Emergency Resuscitative Thoracotomy Webinar

Introduction

• Lecturer: Consultant in emergency medicine and pre-hospital care, clinical director of trauma at the Royal London Hospital.
• Experience: 19 years with London HEMS (London's Air Ambulance), major trauma center experience.
• Webinar Aims:
  • When to undertake an emergency resuscitative thoracotomy.
  • Revise emergency clamshell technique.
  • Discuss potential pitfalls.
  • Increase confidence in performing or supporting the procedure.

Case Scenario

• Example patient: 15-year-old male, central chest stab wound, agonal respirations.
• Importance: Prepare for possible thoracotomy in pre-hospital or ED settings.
• Time Critical: Emphasis on quick decision-making to improve outcomes.

ERC Guidelines

• Procedure part of ERC guidelines for traumatic cardiac arrest.
• HOT Algorithm: Consider thoracotomy alongside other treatments.
• Focus: Basics such as airway management, IV access, etc.

Team and Support

• Role of team members in supporting the physician during the procedure.
• Importance of training and simulation exercises.

Procedure Overview

• Goal: Release cardiac tamponade, control bleeding, restart the heart.
• Techniques:
  • Incision: Clamshell thoracotomy for best access.
  • Surface anatomy: Fourth intercostal space landmarking.
  • Initial thoracostomies to settle nerves and create chest opening.
  • Use of equipment: 22 blade scalpel, Spencer Wells forceps, sterile tough cut shears.

Surgical Steps

• Incision: Count ribs from the sternum, make incision in the mid-axillary line.
• Thoracostomies: Done on both sides, extend posteriorly.
• Sternum Crossing: Use a sterile scalpel and tough cuts.
• Rib Spreaders: Position for best access, ensure proper sterility and positioning.
• Open Pericardium: Tent and lift, use surgical scissors, avoid cutting the phrenic nerve.
• Check and Treat:
  • Identify and cover cardiac wounds.
  • Use sutures or staples as needed.
  • Evaluate heart for volume, consider blood products and aortic compression.

Resuscitation

• Oxygenation & Volume:
  • Important for heart resuscitation.
  • Blood product administration.
  • Consider tranexamic acid.
• Internal Massage: Proper technique essential for effective CPR.
• Monitoring: Use end tidal CO2 for feedback.
• Temperature and Electrolytes:
  • Control potassium and calcium levels.
  • Warm saline if necessary.
• Defibrillation:
  • Use AED or internal defib pads as applicable.

Conclusion

• Team communication and support are vital.
• Detailed medical records for research and legal purposes.
• Continuous improvement through debriefs and simulations.