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Peter Syarief - Dr.H.A.

Rotinsulu Lung Hospital

URGENT THORACOTOMY :
Indications and how to do it

The 8th Annual Indonesian Symposium and Workshop


on Acute Care Surgery - Bandung 2018
HISTORY

• The surgeon who should


attempt to suture a wound of
the heart would lose the
respect of his surgical
colleagues" - Theodore
Bilroth, 1882

• The first successful


'prehospital' thoracotomy and
cardiac repair was carried out
by Hill on a kitchen table in
Montgomery, Alabama in 1902
STATISTICS

• Thoracic trauma accounts for 20-25% deaths due


to injury in US
• 16,000 deaths per year due to chest injury
• Rate of thoracic injuries 12 per million population
per day (~30/day in Miami-Dade County)
• About 50% fatalities of MVA have sustained
some chest injury
• Ratio penetrating/non penetrating variable
usually about 75-85% blunt injuries
WHAT?

immediately at the site of


injury
Emergency
thoracotomy can
in the emergency
be defined as department
thoracotomy
occurring either
operating room as an
integral part of the initial
resuscitation process

Emergency thoracotomy in thoracic trauma—a review, Hunt, P.A. et al. Injury ,


Volume 37 , Issue 1 , 1 - 19
DECISION

The decision to Ethical


Scientific
perform
emergency
thoracotomy
Social
involves careful
Economic
evaluation of

Emergency thoracotomy in thoracic trauma—a review, Hunt, P.A. et al. Injury ,


Volume 37 , Issue 1 , 1 - 19
SURVIVAL RATE

Survival Rate following emergency


thoracotomy:
• The overall survival rates for penetrating
thoracic trauma are around 9–12% but
have been reported to be as high as 38%
• The survival rate for blunt trauma is
approximately 1–2%

Emergency thoracotomy in thoracic trauma—a review, Hunt, P.A. et al. Injury ,


Volume 37 , Issue 1 , 1 - 19
SURVIVAL AFTER EMERGENCY DEPARTMENT
THORACOTOMY
(Review of published data from the past 25 years)
• EDT had an overall survival rate of 7.4%
• Normal neurologic outcomes were noted in 92.4% of
surviving patients
• Factors reported as influencing outcomes were the
mechanism of injury (MOI), location of major injury
(LOMI), and signs of life (SOL)
• The best survival results are seen in patients who
undergo EDT for thoracic stab injuries and who arrive
with SOL in the emergency department

Rhee, Peter M et al., Journal of the American College of Surgeons , Volume 190 ,
Issue 3 , 2000, 288 – 298
ACCEPTED INDICATIONS

Penetrating thoracic injury


• Traumatic arrest with previously witnessed
cardiac activity (pre-hospital or in-hospital)
• Unresponsive hypotension (BP < 70mmHg)
Blunt thoracic injury
• Unresponsive hypotension (BP < 70mmHg)
• Rapid exsanguination from chest tube
(>1500ml)

Trauma.org
RELATIVE INDICATIONS
• Penetrating thoracic injury
Traumatic arrest without previously witnessed
cardiac activity

• Penetrating non-thoracic injury


Traumatic arrest with previously witnessed
cardiac activity (pre-hospital or in-hospital)

• Blunt thoracic injuries


Traumatic arrest with previously witnessed
cardiac activity (pre-hospital or in-hospital)
CONTRAINDICATIONS

Blunt injuries

• Blunt thoracic injuries with no


witnessed cardiac activity

• Multiple blunt trauma

• Severe head injury


RATIONALE
• Overall survival of patients undergoing
emergency thoracotomy is between 4
and 33% depending on the protocols
used in individual departments.
• The main determinants for survivability
of an emergency thoracotomy are the
mechanism of injury (stab, gunshot or
blunt), location of injury and the
presence or absence of vital signs.
THE AIMS
The primary aims of emergency
thoracotomy are:
• Release of cardiac tamponade
• Control of haemorrhage
• Allow access for internal cardiac
massage
Secondary manouvers include cross-
clamping of the descending thoracic aorta

Trauma.org
Vertical Pericardial Incision

LIM
A
Sub-xyphoid Trans-diaphragmatic
Pericardial Window
LACERATION ADJACENT TO
CORONARY ARTERY
VENTRICULAR LACERATIONS AND
REPAIRS
ED Thoracotomy (EDT)
INTERNAL PADDLES FOR DIRECT
CARDIOVERSION
APPLICATION OF AORTIC CROSS
CLAMP
RATIONALE FOR EDT
• Resuscitate agonal patient with
penetrating cardiothoracic injuries
• Evacuation of pericardial tamponade
• Control intra-thoracic hemorrhage
• Perform open CPR
• Repair cardiac injuries
• Apply x-clamp to thoracic aorta
• Apply hilar x-clamp to lung
• Aspirate air embolism
Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-
Based Surgery 2003: 1(1) 11-21.
INDICATIONS FOR EDT

1. Salvageable post-injury cardiac arrest:


 Patients sustaining witnessed penetrating trauma with < 15
minutes of pre-hospital CPR
 Patients sustaining witnessed blunt trauma with < 5 minutes of
pre-hospital CPR
2. Persistent severe post-injury hypotension (SBP<60mmHg) due to:
 Cardiac tamponade
 Hemorrhage – intra-thoracic, intra-abdominal, extremity, cervical
 Air embolism

C Clay Cothren and Ernest E Moore Emergency department thoracotomy for the critically injured patient: Objectives, indications, and
outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA
World Journal of Emergency Surgery 2006, 1:4
CONTRA-INDICATIONS FOR EDT

1. Penetrating trauma: CPR >15 minutes


and no signs of life (pupillary response,
respiratory effort, motor activity)
2. Blunt trauma: CPR > minutes and no
signs of life or asystole

C Clay Cothren and Ernest E Moore Emergency department thoracotomy for the critically injured patient: Objectives, indications, and
outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA
World Journal of Emergency Surgery 2006, 1:4
EMERGENCY DEPARTMENT
THORACOTOMY: OUTCOMES
Review of 42 published series

Survivors/ Survivors/ Survivors/


Total EDT Penetrating Blunt
Trauma Trauma
537/8744 500/8619 35/7945
(6.1%) (5.8%) (0.44%)

Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-
Based Surgery 2003: 1(1) 11-21.
Nontraumatic (urgent)
Thoracotomy ?
• Acute mediastinitis
 descending necrotizing
mediastinitis (DNM)

• Complication of odontogenic,
peritonsilar, or other pharyngeal
infections

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