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KIRUB

2008


EDT
Emergency Department Thoracotomy
Thoracic trauma



Katastrofmedicinsk Centrum
Universitetssjukhuset
Linkping


Tore Vikstrm

Theodore Billroth 1883
The 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 <10% require operation

Majority: simple procedures
Hunt PA, Greaves I, Owens WA.
Department of Academic Emergency Medicine, James Cook University Hospital, Marton Road, Middlesbrough, Cleveland TS4 3BW, UK
Thoracic Trauma and Critical Care (textbook)



EDT
Indications
Penetrating thoracic injury
PEA
Contraindications
Blunt 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% B
Stab: 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 skadeplats 1.2%
Finns under transport 8.9%
Saknas vid ankomst till sjukhus 2.6%
Finns vid ankomst till sjukhus 11.5%


Best survival rates
EDT for stab injuries who arrive with SOL


Low survival rates
Blunt trauma/multitrauma
No SOL in the field
Time is of essense
Scoop and run !

10 min av CPR


VOMIT



Victim Of Modern ImaginTechnology
Choose the right track
ATLS
Airway
Breathing
Circulation
Disability
Exposure
CTLS
Airway
Breathing
CT scan
Death
Eternity
Pitfalls
Delay
Too small incision
Peroperative heart injury
Suture over coronary artery
Peroperative lung injury
Peroperative oesophagus injury
Indication ?
...in the ED

Thoracotomi equipment
Prepared personell
Resuscitation area
Summary EDT
Indications
Stab wounds
Deep shock (BP<70 mmHg)
Non responder
Cardiac arrest in the ED
10 min CPR
Emergency procedure now !

1 out of 4 can be saved

EDT is part of damage control
References
Hunt 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.