Every now and again someone raises the issue on social media about resuscitative thoracotomy. What are the indications (we have the EAST guidelines for that), what are the risks (highlighted in this important recent paper), and of course, whether EM or surgery should be doing it in the trauma bay (guess what – it’s in the curriculum for bothspecialties).
That’s not the point of this post. This post is about how I think you, as the emergency medicine physician (EP), working in a system where your surgeon is not in-house, but is available in a reasonable amount of time, should proceed when faced with the patient who meets the indications. You’ve gone through your HOTTT(T) algorithm and are now at that final “T” – you have to open the chest....Read More
If the patient is a clear traumatic arrest, compressions aren’t indicated and, instead we should focus on the important interventions that need to be done.
Ultrasound can be incredibly helpful in traumatic arrest. If you’ve got a traumatic arrest patient with neither pericardial fluid nor cardiac activity, it may be reasonable to stop resuscitation without the thoracotomy.
When decompressing the chest, it’s better to place you angiocath in the 5th intercostal space in the anterior axillary line. This helps you avoid the great vessels in the as well as the thick anterior chest wall
And last, if you are doing a thoracostomy, you may as well go bilaterally. You are doing invasive things to a dying patient, there is no reason to guess where the problem is. Similarly, if you have to do a thoracotomy, you could consider making it a clamshell as it space to look into and making sure the right side of the chest is accessed.
Welcome to the October 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Trauma, specifically ED Thoracotomy. Now we all know that ED thoracotomy is a last ditch salvage effort, performed under specific clinical circumstances, during a traumatic arrest. The purpose of the ED thoracotomy is to evacuate pericardial tamponade, control hemorrhage, improve coronary/cerebral blood flow, and if needed internal cardiac massage. The purpose of this podcast is to discuss specific indications where this already low yield procedure may have some benefit.
Topic #1: FAST US Examination as a Predictor of Outcomes After Resuscitative Thoracotomy