急診緊急開胸術 How / When / Why ?

急診緊急開胸術急診緊急開胸術How / When / Why ?How / When / Why ?

陳昭文醫師陳昭文醫師高雄醫學大學附設醫院外傷科高雄醫學大學附設醫院外傷科

Trauma Service / KMUHTrauma Service / KMUH

急診緊急開胸術急診緊急開胸術 Emergent room thoracotomy (ERT)Emergent room thoracotomy (ERT) Emergency department thoracotomy (EDEmergency department thoracotomy (ED

T)T) ER Resuscitative thoracotmy (ERRT)ER Resuscitative thoracotmy (ERRT) Open-chest cardiac messageOpen-chest cardiac message


急診緊急開胸術急診緊急開胸術 The term “emergency room resuscitative tThe term “emergency room resuscitative t

horacotomy” (ERRT) should be restricted thoracotomy” (ERRT) should be restricted to a thoracotomy that is performed on a pato a thoracotomy that is performed on a patient in extremis (impending death) outside ient in extremis (impending death) outside the operating room…the operating room…


Patient in extremisPatient in extremisOpen Abdomen + Open ChestOpen Abdomen + Open Chest


急診緊急開胸術急診緊急開胸術Why?Why?


Time!Time!

外傷病患愈早得到終極而適切之照護其外傷病患愈早得到終極而適切之照護其生存機會愈高生存機會愈高•出血控制出血控制•復甦治療復甦治療


急診緊急開胸術急診緊急開胸術When?When?


Clear indication for EDTClear indication for EDTTrauma 5th ed (2004)Trauma 5th ed (2004)

Salvageable postinjury cardiac arrestSalvageable postinjury cardiac arrest• Sustain witnessed cardiac arrest with high likeSustain witnessed cardiac arrest with high like

lihood of isolated intrathoracic injury, particulalihood of isolated intrathoracic injury, particularly penetrating rly penetrating cardiaccardiac wounds wounds

Persistent severe post-injury hypotension Persistent severe post-injury hypotension (Sys Bp < 60mmHg)(Sys Bp < 60mmHg)

• Cardiac tamponadeCardiac tamponade• Intrathoracic hemorrhageIntrathoracic hemorrhage• Air embolismAir embolism• Active intra-abdominal hemorrhageActive intra-abdominal hemorrhage


Relative indication for EDTRelative indication for EDTTrauma 5th ed (2004)Trauma 5th ed (2004)

Refractory moderate post-injury hypotensiRefractory moderate post-injury hypotension on (Sys Bp < 60mmHg) (Sys Bp < 60mmHg) due todue to• Cardiac tamponadeCardiac tamponade• Intrathoracic hemorrhageIntrathoracic hemorrhage• Air embolismAir embolism• Active intra-abdominal hemorrhageActive intra-abdominal hemorrhage


EDT IndicationEDT IndicationUSC guidelines 2004USC guidelines 2004

Liberal Use CriteriaLiberal Use Criteria• Some lives may be savedSome lives may be saved• Some patients may become organ donors Some patients may become organ donors • Excellent resident staff educationExcellent resident staff education

Strict useStrict use• CostCost• Infective diseases Infective diseases

Actual cause of death - Autopsy?Actual cause of death - Autopsy?


EDT contraindicationEDT contraindicationUSC guidelines 2004USC guidelines 2004

Blunt multiple traumaBlunt multiple trauma Head traumaHead trauma No vital signs > 20 minsNo vital signs > 20 mins


EDT indicationEDT indicationRosen’s Textbook of Emergency MedicineRosen’s Textbook of Emergency Medicine

Penetrating TraumaPenetrating Trauma • Cardiac arrest at any point with initial signs of life in thCardiac arrest at any point with initial signs of life in th

e field e field • Blood pressure < 50 mm Hg systolic after fluid resusciBlood pressure < 50 mm Hg systolic after fluid resusci

tation tation • Severe shock with clinical signs of cardiac tamponadeSevere shock with clinical signs of cardiac tamponade

Blunt TraumaBlunt Trauma • Cardiac arrest in the EDCardiac arrest in the ED

MiscellaneousMiscellaneous • Suspected air embolusSuspected air embolus


急診緊急開胸術急診緊急開胸術How?How?


EDT technical aspectsEDT technical aspects

ED thoracotomy tray - ED thoracotomy tray - Keep it simple!Keep it simple!



Get everything ready!Get everything ready!• Prepare instrumentsPrepare instruments• Sutures (Prolene 2-0)Sutures (Prolene 2-0)• Assign dutiesAssign duties



IncisionIncision• Left antero-lateral thoracotomy Left antero-lateral thoracotomy • 44thth or 5 or 5thth intercostal space intercostal space • Below nipple in malesBelow nipple in males• Infra-mammary crease in femalInfra-mammary crease in femal

eses• Left sternal border to anterior axLeft sternal border to anterior ax

illary lineillary line• Clam-Shell incisionClam-Shell incision• Trap-door incisionTrap-door incision


IncisionsIncisions



Incision – Common mistakesIncision – Common mistakes• Too low!Too low!

Injury to diaphragmInjury to diaphragm

• Do not follow intercostal spaceDo not follow intercostal space Hard to open chestHard to open chest Messy!Messy!

• Injury to lungInjury to lung• Miss injury to IMAMiss injury to IMA



ProceduresProcedures• Enter chestEnter chest• Evacuate bloodEvacuate blood• Control any extracardial bleedingControl any extracardial bleeding• Open pericardiumOpen pericardium• Cardiac messageCardiac message• Thoracic aortic cross-clampingThoracic aortic cross-clamping



Cardiac injuryCardiac injury• ““Finger of 8” or “Continuous suture”Finger of 8” or “Continuous suture”• Staples!?Staples!?• Avoid coronary vesselsAvoid coronary vessels• Foley’s catheter in appropriate cases Foley’s catheter in appropriate cases



Cardiac injuryCardiac injury• Common mistakesCommon mistakes

Pledgets!Pledgets! Cut the phrenic nerveCut the phrenic nerve Foley’s catheter in atrial wouFoley’s catheter in atrial wou

ndsnds Failure to examine posterior Failure to examine posterior

aspectaspect Not prepared!Not prepared! ””Give me a 2-0 suture!”Give me a 2-0 suture!”



Aortic cross-clampingAortic cross-clamping• Redistribute limited volume of blood to heart aRedistribute limited volume of blood to heart a

nd brainnd brain• Decrease subdiaphragmatic bleedingDecrease subdiaphragmatic bleeding• 2-3 cm above diaphragm2-3 cm above diaphragm• Sharp dissectionSharp dissection



Aortic cross-clampingAortic cross-clamping• Common mistakesCommon mistakes

Clamp the esophagus!Clamp the esophagus! Injury to the esophagusInjury to the esophagus Tear intercostal vesselsTear intercostal vessels Try to clamp a “collapsed” aTry to clamp a “collapsed” a

orta without dissectionorta without dissection



Cardiac resuscitationCardiac resuscitation• Fluid resuscitation (Level 1 infuser!?)Fluid resuscitation (Level 1 infuser!?)• Cardiac messageCardiac message• Epinephrine, defibrillationEpinephrine, defibrillation• Cardiac aspiration for air embolismCardiac aspiration for air embolism• Rewarm heartRewarm heart• Remove aortic clamp ASAPRemove aortic clamp ASAP• Cardiac pacer?Cardiac pacer?



Air embolismAir embolism• SourceSource

Lung injuriesLung injuries Low-pressure heart chambersLow-pressure heart chambers Major venous injuriesMajor venous injuries Often air in coronary veinOften air in coronary vein Aspirate ventriclesAspirate ventricles



Cardiac resuscitation – common mistakesCardiac resuscitation – common mistakes• Defibrillate an empty heartDefibrillate an empty heart• Forget the air embolismForget the air embolism• Massive fluid administration in cardiac tamponMassive fluid administration in cardiac tampon

ade without major blood lossade without major blood loss


OutcomeOutcome

Survival rate varies Survival rate varies • Threshold - Indications of EDTThreshold - Indications of EDT• MechanismMechanism• Anatomical site of injuryAnatomical site of injury• Vital signs – Field ,Transport, ERVital signs – Field ,Transport, ER


OutcomeOutcome

Hopson et al. 2003Hopson et al. 20032%2% 16%16%


OutcomeOutcome


Some facts we have to know…Some facts we have to know…

The greatest mistake in ED Thoractomy is The greatest mistake in ED Thoractomy is not doing it early enough! …not doing it early enough! …be brave!be brave!

Thoracotomy in the ED should only be perfThoracotomy in the ED should only be performed by an appropriately trained surgeonormed by an appropriately trained surgeon… … Poor experience we have!Poor experience we have!

A trauma patient who loses vital signs in thA trauma patient who loses vital signs in the ED may be saved by immediate thoracote ED may be saved by immediate thoracotomy, especially those with penetrating injuomy, especially those with penetrating injury… ry… be aware of it!be aware of it!


10 Control bleeding! Control bleeding! Grasp every opportunity! Grasp every opportunity!

Time is of essence!Time is of essence!

思考外傷救護目標思考外傷救護目標


THANK YOU!THANK YOU!

急診緊急開胸術 How / When / Why ?

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