KIRUB2008

EDTEmergency Department ThoracotomyThoracic trauma

Katastrofmedicinsk CentrumUniversitetssjukhusetLinkping

Tore Vikstrm

Theodore Billroth 1883The Surgeon who should attempt to suture a wound of the heart would lose the respect of his colleagues

Life-threatening Thoracic trauma

(Airway obstruction) Tension pneumothorax Open pneumothorax Flail chest Massive hemothorax Cardiac tamponade

EDT

Emergency Hurry Go ahead Hurray ! Finnish at the OR

Thoracic trauma 25-50% of deaths

Penetrating < 30% require operation

Blunt

EDTIndicationsPenetrating thoracic injuryPEAContraindicationsBlunt trauma in multitrauma

Corsi PR, Prado Pde A, Rasslan S. Department of Surgery, Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Brazil.Thoracic Trauma and Critical Care (textbook)

Who benefits from EDT ?

The value of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable

Cothren CC, Moore EE. Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA. clay.cothren@dhha.org. World J Emerg Surg. 2006 Mar 24;1:4 Sheppard FR, Cothren CC, Moore EE, Orfanakis A, Ciesla DJ, Johnson JL, Burch JM. Department of Surgery, Denver Health Medical Center, Denver, CO 80204, USA. 1: Surgery. 2006 Apr;139(4):574-6.

Who benefits from EDT ?

That is: half dead and new dead

Cothren CC, Moore EE. Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA. clay.cothren@dhha.org. World J Emerg Surg. 2006 Mar 24;1:4 Sheppard FR, Cothren CC, Moore EE, Orfanakis A, Ciesla DJ, Johnson JL, Burch JM. Department of Surgery, Denver Health Medical Center, Denver, CO 80204, USA. 1: Surgery. 2006 Apr;139(4):574-6.

EDT

Survival rates P/B (n=4 620)

Overall: 7,4% (range 1,8%-27,5%)

MOI: 8,8% P 1,8% BStab: 16,8%Gunshot: 4,3%Normal neurology: 92,4%

Peter M Rhee J Am Coll Surg;2000

Survival rate correlates to: Signs Of Life (SOL) Cardiac electrical activity Respiratory effort Pupillary response

Mechanism Of Injury (MOI)

Location Of Major Injury (LOMI)

MOI LOMI Multitrauma 0.7% Buk 4.5% Thorax 10.7% Hjrta 19.4% Trubbigt vld 1.4% Skottskada 4.3% Stickskada 16.8% SOL Saknas p skadeplats1.2% Finns under transport 8.9% Saknas vid ankomst till sjukhus 2.6% Finns vid ankomst till sjukhus11.5%

Best survival ratesEDT for stab injuries who arrive with SOL

Low survival ratesBlunt trauma/multitraumaNo SOL in the field

Time is of essenseScoop and run ! 10 min av CPR

VOMIT

Victim Of Modern ImaginTechnology

Choose the right trackATLSAirwayBreathingCirculationDisabilityExposureCTLSAirwayBreathingCT scanDeathEternity

Pitfalls Delay Too small incision Peroperative heart injury Suture over coronary artery Peroperative lung injury Peroperative oesophagus injury Indication ?

...in the ED

Thoracotomi equipmentPrepared personellResuscitation area

Summary EDTIndications Stab woundsDeep shock (BP

ReferencesHunt PA, Greaves I, Owens WA.Department of Academic Emergency Medicine, James Cook University Hospital, Marton Road, Middlesbrough, Cleveland TS4 3BW, UK. paulantonyhunt@doctors.org.uk Emergency thoracotomy in thoracic trauma-a [Kiss L, Lapadatu E, Balint I. Sectia chirurgie de urgenta, Spitalul Municipal Petrosani. The incidence of emergency thoracotomy in thoracic trauma. 7000 cases of thoracic trauma (T.T.) treated in the period of 1978-1995]Grove CA, Lemmon G, Anderson G, McCarthy M Emergency thoracotomy: appropriate use in the resuscitation of trauma patients. Am Surg. 2002 Apr;68(4):313-6; discussion 316-7. Jahangiri M, Hyde J, Griffin S, Magee P, Youhana A, Lewis T, Wood A. Emergency thoracotomy for thoracic trauma in the accident and emergency department: indications and outcome. Ann R Coll Surg Engl. 1996 May;78(3 ( Pt 1)):221-4 Mansour MA, Moore EE, Moore FA, Read RR. Exigent postinjury thoracotomy analysis of blunt versus penetrating trauma. Surg Gynecol Obstet. 1992 Aug;175(2):97-101 Washington B, Wilson RF, Steiger Z, Bassett JS.Ann Thorac Surg. 1985 Aug;40(2):188-91. Emergency thoracotomy: a four-year review. Frezza EE, Mezghebe H. J Cardiovasc Surg (Torino). 1999 Feb;40(1):147-51. Bodai BI, Smith JP, Ward RE, O'Neill MB, Auborg R. JAMA. 1983 Apr 8;249(14):1891-6. Emergency thoracotomy in the management of trauma. Mazzorana V, Smith RS, Morabito DJ, Brar HS. Am Surg. 1994 Jul;60(7):516-20; discussion 520-1. Brown SE, Gomez GA, Jacobson LE, Scherer T 3rd, McMillan RA Am Surg. 1996 Jul;62(7):530-3; discussion 533-4. Penetrating chest trauma: should indications for emergency room thoracotomy be limited Bodai BI, Smith JP, Blaisdell FW. J Trauma. 1982 Jun;22(6):487-91 The role of emergency thoracotomy in blunt trauma. Lorenz HP, Steinmetz B, Lieberman J, Schecoter WP, Macho JR. J Trauma. 1992 Jun;32(6):780-5; discussion 785-8. Emergency thoracotomy: survival correlates with physiologic status. Beltrami V, Bertagni A, Gallinaro L, Montesano G, Prece V. Ann Ital Chir. 2000 Jul-Aug;71(4):425-30. Major surgery in thoracic injuries.Karmy-Jones R, Nathens A, Jurkovich GJ, Shatz DV, Brundage S, Wall MJ Jr, Engelhardt S, Hoyt DB, Holcroft J, Knudson MM, Michaels A, Long W. J Trauma. 2004 Mar;56(3):664-8; discussion 668-9. Urgent and emergent thoracotomy for penetrating chest trauma. Lewis G, Knottenbelt JD Injury. 1991 Jan;22(1):5-6. Should emergency room thoracotomy be reserved for cases of cardiac tamponade? Fialka C, Sebok C, Kemetzhofer P, Kwasny O, Sterz F, Vecsei V. J Trauma. 2004 Oct;57(4):809-14 Open-chest cardiopulmonary resuscitation after cardiac arrest in cases of blunt chest or abdominal trauma: a consecutive series of 38 cases. von Oppell UO, Bautz P, De Groot M. Thorac Cardiovasc Surg. 2000 Feb;48(1):55-61. Penetrating thoracic injuries: what we have learnt.