Trauma Thoracotomy Lecture Notes

Introduction

• Common theme: a lot of opinions, not much evidence
• Goal: present data from our service (London Ambulance)

Definition of Traumatic Cardiac Arrest

• Standard Definition: Patient unconscious, unresponsive, no central pulses
• Clarification: May have no measurable cardiac output yet heart not necessarily in VF/asystole

Prevalence and Context

• Traumatic Cardiac Arrest common in trauma cases
• Statistics from London Ambulance:
  • 1 in 10 patients in traumatic arrest
  • ~1 patient/day in traumatic arrest
  • 75-80% occur pre-hospital

Historical Context

• Case Study: First Survivor of Pre-hospital Thoracotomy in London (1993)
• Highlight: Traumatic intervention effective yet not mainstream

European Resuscitation Council Guidelines

• Key Guidelines:
  • Traumatic arrest treatment ≠ medical arrest treatment
  • Prioritize treating the cause: asphyxia, hypovolemia, tension pneumothorax, cardiac tamponade
  • Mention of thoracotomy as a potential treatment for tamponade and exsanguination

Controversies and Questions

• Is it futile?
• Who are the patients that can survive?
• Should it be pre-hospital or in-hospital? ED or operating theater?
• Only for penetrating trauma or is there a role for blunt trauma?

Data Analysis

• Data Set: 21 years of pre-hospital thoracotomies in London (600 thoracotomies out of 46,000 critically injured patients)

Key Metrics

• Primary Outcome: Survival to hospital discharge
• Secondary Outcomes: Survive the event, neurologically intact survival
• Findings: No difference in survival to 6 months or 2 years for those surviving to hospital discharge

Surgical Techniques

• Steps:
  1. Bilateral thoracostomies
  2. Clamshell thoracotomy
  3. Open pericardium, evacuate clot
  4. Control bleeding
  5. Resuscitation: heart massage, aortic occlusion, volume resuscitation

Results and Analysis

Tamponade vs Hemorrhage

• Different disease processes and outcomes

Tamponade

• Time to Arrest: 50% within 11 minutes, 75% within 20 minutes
• Survival based on thoracotomy timing: >50% if immediate, none beyond 15 minutes
• Survivable Window: Best within 10 minutes for survival (>40% survival)
• ECG Usefulness: Correlates with time in arrest and survival chances

Hemorrhage

• Time to Arrest: Slightly longer than tamponade
• Survival: <2%, no survivors beyond 5 minutes
• Key Factors: High volume resuscitation, aortic occlusion

Future Improvements

• More blood carried pre-hospital, improved aortic occlusion techniques
• Importance of quick decision-making and effective system support

Blunt Trauma

• Blunt trauma involves unique challenges
• Survival stats similar between tamponade from blunt and penetrating trauma
• Need for ultrasound and clinical judgment

Final Thoughts and Q&A Highlights

• Traumatic arrest needs rapid intervention, mostly pre-hospital
• Thoracotomy effective for tamponade, limited for hemorrhage
• Decision-making supported by ECG, quick action essential

Key Learnings:

• Effective procedures and survival windows vary between tamponade and exsanguination
• Proper resuscitation techniques crucial for survival
• Continuous training and system support essential