’t
you pass the et tube into the rt mainstream to aid access to left chest?
Hi Scott. Excuse if I already asked but if you do a finger thoracostomy and the or gets rosc and you don’t immediately place the chest tube do you sew that up and place a more sterile incision or just use the original incision? If you don’t place tube do you sew or pack the wound ? Btw I’m giving “traumaconference” lecture Nov 14 to a hundred people.
The link for the recommended article to read “Why You Should Consider Empiric Clamshell” did not work for me.
As a trauma surgeon, I couldn’t agree more with those of you who have a low threshold to extending the thoracotomy for better exposure (partial or full clamshell). I would also add, however, that the VAST majority of saves will happen because you release tamponade and/or stopping bleeding on the heart with a finger. Correctly and effectively cross clamping the aorta is VERY difficult and surprisingly time consuming and has little utility in my real-life personal experience. I personally don’t even attempt it outside of the operating room. (are there exceptions to everything – of course).
I was at a trauma seminar at Jacobi Medical Center, in da Bronx, a few years ago, and a panel of docs from all over, during the round table portion, were ringing their hands and fussing about their 3% survival for ER resuscitative thoracotomies, praying that REBOA will be their panacea, it won’t be. Try doing them 20 minutes sooner, but that requires coming to the patient. Reading a recent JOSOM, US Army team, 2 surgeons and 2 CRNAs. Dust off called, CRNA no place to be found, so the Doc hops on the Blackhawk with the flight medic. Afghan… Read more »
amazing story
Yeah, but Doc, how do we fix this? Absolutely, we should be doing everything we can to improve the knowledge and abilities of our pre hospital folks, but there will always be things only a doc can do. Look at Doc Hinds (RIP) and their unorthodox approach to traumatic arrest, most likely a direct result of near immediate intervention, hence it wouldn’t travel well. I talk to ER docs at Jacobi, and like here, I’m not telling you anything you don’t already know. Somebody just needs to fix this. ER docs at Jacobi think major trauma is a BLS thing…… Read more »