Contraindication of Emergency room thoracotomy: 1. Blunt trauma: * CPR> 5 min with no sign of life. * Asystole with cardiac temponade. 2. Penetrating trauma: * CPR>15 min. * Asystole without cardiac temponade. Also, Severe head injury Severe multisystem injury Improperly trained team Insufficient equipment Approach: A supine anterolateral thoracotomy is the accepted approach for emergency department thoracotomy. A left sided approach is used in all patients in traumatic arrest and with injuries to the left chest. Patients who are not arrested but with profound hypotension and right sided injuries have their right chest opened first. Procedure: 1. Pericardiotomy for pericardial temponade - The pericardium is opened longitudinally to avoid damage to the phrenic nerve, which runs along its lateral border.Evacuate any blood and clot from the pericardial cavity. 2. Cross Clamping the Aorta: Cross-clamping the descending aorta redistributes the available blood flow to the coronary and cerebral arteries.Selective clamping of the descending aorta near the level of the diaphragm can also be used to control hemorrhage in abdominal vascular injuries. Specific operative approaches: 1. Repair of the heart by- Digital occlusion of the laceration Satinsky clamp for atrial wounds Interrupted sutures. 2.Internal (open) Cardiac Massage : Perform internal cardiac massage with a 2-handed technique to avoid perforation of the ventricle with your thumb. Compared with standard CPR, which delivers up to 20% of the cardiac output, internal CPR produces up to 55% of the bodys baseline perfusion. Open-chest CPR has been shown to improve coronary perfusion pressure and increases return of spontaneous circulation with equal benefit in penetrating and blunt trauma.Continue this resuscitation effort for 20 minutes before termination.. 3. Cross Clamp Pulmonary Hilum: Air embolism may result from severe lung trauma where air passages, and pulmonary veins are ruptured in continuity, and air embolism to the coronaries may occur. Partial or complete rupture of the pulmonary artery or pulmonary vein may also be controlled. Cessation of EDT-- Cessation of an resuscitation and an emergency department thoracotomy requires careful consideration and should be terminated if:- Irreparable damage Massive head injuries Pulseless electrical activity (PEA) Systolic BP< 70 after 15-20 mins Asystolic arrest. Complications: EDT is a potentially lifesaving procedure; however, its complications must be weighed against its benefits. Specific complications of EDT include the following: Neurologic complications from hypoperfusion: Anoxic brain death occurs in as many as 50% of survivors, requiring ongoing institutional care. * Recurrent bleeding from chest wall or internal mammary artery * Damage to the coronary arteries * Other cardiac damage resulting in ventricular septal defects, aortic valvular irregularities, atrial septal defects, and cardiac conduction defects * Damage to the esophagus during aortic cross-clamping * Damage to the phrenic nerve * Ischemia to distal organs and spinal cord due to cross-clamping of aorta
Posted on: Sun, 16 Mar 2014 16:37:50 +0000
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