Morning Report

Morning Report: Thoracotomy

Resident Presenter:  Anastassia Sullivan

Summary: Patient was a 49 y/o helmeted bicyclist struck by a motor vehicle.  Unknown if there was LOC.  Patient was found by BLS responsive, combative but answering questions appropriately; was placed in C-collar and on backboard.    On arrival he was combative but oriented, moving all extremities spontaneously, diaphoretic and pale.  Initial fast exam was negative.  Due to agitation, decision was made to intubate.  While preparing for intubation, patient became apneic and unresponsive, lost pulses, and CPR began.  After about 20 minutes, FAST was repeat, remained negative, no cardiac motion.  An anterolateral thoracotomy was performed while CPR continued; then cardiac massage began.  Patient was defibrillated twice using internal defibrillators at 20J, which brought patient into Vfib for a short time, did not regain pulses.  The aorta was clamped, but patient fell back into systole and was pronounced.

Learning Points:

  • Goals of thoracotomy include hemorrhage control, release of tamponade, cardiac massage, exposure of descending thoracic aorta for cross-clamping, and repair of cardiac or pulmonary injury
  • Indications for thoracotomy in blunt trauma include blunt thoracic injury with previously witnessed cardiac activity, rapid exsanguination from the chest tube, and unresponsive hypotension despite resuscitation
  • Increased thoracotomy survival rates are associated with previously noted pupillary response, spontaneous ventilation, carotid pulse, measurable blood pressure, extremity movement and cardiac electrical activity

EBM Article:

Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective.

Cases of ED thoracotomy over eighteen institutions from 2003 to 2009 were analyzed to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival.  They found that ED thoracotomy can be considered futile when prehospital CPR exceeds 10 minutes after blunt trauma, prehospital CPR exceeds 15 minutes after penetrating trauma, and in asystole without cardiac tamponade.

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