Emergency Resuscitative Thoracotomy Webinar Notes

Hello everyone, I can't see you but I can see from the screen that there's quite a few of you there from all over the world. So many thanks for giving up an hour of your evening to come and join us at the webinar. I'm a consultant in emergency medicine and pre-hospital care and the clinical director of trauma at the Royal London Hospital. And I guess my credentials for giving this lecture are really based on the fact that I've worked for London Hems or London's Air Ambulance for 19 years now and working in a major trauma centre in London. Unfortunately, we have a fairly high level of penetrating trauma. Between me and my colleagues we've actually got a lot of experience of undertaking this procedure so I'm delighted to join you this evening and I hope that we'll be able to share some of our collective experience, knowledge and actually some new data with you which I hope will influence your practice. So the aims of the webinar are I hope that I'm going to encourage you and teach a little bit so that you'll know when it's appropriate to undertake an emergency resuscitative phylacotomy. We're going to revise the emergency clamshell technique for doing this procedure. I'm going to talk quite a lot about the potential pitfalls because I think that's really important in getting the procedure right and optimising your chance of generating survival. And ultimately, at the end of this, I hope that you'll all feel more confident if you're a physician to undertake the procedure. And if you're whether you're a nurse, a paramedic, an EEC, technician, depending where you work in the country, I hope that you'll feel able to support someone. who's the physician who perhaps may be undertaking this for the first time. Believe it or not some doctors who have done this for the first time have got a survivor out of their first procedure so and a lot of the time it's about having people around them that are supportive, encouraging and also know what's going to happen next and help them through it. So It is an operation. I'm going to talk a bit about the procedure I'm going to teach you or talk to you about is appropriate for doing pre-hospital in an emergency department or even in an operating theatre. It is the technique that surgeons use for an emergency resuscitative thoracotomy. But it does have to be done to as high a standard as possible. We would hope to the same standard it would be done in an operating theatre. So everything I'm going to teach you tonight is about how to do it properly using the right surgical equipment. So many of you probably work in areas where you don't see a high amount of penetrating trauma. So the case I want you to think about as we go through this evening is a fairly what I would say a standard call in London, unfortunately, but would probably prompt you to anticipate that you think you might have to do a thoracotomy when the patient arrives. So we're going to assume that an ambulance service has put a call in. It's not an advanced pre-hospital team with a physician, but they've put a blue call in to say there's a 15 year old male who has a central chest stab wound. He's got agonal respirations and they're going to be with you in 12 minutes. So if you're a paramedic or pre-hospital physician, you can think about what you might be doing if you were looking after this patient in the pre-hospital setting. Are you going to pull your ambulance over? Are you going to stop? Are you going to keep going? But if you're in the emergency department or in a hospital, think about perhaps what you might be getting ready and what might happen once the patient arrives. So time is absolutely critical. We talk about time quite a lot as we go through. I just want you to keep that in mind. And part of the great thing about education like this webinar is that by sitting down in the calm of your lounge or, you know, your study and thinking about these things in advance. and improving your understanding of the physiology and decision making. When it actually happens in front of you, you'll be able to make your decisions more quickly because you spent that time preparing. Many of you will be familiar with the ERC guidelines for the management of traumatic arrest. And just to reassure you, what I'm teaching you tonight is absolutely part of the guidelines. So whilst you're thinking about the pathology behind the cause of the traumatic cardiac arrest. If you suspect that the patient has cardiac tamponade or indeed has exsanguinated in a short period of time, number four on this list says to relieve tamponade. Now it says for penetrating chest injury, but hopefully by the end of the evening, you'll realise that there's more utility for this procedure than just penetrating chest injury. But the purpose of the lecture is to give you the expertise and talk about the equipment required so that you feel better equipped to do it. But it is in the guidelines and it's absolutely an appropriate procedure for you to consider doing. Some of you will know about the HOT algorithm, the two H's and two T's to help you diagnose what's going on in a traumatic arrest, but also the HOT algorithm for deciding what treatments are appropriate. Now, thoracotomy is at the bottom of this list and you may have to do some of these other things as well whilst you're contemplating doing a thoracotomy. Thoracotomy. But again, it should be on your list of considerations for a traumatic cardiac arrest. So by the end of the talk, I want you to try and be a bit clearer in your mind about what your role might actually be and what you're actually going to do if this patient presents to you. It's always worth remembering that basics are important. So I'm going to focus totally on the procedure, but other things such as airway management, getting IV access and having all the other things happening around the patient are equally important. And that's the sort of thing you can cover if you do a simulation or a training exercise related to thoracotomy. One top tip that I often give people is that if you're the team leader or indeed the pre-hospital team at Turn Up, while you're being told what's happened to the patient, just try and do a primary survey with your eyes whilst people are talking to you. So you can try and work out as quickly as possible whether a thoracotomy or another procedure is actually indicated. We're also really sort of hot in our service about teaching people about attention to detail and trying to do things correctly the first time. Also anticipating what needs to happen next. And that's a really important role for the person supporting the person doing the operation. We're always trying to provide support to our team members. And of course, that's backed up by having good knowledge of standard operating procedures and the ongoing trauma pathway for after the thoracotomy. So if you're involved as a team, be it pre-hospital or in the emergency department, your job before you undertake thoracotomy is to perform an assessment, which is often quite brief, but you're rapidly trying to identify injuries. You're then going to provide appropriate treatment to a high standard of care. As I said, this is a surgical procedure. But there will be simultaneous activity around you. And we're operating at a level here beyond ATLS. That's not one thing at a time in a stepwise fashion. It's simultaneous activity and it will be patient focused. So whilst we have algorithms for what to do in traumatic arrest, you're going to treat the patient in front of you and provide appropriate care. So hopefully this is how you're all feeling now. Hopefully you've got a cup of coffee, glass of wine or your dinner. That's probably not how you're going to feel when this patient presents themselves to you. And what we're trying to get. to the point of is making sure that everyone in the team, be it a small team or a large team, knows what they've got to do and the person who's going to undertake the procedure is prepared to do it. Now if you're working in ED there'll be a lot of people and especially if they know that this call's coming in and certainly at the Royal London for a call like this there'll probably be 40 or 50 people that would turn up whether it's observing or being involved with the resuscitation of the patient. If you're a pre-hospital team, it might just be doctor and a paramedic with the ambulance crew and perhaps police who are on scene. So team size alters, but actually you probably you don't really need everybody in the team to understand what you're doing. But the more that do know, the better it generally goes. So what we're trying to achieve is survivors with good neurological outcome. And these are just a few of the patients that London Hems or London's Air Ambulance has treated over the years. And you can see they've got. They've got some scars, which are perhaps not to the standard a plastic surgeon would like. But actually, all of these patients have survived with good neurological outcome. As I said, some of these were done by people doing it for the first time. They weren't all surgeons. Some were anaesthetists, some were emergency physicians. So the bottom line is you can do this procedure. So I've used this slide for quite a couple of years now to try and explain to people when you have the best chance of survival. But in a moment, I'm going to show you some data and I've updated this slide as a result of that. So in the past, what I've taught people is that generally, if you undertake a thoracotomy, you're more likely to have a successful outcome. If the pathology is penetrated or the mechanism injury is penetrating compared to blunt injury. And that's really because if you're going in to do a thoracotomy, you're really hoping that you're going to find a cardiac wound with tamponade. So a cardiac wound would tend to have. a better outcome because it's more manageable than for example thoracic bleeding and equally you're better to have an injury that's in the car that's cardiac or thoracic when you're in the thoracic cavity than you would be if they were bleeding below the diaphragm so you had an extra thoracic injury equally your chances of getting a survivor are better if the patient has signs of life when you arrive compared to if there's no signs of life or they've had prolonged cpr London's Air Ambulance, as I said, we've done quite a few thoracotomies over the years and in about 2016 we published this paper which is about 13 of our survivors. If you look at the site of injury, you can see that nearly all of these patients had a right ventricular wound with cardiac tamponade. And if you think about why they might have survived, it's probably... because the primary pathology was tamponade, but also because the wound was right ventricle, which is right at the front of the heart, hence it's relatively easy to suture. The other key thing about this group of patients was that you can see the time from cardiac arrest to the time of the team attending. In over half the cases, the HEMS team were actually on scene when the patient arrests. All of these patients had a very short time from cardiac arrest to the team being there, in all cases, less than 10 minutes. Also, if you look at the cardiac rhythm, the presenting rhythm before the patient had the thoracotomy. about 50% actually had organised electrical activity or PEA. But of note, there were also a few that had asystole. And as you can see, most of them survived with a good neurological outcome. So that data is interesting. And I guess it encourages you to say, well, asystole doesn't show futility. and that the quicker you do this procedure the better and they are definitely good takeaway messages. But recently Zane Perkins who's one of the HEMS consultants and a trauma surgeon at London has reviewed all of our thoracotomies over the last 21 years and that's 600 procedures. So this is the largest series of pre-hospital thoracotomies in the world. It's going to be published I'm just going to share a couple of slides with you which is credit to Zane and the colleagues that have actually analyzed these cases. Now, when you're deciding whether to do this procedure, it's really important to think about what the underlying pathology is. And as you'll see from these two survival curves, there's a big difference between the patients who have cardiac tamponade compared to the patients who have exsanguinated from other injuries. So the curve on the left hand side, the black line in the middle of the red shows the best fit curve for all of our data. So 105 patients had cardiac tamponade when they had their thoracotomy undertaken. And what you can see is that within 15 minutes, the survival rate drops from 50 percent to zero. It's quite it's a it's a steep curve, but actually you've probably got 15 minutes before your potential survival rate is almost zero. If you look at the exsanguinating group of patients and there are 418 patients in this group, you can see that the survival rate starts at 10 percent from the time of arrest. and drops down to zero within about five minutes. So just to be clear, these curves show the time from time of cardiac arrest to time of starting the intervention, so the duration of arrest before intervention. So there's a difference. If the patient has tamponade, you've probably got 15 minutes to intervene. But if you intervene within the first 10 minutes, you've got a much better chance of getting a survivor. If your patient is exsanguinated and you intervene within the first five minutes, you have a chance, but it's much less of a chance of generating a survivor with exsanguination than tamponade. However, you do get survivors from exsanguination. And of the 418 patients, we've got eight survivors over 21 years. And what you can see is that the mechanisms of injury, they're all penetrating trauma, but they're not all thoracic penetrating trauma. Some of them are thigh injuries, neck injuries. abdominal stab wounds. Again it's interesting to look at their rhythm they all had organised ECG activity be it a sinus tachy or sinus brady and they all had a very short time from cardiac arrest to intervention so the traumatic arrest time was less than five minutes in all cases and usually less than one minute i.e the HEMS team were present when it happened. They also had fairly aggressive management in that they all had aortic occlusion and they all had volume loading. Some of the patients were quite a long time ago, so you can see had large volumes of crystalloid and some were more recent where they had packed red blood cells and plasma as a single unit. So in order to help you make your decisions, you need to think about the survival window, which is mostly around the duration of arrest to procedure. So for tamponade, you've got up to 15 minutes and for exsanguination, you've got less than five minutes from the time of arrest. So particularly if you're a team leader in an emergency department, this should help you make a decision about whether it's appropriate to start the procedure. OK, we're going to move on to how to do the procedure. So back in 2005, David Wise and some colleagues wrote an excellent article called How to Do It, Emergency Thraucotomy, and that was published in the EMJ. And although that's quite a long time ago now, we still teach and we still use exactly the same technique with a few tweaks. But it's a really good article to read if you just want to see it in black and white. And what I would say is I'm going to take you through the procedure, but there isn't really a substitute for doing some hands on practical training. There are lots of courses around the country, but actually the PERC course run by the Royal College of Surgeons is an excellent course, which quite a lot of us teach on around the country. It's run all over the UK. and the pig model is actually very good to allow you to get a real feel of the anatomy and actually undertake the procedure in a very similar model to the humans. So to start with, if you were going to do your first thoracotomy and you were presented with this amount of kit you would probably be quite daunted. The good news is we like to keep equipment simple and actually this is all you need to start the thoracotomy. You can do most of it with this equipment. In fact, you don't even really need the jiggly saw and the handles on the left hand side. But your main pieces of kit are going to be a 22 blade scalpel. a pair of Spencer Wells forceps, which are both the pieces of equipment you use to do chest drains, so many of you will be familiar with that anyway, and then right-hand side, something that's in every nurse's and every paramedic's pocket, a pair of tough cut shears, although ideally you would like them to be sterile, not that have been used on cutting lots of patients'clothes off before. So a very simple kit that you're all familiar with. The key things you're going to try and do are release cardiac tamponade if it's present, you're going to control any bleeding and then you're going to restart the heart. So three pretty simple things in isolation. But obviously when you put it together, there's more to do. The ultimate goal of this procedure, though, is to resuscitate the heart. We're trying to get oxygenated blood to the coronary arteries and to maintain cerebral perfusion. We're trying to create a good metabolic environment for the. myocardium to allow the heart the best environment to beat before we actually force it to by doing internal cardiac massage if we need to. So it's not just about the operation, but it's also about how we resuscitate the heart in order to get perfusion. This is what we're aiming to do. And this is a really excellent example. Some of you will have seen this photo before. This is a thoracotomy that was done about 20 years ago by a hematologist who was an emergency physician. This is absolutely textbook. You can see it's a beautiful wide incision, clean edges around the skin. It's been done with a single scalpel incision. You can see there's no rib ends sticking through. You've got good access to the lungs. The heart is sitting centrally. You can see the top and the bottom of the heart. The pericardium has been opened and you can clearly see the left anterior descending coronary artery. You can see the left ventricle, the meaty part, and then the large right ventricle at the front of the heart. You can see what great access you get. And this is why we teach clamshell thoracotomy. If you're a cardiothoracic surgeon, you can probably manage some pathologies through a left lateral thoracotomy. But most of us want good access, i.e. clamshell, so we can see what we're doing and we can actually diagnose and then fix the problem. So this is what we're going to try and teach you to do. So surface anatomy is really important. For some of you, you'll still be learning your anatomy now. And I guess this is a good reason to know why anatomy is important and why if you don't enjoy it, just stick with it. But the red dotted line is the line that your incision should take. It's a bit like a swallow shape or an underwired bra, if you like. And this dotted line is marked in the fourth intercostal space. If you remember from your anatomy. your if you go from your suprasternal notch and you come down about an inch and a half you'll get to your angle of lewy which is where you get your first junction on your sternum the immediate lateral relation of the angle of lewy is the second rib okay so first rib you can't feel it's underneath the clavicle the second rib is at the angle of lewy so if you can feel the little uplift on your sternum that's where your second rib is you My advice to people is that you count down the centre of the sternum, you count your rib spaces centrally, you don't go round to the side to do it. So you count from your second rib, second interspace, third rib, third interspace, fourth rib, fourth interspace. And when you get to that point on the sternum, what I do is I look at it and I try and find either a freckle or a mark on the skin, or I push it with my finger to make a slight indentation. And that's where I want to cross the sternum. You are going to move around the side within the rib space to find where you're going to do your thoracostomy in the mid-axillary line. But it's where you cross the sternum, which is the important part of this procedure. You want to go in the fourth intercostal space, ideally, because that gives you that perfect positioning where you can see the top and the bottom of the heart. It also gives you two solid bone ends for your rib spreaders to sit on. If you go in the fifth or sixth, if you get the fifth intercostal space, that's fine too. But if you miss the fifth and you end up in the sixth, you're getting towards the end of the sternum. And there's a risk that you either end up in the wrong cavity in the abdomen or you get right down to the zippo sternum where there isn't anything solid for the rib spreaders to sit on. So counting down carefully and then recognising that ribs are not flat, that there is a curve to them. And when you move around the side to the mid-axillary line, you want to send the fourth into costal space. So it's worth revising this anatomy. Have a look on a skeleton if you've got... one at work or somewhere near home. So to start the actual procedure you've identified your anatomical landmarks and what we do first is just the chest drain incisions or the thoracostomies. This is partly to settle your nerves because if you're a doctor you've probably done a chest drain before and you're going to make exactly the same incision except you're going to extend it backwards. So you're still using a 22 blade scalpel, a nice decent sized scalpel. you're going to count down to your fourth interspace and you're going to make a note of where to cross the sternum you're going to go round to the side mid-axillary line and you're going to make the incision in the line of the intercostal space so I tend to hold the skin above and then cut down away from me um with um in the in the intercostal space what I also do at the same time is you extend posteriorly you make it bigger than usual and you extend to the posterior axillary line and that's going to save you time later because it'll allow the chest to open up nice and wide. So you're going to cut through your skin, fat and a little bit of muscle and then you're going to use your Spencer Wells to push through as you would do for a chest strain. What I do, I'm left-handed but I use my non-dominant hand as a guard and I hold the end of the Spencer Wells probably about an inch from the tip so that I can push hard with my body weight and not plunge through into the thoracic cavity but my... non-dominant hand will stop me from going in too far. I also use a mixture of techniques. So ATLS teaches you to dissect at 90 degree angles to try and divide the intercostal layers, external oblique, internal oblique, transversalis. So I do a little bit of that, but I also push quite hard and I scratch the muscle off the rib below so that I'm just trying to get in as fast as I can. This needs to be done quickly. This patient is in cardiac arrest and you need to help me out. So you can't take 20 minutes to do it. So once you push through, you push your finger through and you make the hole a little bit bigger. And you just make you're checking to see if the lung is up or down. But you're not going to stop even if you get a tension in the thorax, because that isn't the pathology you're looking for. You think this patient has probably got cardiac tamponade. So you're going to do that on both sides. And certainly if it's your first time, I advise you to do. um the thoracostomy on the left the thoracostomy on the right and then whichever side it doesn't matter which side you start with but then you go to the sternum to the mark that you've identified on the sternum and then you join the dots you go from the sternum down to the thoracostomy and you do that on each side and again it's not a straight line it's a curve if it's a lady you're going to lift the breast tissue up and do it in the inframammary fold if it's in a guy you will go under the nipple that's a sort of safe landmark to use but you don't really want to cut right across pec major so it is going to be a curve. If you're super confident you might do the whole incision from side to side in one go that's fine if you feel comfortable doing that. This is where there's one error on the EMJ paper because it draws a very flat line across the chest it's much better if you can do a nice curve because that is where the rib space is on it's going to help you when you then cut through the intercostal muscles. So again, your surgical technique with the scalpel from sternum to thoracostomy is cutting through as deep as you dare, really. This is going to save you time. You want to go through skin, fat and some of the intercostal muscle. When you've done that, you're then going to put the sterile tough cuts into the thoracostomy hole. And again, this is easier if you've extended posteriorly, you can get a better angle. You're going to use your non-dominant index finger to guide you and to protect the lung underneath because you're using new tough cuts, which can sometimes be quite sharp. And you're going to cut in the intercostal space with the tough cuts and you're going to follow the rib space. Don't dive across ribs because if you cut ribs, it takes longer. It blunts your scissors. And if the patient survives, they get horrible neuropathic pain. So just try and cut in that space. You'll come up to the sternum. And when you get to the sternum, if you use two hands on your tough cuts, you will get across most people's sternum. There's some who have very dense or tough bones and you might have to use a jiggly saw, but that doesn't happen very often. And. And then you can complete the other side. And if you've got two people, if you're in an emergency department, you've got two people, you can do a side each and you join at the middle. And the first person to the middle cuts the sternum. If you do have to use a jiggly saw, all you need to do is pass the Spencer Wells force set underneath the sternum, open the jaws of the Spencer Wells and someone will place the jiggly blade into the Spencer Wells. You pull it under the sternum and then you put a handle on each end. We then use the Spencer Wells across the sternum so that when the blade lifts, it doesn't fly off. And then one person holds both handles of the jiggly saw and tends to hold them quite far apart. Don't hold them too close together. Quite far apart to get maximum benefit. And you want to aim to do it in three. So you're probably doing about four or five. If you don't have an aim, you'll do it about 20. So you want to go one, two, three, lift as you do it. And as it comes up, your colleague will put the Spencer Wells on, which will stop them pinging. And as you lift up, if you pull your hands apart, it pulls the jiggly blade tight, which will stop it flying off the handles. You'll be through the sternum. Now, hopefully you've got a good assistant who's done some training. They'll know what to do. So whether it's your EEC, paramedic, an ED nurse, scrub nurse, they will now hopefully have the rib spreaders ready and not completely closed because, again, it uses up time. You want them partly open. Your chest will open naturally. And especially when you lift it a little bit, if you've done a good incision. and you've extended back into the posterior auxiliary line. So the rib spreaders, the official name is finichettos, but if you say rib spreaders, people will know what you mean. We tend to position them with the bar on the right hand side of the patient. There's a couple of reasons for that. It gives you much better access to the left side of the chest for doing aortic occlusion and internal massage. And when you put it in, you want to make sure that the blade is set properly on the ends of the sternum. It should feel quite solid, especially if you've picked the right size as well. You want to make sure you're not trapping any lung when you do that. So you have to just be looking at what you're doing. And then you ratchet it open to give you the best possible access. And if you forgot to extend your thoracostomies, you're going to do that now. So when you're doing this, you're thinking, what can I see? Now, the pathology you're hoping to see is cardiac tamponade, in which case you should see a bulging pericardium, which looks a bit bluey purple and may even look, you know, sort of quite globular. bit like a not a football not quite that big but actually it will look quite abnormal sitting in the middle of the chest so that's good news if you get a lot of blood in thoracic cavity and it looks like massive hemorrhage that's actually not so hopeful for a survivor so the skills you're going to need you've opened the chest the next thing we're going to do is open the pericardium then hopefully we're going to find a cardiac injury we're going to put a finger on the hole decide how we're going to close it decide if we need to do aortic occlusion We're not going to talk about controlling the hyaluronidase. That is a technique that you might have to do, but it's pretty rare, to be honest, and it is a bit more advanced. So opening the pericardium. This is a surgical technique. So you are going to use surgical equipment. Hopefully you will have a thoracotomy kit of some sort. It should be a smaller version of the equipment I showed initially, not the big theatre set, but hopefully an emergency department set. pre-hospital care set which would have some mayo scissors proper curved surgical scissors generally we use those to open the pericardium you need to tent the pericardium and lift it up it's actually a really fibrous layer which is why you get cardiac tamponade because it doesn't really stretch it's not a little wispy layer of um sort of you know adhesion so you have to pick up an actual fibrous um piece of tissue if you've got very tense tamponade that can be difficult to pick it up with the Spencer Wells or mosquito forceps so what you might do is turn the scalpel upside down to the blade towards the sky make a tiny nick and then get your surgical scissors in and that's okay if there's a big tamponade because the heart is protected but you don't want the scalpel blade to be down towards the heart where you might lacerate it if it's not a tense tamponade or you don't even see a tamponade you're still going to open the pericardium so you still you will pick it up with your Spencer Wells and then put your scissors in if you if you can and then what I do is I use my non-dominant index finger to guide the scissors up to the top of the heart and your finger will automatically stop where you hit the reflection around the great vessels then that way you know you've opened right up to the top and you're not going to leave a little flap which is going to obstruct outflow later you then come back down to the bottom so in this yellow dotted line you've cut up the front you go back to the bottom and then you cut cut one side and then the other. Running down the side of the heart is the phrenic nerve. It looks like a little white shoelace. You could look at it. We shouldn't be anywhere near it, to be honest, if we don't cut that far back. But you just want to open the pericardium so that you can look at the front and the back of the heart. If you've had a through and through wound, you might not get a tamponade because it would have decompressed already. So it doesn't mean there's not a cardiac wound if you haven't got tamponade. So have a good look at the front and the back of the heart, looking for your wounds. And think at the same time about whether this heart has actually got volume in it or whether it's empty and communicate that to your team, because that will then allow them to get some blood ready if they need it. It will also signal to you if the heart's empty that you're probably going to need to do a aortic occlusion as well. So now you've opened the pericardium, you're hopefully going to find a wound. And we'd like it if it was right on the front of the heart, partly because it's easier to suture. I think I've covered all this. And the reason. to actually say why the heart is empty or full you tamponade and exsanguination have two different treatments so for the tamponade you might actually get rosk straight away once you release the tamponade and close the hole the exsanguination we're going to need to do a autoclusion give some volume etc so different treatment priorities for the two pathologies so how are you going to close the hole well the first thing you do is put your finger on it while you have a quick think and a chat with your colleague and tell them what you want If you're very close to hospital, you're in hospital and there's a cardiac surgeon coming, you might just keep your finger on the hole if you've got ROSC, but actually you can probably close the hole if it's not too big. Your options are generally a handheld silk needle or a stapler in the emergency department. We don't tend to use needle holders because it just adds extra sort of faff to the process. And the handheld silk allows you to control the depth and the width of your suture. You can also do running suture if it's a bigger wound to save time because every knot you tie takes a bit of time to do. Staples are also good. They're particularly good for left ventricular wounds because it's quite a meaty chamber and obviously the edges are likely to be closer together. They're a bit of a challenge to use on the right ventricle if the heart is empty because you can't get the edges together. The staples are obviously a set depth and width so you can't adjust your sort of bite like you can with a suture. So there's pros and cons to both types of closure. And it's worth having a practice with both so you can decide what you want to use on a particularly given cardiac wound. So once you close the wound, you've then got to do check the back of the heart, make absolutely sure there's no wounds that you've missed. Once you close the wound, you've got to then restart the heart. We're going to assume this patient is still in a rest. So oxygenation is important. Hopefully someone's managed the airway that's been delegated and that's been done well. You've then got to decide whether the patient needs volume. You've made that assessment by looking at the heart and also from your initial assessment of the patient about their volume status. That might involve giving blood products. If you do give blood products, ideally you want to give them in a one to one ratio, which pre-hospital would probably be Paxils and plasma. In hospital, you can probably add in other products shortly after arrival. And you should also give tranexamic acid. We give two grams to our code red patients. The protocol in most parts of the country is still to give one gram at the moment. That certainly gives some tranexamic acid as soon as you can. And then just to remind you, so we're looking at the heart and you want to know what the status of this patient is. And actually now you've got to decide you're going to give some volume. If the heart is empty, you really want to put aortic occlusion on. We don't advise that you do an aortic clamp unless you're a surgeon, you absolutely know what you're doing. But manual aortic compression like you can see in this picture, someone's hand with a long glove, ideally a glove that's up to the elbow, with their hand in behind the left lung, pushing against the left hand side of the spinal column. People think they're going to feel a tube when they put their hand in. You will not feel aorta. It feels like a flat piece of squid and they're just going to put their palm down, hand in the back. and just push down at the side, the left-hand side of the spine of the vertebra and against the back of the chest. It won't be total aortic occlusion, but it should be enough to improve the coronary and hence the cerebral circulation with some volume going in through whichever access has been achieved before. And ideally you want that access to be above the diaphragm. So it can be external jugular, subclavian central line. antecubital fossa access so that should all be happening hopefully while someone's doing this procedure. So oxygen volume you may now have to do internal massage there's no point doing cardiac massage on a heart that is empty because you'll damage the conducting system and the valves so you want some volume going in and then you what you'll do is you put your hands on the heart take you back to this picture and you want to keep the heart lying flat in its bed. So one hand underneath the heart and one on front. We do massages with two flat hands, none of this using your thumb. Some people have put their thumb through the front of the heart, so you want to have your heels of your hands together around the apex and then you're effectively just doing systole by compressing the whole heart from the bottom to the top. You need to give it time to fill and then you allow, then you support it in emptying. You don't go at 100 a minute. You start very slow, allowing it to fill, and then the rate can gradually increase as the heart fills and starts to improve. Up to now, we haven't mentioned monitoring, so you don't need any monitoring on in particular at this point. And actually, it may be a hindrance to your incision if there are defib pads or monitor leads in the way. But now it would be quite helpful to put particularly end tidal CO2 monitoring because it's going to allow you to adjust your contract. your internal massage to get the best end tidal CO2 you can. You have to do massage a little bit harder than you might imagine. So you really got to get your hands around the heart and you can have a bit of an internal competition with yourself by getting the end tidal CO2 as high as you possibly can. Other things to think about temperature. When you do a thoracotomy, patients cool really, really quickly. You may, particularly if you're outside in the winter, you might have to tip some warm saline into the chest cavity to get the heart to restart. You can microwave a bag of IV fluids, if there's a microwave somewhere to hand for 60 seconds, give it a shake. And then you can tip it into the chest cavity. Or if you're in a hospital, you may actually have a cabinet with warm saline. Other things to think about for restarting the heart are electrolytes and also VF. So it's likely if your patient's been in a rest for a little while or they've had a blood transfusion that their potassium may go up. We treat this with boluses of 10 mils of 10% calcium chloride. You may not give the 10 straight away. If they're peri-arrest, it might be 5 mils repeated. If you're in hospital, you'll have access to insulin and dextrose in a blood gas machine. And you may have to give boluses rather than infusion of insulin and dextrose to get the potassium under control. Calcium is often low in major trauma patients, particularly those who've had transfusion. And again, we use calcium chloride. It has better bioavailability than gluconate. And you need three times the volume of gluconate for the same effect. If you need to do... just keep massaging until you're ready to shock. Pre-hospital, we don't carry internal defib pads. In a hospital, 10 joules would be the first shock. Out of hospital, we just use an AED. We take the metalwork out of the chest, close the chest down, and then shock with the defib pads in the standard position. And then once the shock's delivered, open the chest, get back on with massage unless you've got spontaneous sinus rhythm. So the doctor, just going back to the actual roles, the doctor... hopefully will be ready to do this procedure whether they're pre-hospital or NED. Just a bit of advice about PPE, double glove, it's worth wearing your standard rubber gloves with surgical gloves on top. If you're pre-hospital wearing a pencil headlight will help and then eye protection and standard kit and if you're in hospital you can wear a gown. There's a few important things pre-hospital. You need to make it very clear what you're about to do. So everyone understands you need to have hands out of the way. So saying something like we need to open the chest and making sure that all other activity on the chest stops, such as CPR. And just remember when you're doing this, you're going to start as a surgeon. Then you're going to turn into a physician when you troubleshoot why you can't start the heart. Think carefully about the pathology. and the order of intervention. So if you've just had a tamponade, the patient's heart isn't empty, they may not need aortic compression, they may not need blood products. Equally, if they've exsanguinated, you may not have a cardiac wound to suture, but actually you have to focus on getting aortic occlusion and volume in and really good massage. Whoever's assisting has got a lot of work to do, they won't be doing the actual procedure. But certainly pre-hospital, making sure you're doing it in the right space with 360 degree access, making sure you've got additional equipment as listed and actually being a strong advocate and supporting running the scene is really important. And then leading the packaging and getting going to an MTC. And of course, reminding the doctor to do the blue call because they're probably a bit maxed out by now. So pitfalls, I'm going to run through these super fast. There's quite a few. I know you'll have access to the slides that later and I've covered most of them. But. I'm not really going to apologise for having quite a few slides on this because this is where people really go wrong. So just a little note, some of the US guidelines say that asystole, fixed dilated pupils and more than a 10 minute downtime is futility and you shouldn't start the procedure. As I mentioned at the beginning, we've got survivors who fall into this group, which would be deemed futile in the States. So none of these things are against starting the procedure, certainly in the UK. 360 degree access is really important make your space as much like an operating theatre as you can you know if you've got a trolley get the patient at the right height have suction ready and get the lighting the best you possibly can I've talked a lot about the landmarks and surface anatomy that's really important because if you don't get into the right place and get good access yes you're not going to be able to fix the problem you If you don't extend the incision posteriorly, the chest just won't open, you'll have to go back and do something again, which just delays everything. And as I said at the beginning, time to actually solving the problem, relieving the tamponade or getting an aortic occlusion on is what's going to make a difference and hopefully get a survivor. If you don't open the pericardium, you can't inspect the heart. You might miss that wound at the back and the chance to close a hole. You might get ROSC. Once you've got ROSC, you'll then get further bleeding, which is harder to fix with a beating heart. So just have a really good look. And as I said, make sure you extend the pericardium superiorly to prevent any outflow obstruction. Talked about that. Try and close the hole quite quickly. Don't let the patient lose more blood than they need to. So get your finger on the hole. and then have a quick think about what you're going to do. Some courses teach you to do things like use pledges. You just don't need to do that as an emergency. Just close the hole and then someone else with more surgical technique can fix it in theatre and use some pledges. If you have a wound that's very close to a coronary artery, you might have to do a mattress suture just to dive underneath it so you don't actually occlude the coronary artery. And if a patient goes into VF just after you've put a stitch in your coronary artery, you probably just, you know, cause that deliberately. So just cut it out and then have another go. Remember to include the aorta. It's sort of your best friend. Because effectively. reducing the circulating volume um and you know don't forget the aim is to resuscitate the brain and coronary arteries um i mentioned i wasn't going to talk about what's going on around the procedure but it's really important someone does allocate getting iv access is an important task as i mentioned there's various options um but you do want someone to have some blood product ready if that heart is empty and some access to allow you to start filling the heart before you do internal massage so it's all about prioritization and getting things you done and lined up so that they're ready when you need them. I talked about the importance of good don't delegate this to someone who has no idea what they're trying to do. It needs to be slow to start with and you need to have take this bit like bagging a patient you need to be able to feel how much the heart needs and support the heart until you get a good ROSC and as I said have that sort of competition with yourself about how good you can get the end tidal CO2. If you can't start the heart it's probably because it's too empty you too cold, too acidotic, potassium's through the roof, or you haven't managed to get them out of the air. So try and troubleshoot those problems as early as you can. Little note for pre-hospital, when we package a patient, if we're going to hospital, we tend to put them the wrong way around in the ambulance. So the right way on the scoop, and then the scoop loaded in upside down or back to front, if you like, so that patient's head is near the back. door. That's so that you can actually kneel down next to the patient's left hand side and either do massage or a aorta conclusion. And then when we get to hospital, if we've still got a aorta or we're doing massage, we would load the patient end to end rather than side to side on the bed. When you hand over, it's normally quite stressful because there'll be a lot of people. So if you're a team leader, be kind and patient to the people handing over. And if you're the person handing over, just try and get your breath. Probably the most important thing in the handover is to actually mention the important times and what procedures have been done. Debriefs are important as well. These procedures are sort of normal in London, which is a bit sad, but not everywhere else. So it's worth just remembering that seeing the inside of a chest is not a normal activity for most police officers, ambulance service personnel or even ED nurses. So if this does happen, someone's probably made a fairly heroic decision to do it. and just make sure that everyone gets a chance to do both a hot and a cold debrief. Notes are really important as well, partly for research purposes. And also, if you've been unlucky enough that the patient hasn't survived, it will be a coronial inquiry. So just to make sure that your notes are really good. So the patient will then move on to theatre, hopefully, if you have got ROSC, which is good news. They often don't do very much. They never close the pericardium. They often don't take our sutures out and they'll probably just wash out the chest. because although we try and do it aseptically obviously there's a potential risk of contamination they will probably place two or four chest drains and then close the chest up and the patient will go to intensive care but hopefully if you've done a good job your patient will be awake and chatting to you in a couple of days time saying thank you. Our trauma anesthetist use this little acronym based for how they manage the patient in theatre thinking about the same things acid-based status electrolytes. blood product ratios, thinking about time, temperature and correcting electrolytes. So I promised to do a few quick tips. I know I'm running short of time. But this is really just to acknowledge all the people that have helped teach me in the first place, then support me and who also teach on the PERC course that I mentioned before, the whole mixture of surgeons, emergency physicians here. And you'll recognize some famous faces, but I asked all of them probably about 18 months ago to give me their top tips. which are just summarised on the next couple of slides. I've covered most of them in the talk, but it's interesting that even though these people are all very experienced and have done many, many thoracotomies, they still go back to the basics. They still check the positioning of their incision. They always open the pericardium. They always do cardiac massage from the patient's left hand side and start slow. And with suturing, they do good anecdote as much as is needed, but as little as possible. every knot you have to tie is a delay to getting the heart started so just do as much as you need to close that hole and then if you're a team leader these are top tips is it the right thing to do make sure you've got your team wearing ppe flatten the hierarchy you need other people listening out and looking for pitfalls get them to speak up so all really good advice but all quite basic stuff that we can all do you So hopefully you've got a better understanding now, or if you're some of you, and I've seen a couple of people in there who I know that can do thoracotomy very well. But hopefully it's just giving you a bit of an idea about where we are now. Certainly with the London's Air Ambulance and our data. If you still want to learn a bit more, I would go and have a cup of coffee with your local friendly trauma surgeon and just talk it through. Ask them for their top tips. There's some quite good online resources. Rebel EM has got a good explanation of how to do a clamshell. They do it the same as us. And actually East Midlands Emergency Medicine, Education and Media have got some really good sort of preset drills that you can do in your emergency room with your nursing staff with very simple kit that will just get everyone in the same sort of... mind space if you like so what I'd advise you to do if you've never done this before you think you might be put in this situation just perhaps later tonight when you just have a quiet moment shut your eyes imagine you're in your ED or in your ambulance and by the way don't do this in ambulance take them out of the back of the ambulance if you've got to do it but just think it through think about what you do what kit you need what you'd say what order you're going to do things in and then when the patient presents himself hopefully you'll feel more competent than you might have done at half past seven this evening. And I hope this has helped. I've rushed through a little bit because I have loads of slides, but I hope it's been useful. And if anyone wants to get in touch, you can drop me an email. OK, thanks very much, everyone.

And I guess my credentials for giving this lecture are really based on the fact that I've worked for London Hems or London's Air Ambulance for 19 years now and working in a major trauma centre in London. Unfortunately, we have a fairly high level of penetrating trauma. Between me and my colleagues we've actually got a lot of experience of undertaking this procedure so I'm delighted to join you this evening and I hope that we'll be able to share some of our collective experience, knowledge and actually some new data with you which I hope will influence your practice. So the aims of the webinar are I hope that I'm going to encourage you and teach a little bit so that you'll know when it's appropriate to undertake an emergency resuscitative phylacotomy. We're going to revise the emergency clamshell technique for doing this procedure.

I'm going to talk quite a lot about the potential pitfalls because I think that's really important in getting the procedure right and optimising your chance of generating survival. And ultimately, at the end of this, I hope that you'll all feel more confident if you're a physician to undertake the procedure. And if you're whether you're a nurse, a paramedic, an EEC, technician, depending where you work in the country, I hope that you'll feel able to support someone.

who's the physician who perhaps may be undertaking this for the first time. Believe it or not some doctors who have done this for the first time have got a survivor out of their first procedure so and a lot of the time it's about having people around them that are supportive, encouraging and also know what's going to happen next and help them through it. So It is an operation.

I'm going to talk a bit about the procedure I'm going to teach you or talk to you about is appropriate for doing pre-hospital in an emergency department or even in an operating theatre. It is the technique that surgeons use for an emergency resuscitative thoracotomy. But it does have to be done to as high a standard as possible.

We would hope to the same standard it would be done in an operating theatre. So everything I'm going to teach you tonight is about how to do it properly using the right surgical equipment. So many of you probably work in areas where you don't see a high amount of penetrating trauma.

So the case I want you to think about as we go through this evening is a fairly what I would say a standard call in London, unfortunately, but would probably prompt you to anticipate that you think you might have to do a thoracotomy when the patient arrives. So we're going to assume that an ambulance service has put a call in. It's not an advanced pre-hospital team with a physician, but they've put a blue call in to say there's a 15 year old male who has a central chest stab wound. He's got agonal respirations and they're going to be with you in 12 minutes. So if you're a paramedic or pre-hospital physician, you can think about what you might be doing if you were looking after this patient in the pre-hospital setting.

Are you going to pull your ambulance over? Are you going to stop? Are you going to keep going? But if you're in the emergency department or in a hospital, think about perhaps what you might be getting ready and what might happen once the patient arrives.

So time is absolutely critical. We talk about time quite a lot as we go through. I just want you to keep that in mind.

And part of the great thing about education like this webinar is that by sitting down in the calm of your lounge or, you know, your study and thinking about these things in advance. and improving your understanding of the physiology and decision making. When it actually happens in front of you, you'll be able to make your decisions more quickly because you spent that time preparing. Many of you will be familiar with the ERC guidelines for the management of traumatic arrest. And just to reassure you, what I'm teaching you tonight is absolutely part of the guidelines.

So whilst you're thinking about the pathology behind the cause of the traumatic cardiac arrest. If you suspect that the patient has cardiac tamponade or indeed has exsanguinated in a short period of time, number four on this list says to relieve tamponade. Now it says for penetrating chest injury, but hopefully by the end of the evening, you'll realise that there's more utility for this procedure than just penetrating chest injury.

But the purpose of the lecture is to give you the expertise and talk about the equipment required so that you feel better equipped to do it. But it is in the guidelines and it's absolutely an appropriate procedure for you to consider doing. Some of you will know about the HOT algorithm, the two H's and two T's to help you diagnose what's going on in a traumatic arrest, but also the HOT algorithm for deciding what treatments are appropriate. Now, thoracotomy is at the bottom of this list and you may have to do some of these other things as well whilst you're contemplating doing a thoracotomy. Thoracotomy.

But again, it should be on your list of considerations for a traumatic cardiac arrest. So by the end of the talk, I want you to try and be a bit clearer in your mind about what your role might actually be and what you're actually going to do if this patient presents to you. It's always worth remembering that basics are important. So I'm going to focus totally on the procedure, but other things such as airway management, getting IV access and having all the other things happening around the patient are equally important.

And that's the sort of thing you can cover if you do a simulation or a training exercise related to thoracotomy. One top tip that I often give people is that if you're the team leader or indeed the pre-hospital team at Turn Up, while you're being told what's happened to the patient, just try and do a primary survey with your eyes whilst people are talking to you. So you can try and work out as quickly as possible whether a thoracotomy or another procedure is actually indicated. We're also really sort of hot in our service about teaching people about attention to detail and trying to do things correctly the first time.

Also anticipating what needs to happen next. And that's a really important role for the person supporting the person doing the operation. We're always trying to provide support to our team members. And of course, that's backed up by having good knowledge of standard operating procedures and the ongoing trauma pathway for after the thoracotomy.

So if you're involved as a team, be it pre-hospital or in the emergency department, your job before you undertake thoracotomy is to perform an assessment, which is often quite brief, but you're rapidly trying to identify injuries. You're then going to provide appropriate treatment to a high standard of care. As I said, this is a surgical procedure.

But there will be simultaneous activity around you. And we're operating at a level here beyond ATLS. That's not one thing at a time in a stepwise fashion. It's simultaneous activity and it will be patient focused.

So whilst we have algorithms for what to do in traumatic arrest, you're going to treat the patient in front of you and provide appropriate care. So hopefully this is how you're all feeling now. Hopefully you've got a cup of coffee, glass of wine or your dinner.

That's probably not how you're going to feel when this patient presents themselves to you. And what we're trying to get. to the point of is making sure that everyone in the team, be it a small team or a large team, knows what they've got to do and the person who's going to undertake the procedure is prepared to do it. Now if you're working in ED there'll be a lot of people and especially if they know that this call's coming in and certainly at the Royal London for a call like this there'll probably be 40 or 50 people that would turn up whether it's observing or being involved with the resuscitation of the patient.

If you're a pre-hospital team, it might just be doctor and a paramedic with the ambulance crew and perhaps police who are on scene. So team size alters, but actually you probably you don't really need everybody in the team to understand what you're doing. But the more that do know, the better it generally goes. So what we're trying to achieve is survivors with good neurological outcome. And these are just a few of the patients that London Hems or London's Air Ambulance has treated over the years.

And you can see they've got. They've got some scars, which are perhaps not to the standard a plastic surgeon would like. But actually, all of these patients have survived with good neurological outcome.

As I said, some of these were done by people doing it for the first time. They weren't all surgeons. Some were anaesthetists, some were emergency physicians. So the bottom line is you can do this procedure.

So I've used this slide for quite a couple of years now to try and explain to people when you have the best chance of survival. But in a moment, I'm going to show you some data and I've updated this slide as a result of that. So in the past, what I've taught people is that generally, if you undertake a thoracotomy, you're more likely to have a successful outcome.

If the pathology is penetrated or the mechanism injury is penetrating compared to blunt injury. And that's really because if you're going in to do a thoracotomy, you're really hoping that you're going to find a cardiac wound with tamponade. So a cardiac wound would tend to have. a better outcome because it's more manageable than for example thoracic bleeding and equally you're better to have an injury that's in the car that's cardiac or thoracic when you're in the thoracic cavity than you would be if they were bleeding below the diaphragm so you had an extra thoracic injury equally your chances of getting a survivor are better if the patient has signs of life when you arrive compared to if there's no signs of life or they've had prolonged cpr London's Air Ambulance, as I said, we've done quite a few thoracotomies over the years and in about 2016 we published this paper which is about 13 of our survivors.

If you look at the site of injury, you can see that nearly all of these patients had a right ventricular wound with cardiac tamponade. And if you think about why they might have survived, it's probably... because the primary pathology was tamponade, but also because the wound was right ventricle, which is right at the front of the heart, hence it's relatively easy to suture. The other key thing about this group of patients was that you can see the time from cardiac arrest to the time of the team attending. In over half the cases, the HEMS team were actually on scene when the patient arrests.

All of these patients had a very short time from cardiac arrest to the team being there, in all cases, less than 10 minutes. Also, if you look at the cardiac rhythm, the presenting rhythm before the patient had the thoracotomy. about 50% actually had organised electrical activity or PEA. But of note, there were also a few that had asystole.

And as you can see, most of them survived with a good neurological outcome. So that data is interesting. And I guess it encourages you to say, well, asystole doesn't show futility. and that the quicker you do this procedure the better and they are definitely good takeaway messages.

But recently Zane Perkins who's one of the HEMS consultants and a trauma surgeon at London has reviewed all of our thoracotomies over the last 21 years and that's 600 procedures. So this is the largest series of pre-hospital thoracotomies in the world. It's going to be published I'm just going to share a couple of slides with you which is credit to Zane and the colleagues that have actually analyzed these cases. Now, when you're deciding whether to do this procedure, it's really important to think about what the underlying pathology is.

And as you'll see from these two survival curves, there's a big difference between the patients who have cardiac tamponade compared to the patients who have exsanguinated from other injuries. So the curve on the left hand side, the black line in the middle of the red shows the best fit curve for all of our data. So 105 patients had cardiac tamponade when they had their thoracotomy undertaken. And what you can see is that within 15 minutes, the survival rate drops from 50 percent to zero.

It's quite it's a it's a steep curve, but actually you've probably got 15 minutes before your potential survival rate is almost zero. If you look at the exsanguinating group of patients and there are 418 patients in this group, you can see that the survival rate starts at 10 percent from the time of arrest. and drops down to zero within about five minutes. So just to be clear, these curves show the time from time of cardiac arrest to time of starting the intervention, so the duration of arrest before intervention. So there's a difference.

If the patient has tamponade, you've probably got 15 minutes to intervene. But if you intervene within the first 10 minutes, you've got a much better chance of getting a survivor. If your patient is exsanguinated and you intervene within the first five minutes, you have a chance, but it's much less of a chance of generating a survivor with exsanguination than tamponade. However, you do get survivors from exsanguination. And of the 418 patients, we've got eight survivors over 21 years.

And what you can see is that the mechanisms of injury, they're all penetrating trauma, but they're not all thoracic penetrating trauma. Some of them are thigh injuries, neck injuries. abdominal stab wounds. Again it's interesting to look at their rhythm they all had organised ECG activity be it a sinus tachy or sinus brady and they all had a very short time from cardiac arrest to intervention so the traumatic arrest time was less than five minutes in all cases and usually less than one minute i.e the HEMS team were present when it happened. They also had fairly aggressive management in that they all had aortic occlusion and they all had volume loading.

Some of the patients were quite a long time ago, so you can see had large volumes of crystalloid and some were more recent where they had packed red blood cells and plasma as a single unit. So in order to help you make your decisions, you need to think about the survival window, which is mostly around the duration of arrest to procedure. So for tamponade, you've got up to 15 minutes and for exsanguination, you've got less than five minutes from the time of arrest.

So particularly if you're a team leader in an emergency department, this should help you make a decision about whether it's appropriate to start the procedure. OK, we're going to move on to how to do the procedure. So back in 2005, David Wise and some colleagues wrote an excellent article called How to Do It, Emergency Thraucotomy, and that was published in the EMJ. And although that's quite a long time ago now, we still teach and we still use exactly the same technique with a few tweaks.

But it's a really good article to read if you just want to see it in black and white. And what I would say is I'm going to take you through the procedure, but there isn't really a substitute for doing some hands on practical training. There are lots of courses around the country, but actually the PERC course run by the Royal College of Surgeons is an excellent course, which quite a lot of us teach on around the country.

It's run all over the UK. and the pig model is actually very good to allow you to get a real feel of the anatomy and actually undertake the procedure in a very similar model to the humans. So to start with, if you were going to do your first thoracotomy and you were presented with this amount of kit you would probably be quite daunted.

The good news is we like to keep equipment simple and actually this is all you need to start the thoracotomy. You can do most of it with this equipment. In fact, you don't even really need the jiggly saw and the handles on the left hand side.

But your main pieces of kit are going to be a 22 blade scalpel. a pair of Spencer Wells forceps, which are both the pieces of equipment you use to do chest drains, so many of you will be familiar with that anyway, and then right-hand side, something that's in every nurse's and every paramedic's pocket, a pair of tough cut shears, although ideally you would like them to be sterile, not that have been used on cutting lots of patients'clothes off before. So a very simple kit that you're all familiar with. The key things you're going to try and do are release cardiac tamponade if it's present, you're going to control any bleeding and then you're going to restart the heart.

So three pretty simple things in isolation. But obviously when you put it together, there's more to do. The ultimate goal of this procedure, though, is to resuscitate the heart. We're trying to get oxygenated blood to the coronary arteries and to maintain cerebral perfusion.

We're trying to create a good metabolic environment for the. myocardium to allow the heart the best environment to beat before we actually force it to by doing internal cardiac massage if we need to. So it's not just about the operation, but it's also about how we resuscitate the heart in order to get perfusion.

This is what we're aiming to do. And this is a really excellent example. Some of you will have seen this photo before. This is a thoracotomy that was done about 20 years ago by a hematologist who was an emergency physician. This is absolutely textbook.

You can see it's a beautiful wide incision, clean edges around the skin. It's been done with a single scalpel incision. You can see there's no rib ends sticking through. You've got good access to the lungs.

The heart is sitting centrally. You can see the top and the bottom of the heart. The pericardium has been opened and you can clearly see the left anterior descending coronary artery.

You can see the left ventricle, the meaty part, and then the large right ventricle at the front of the heart. You can see what great access you get. And this is why we teach clamshell thoracotomy. If you're a cardiothoracic surgeon, you can probably manage some pathologies through a left lateral thoracotomy.

But most of us want good access, i.e. clamshell, so we can see what we're doing and we can actually diagnose and then fix the problem. So this is what we're going to try and teach you to do. So surface anatomy is really important.

For some of you, you'll still be learning your anatomy now. And I guess this is a good reason to know why anatomy is important and why if you don't enjoy it, just stick with it. But the red dotted line is the line that your incision should take.

It's a bit like a swallow shape or an underwired bra, if you like. And this dotted line is marked in the fourth intercostal space. If you remember from your anatomy. your if you go from your suprasternal notch and you come down about an inch and a half you'll get to your angle of lewy which is where you get your first junction on your sternum the immediate lateral relation of the angle of lewy is the second rib okay so first rib you can't feel it's underneath the clavicle the second rib is at the angle of lewy so if you can feel the little uplift on your sternum that's where your second rib is you My advice to people is that you count down the centre of the sternum, you count your rib spaces centrally, you don't go round to the side to do it.

So you count from your second rib, second interspace, third rib, third interspace, fourth rib, fourth interspace. And when you get to that point on the sternum, what I do is I look at it and I try and find either a freckle or a mark on the skin, or I push it with my finger to make a slight indentation. And that's where I want to cross the sternum. You are going to move around the side within the rib space to find where you're going to do your thoracostomy in the mid-axillary line.

But it's where you cross the sternum, which is the important part of this procedure. You want to go in the fourth intercostal space, ideally, because that gives you that perfect positioning where you can see the top and the bottom of the heart. It also gives you two solid bone ends for your rib spreaders to sit on. If you go in the fifth or sixth, if you get the fifth intercostal space, that's fine too. But if you miss the fifth and you end up in the sixth, you're getting towards the end of the sternum.

And there's a risk that you either end up in the wrong cavity in the abdomen or you get right down to the zippo sternum where there isn't anything solid for the rib spreaders to sit on. So counting down carefully and then recognising that ribs are not flat, that there is a curve to them. And when you move around the side to the mid-axillary line, you want to send the fourth into costal space. So it's worth revising this anatomy. Have a look on a skeleton if you've got...

one at work or somewhere near home. So to start the actual procedure you've identified your anatomical landmarks and what we do first is just the chest drain incisions or the thoracostomies. This is partly to settle your nerves because if you're a doctor you've probably done a chest drain before and you're going to make exactly the same incision except you're going to extend it backwards.

So you're still using a 22 blade scalpel, a nice decent sized scalpel. you're going to count down to your fourth interspace and you're going to make a note of where to cross the sternum you're going to go round to the side mid-axillary line and you're going to make the incision in the line of the intercostal space so I tend to hold the skin above and then cut down away from me um with um in the in the intercostal space what I also do at the same time is you extend posteriorly you make it bigger than usual and you extend to the posterior axillary line and that's going to save you time later because it'll allow the chest to open up nice and wide. So you're going to cut through your skin, fat and a little bit of muscle and then you're going to use your Spencer Wells to push through as you would do for a chest strain.

What I do, I'm left-handed but I use my non-dominant hand as a guard and I hold the end of the Spencer Wells probably about an inch from the tip so that I can push hard with my body weight and not plunge through into the thoracic cavity but my... non-dominant hand will stop me from going in too far. I also use a mixture of techniques. So ATLS teaches you to dissect at 90 degree angles to try and divide the intercostal layers, external oblique, internal oblique, transversalis.

So I do a little bit of that, but I also push quite hard and I scratch the muscle off the rib below so that I'm just trying to get in as fast as I can. This needs to be done quickly. This patient is in cardiac arrest and you need to help me out. So you can't take 20 minutes to do it.

So once you push through, you push your finger through and you make the hole a little bit bigger. And you just make you're checking to see if the lung is up or down. But you're not going to stop even if you get a tension in the thorax, because that isn't the pathology you're looking for. You think this patient has probably got cardiac tamponade. So you're going to do that on both sides.

And certainly if it's your first time, I advise you to do. um the thoracostomy on the left the thoracostomy on the right and then whichever side it doesn't matter which side you start with but then you go to the sternum to the mark that you've identified on the sternum and then you join the dots you go from the sternum down to the thoracostomy and you do that on each side and again it's not a straight line it's a curve if it's a lady you're going to lift the breast tissue up and do it in the inframammary fold if it's in a guy you will go under the nipple that's a sort of safe landmark to use but you don't really want to cut right across pec major so it is going to be a curve. If you're super confident you might do the whole incision from side to side in one go that's fine if you feel comfortable doing that.

This is where there's one error on the EMJ paper because it draws a very flat line across the chest it's much better if you can do a nice curve because that is where the rib space is on it's going to help you when you then cut through the intercostal muscles. So again, your surgical technique with the scalpel from sternum to thoracostomy is cutting through as deep as you dare, really. This is going to save you time. You want to go through skin, fat and some of the intercostal muscle.

When you've done that, you're then going to put the sterile tough cuts into the thoracostomy hole. And again, this is easier if you've extended posteriorly, you can get a better angle. You're going to use your non-dominant index finger to guide you and to protect the lung underneath because you're using new tough cuts, which can sometimes be quite sharp.

And you're going to cut in the intercostal space with the tough cuts and you're going to follow the rib space. Don't dive across ribs because if you cut ribs, it takes longer. It blunts your scissors.

And if the patient survives, they get horrible neuropathic pain. So just try and cut in that space. You'll come up to the sternum. And when you get to the sternum, if you use two hands on your tough cuts, you will get across most people's sternum.

There's some who have very dense or tough bones and you might have to use a jiggly saw, but that doesn't happen very often. And. And then you can complete the other side.

And if you've got two people, if you're in an emergency department, you've got two people, you can do a side each and you join at the middle. And the first person to the middle cuts the sternum. If you do have to use a jiggly saw, all you need to do is pass the Spencer Wells force set underneath the sternum, open the jaws of the Spencer Wells and someone will place the jiggly blade into the Spencer Wells.

You pull it under the sternum and then you put a handle on each end. We then use the Spencer Wells across the sternum so that when the blade lifts, it doesn't fly off. And then one person holds both handles of the jiggly saw and tends to hold them quite far apart. Don't hold them too close together.

Quite far apart to get maximum benefit. And you want to aim to do it in three. So you're probably doing about four or five. If you don't have an aim, you'll do it about 20. So you want to go one, two, three, lift as you do it.

And as it comes up, your colleague will put the Spencer Wells on, which will stop them pinging. And as you lift up, if you pull your hands apart, it pulls the jiggly blade tight, which will stop it flying off the handles. You'll be through the sternum.

Now, hopefully you've got a good assistant who's done some training. They'll know what to do. So whether it's your EEC, paramedic, an ED nurse, scrub nurse, they will now hopefully have the rib spreaders ready and not completely closed because, again, it uses up time.

You want them partly open. Your chest will open naturally. And especially when you lift it a little bit, if you've done a good incision.

and you've extended back into the posterior auxiliary line. So the rib spreaders, the official name is finichettos, but if you say rib spreaders, people will know what you mean. We tend to position them with the bar on the right hand side of the patient.

There's a couple of reasons for that. It gives you much better access to the left side of the chest for doing aortic occlusion and internal massage. And when you put it in, you want to make sure that the blade is set properly on the ends of the sternum.

It should feel quite solid, especially if you've picked the right size as well. You want to make sure you're not trapping any lung when you do that. So you have to just be looking at what you're doing. And then you ratchet it open to give you the best possible access.

And if you forgot to extend your thoracostomies, you're going to do that now. So when you're doing this, you're thinking, what can I see? Now, the pathology you're hoping to see is cardiac tamponade, in which case you should see a bulging pericardium, which looks a bit bluey purple and may even look, you know, sort of quite globular. bit like a not a football not quite that big but actually it will look quite abnormal sitting in the middle of the chest so that's good news if you get a lot of blood in thoracic cavity and it looks like massive hemorrhage that's actually not so hopeful for a survivor so the skills you're going to need you've opened the chest the next thing we're going to do is open the pericardium then hopefully we're going to find a cardiac injury we're going to put a finger on the hole decide how we're going to close it decide if we need to do aortic occlusion We're not going to talk about controlling the hyaluronidase.

That is a technique that you might have to do, but it's pretty rare, to be honest, and it is a bit more advanced. So opening the pericardium. This is a surgical technique.

So you are going to use surgical equipment. Hopefully you will have a thoracotomy kit of some sort. It should be a smaller version of the equipment I showed initially, not the big theatre set, but hopefully an emergency department set. pre-hospital care set which would have some mayo scissors proper curved surgical scissors generally we use those to open the pericardium you need to tent the pericardium and lift it up it's actually a really fibrous layer which is why you get cardiac tamponade because it doesn't really stretch it's not a little wispy layer of um sort of you know adhesion so you have to pick up an actual fibrous um piece of tissue if you've got very tense tamponade that can be difficult to pick it up with the Spencer Wells or mosquito forceps so what you might do is turn the scalpel upside down to the blade towards the sky make a tiny nick and then get your surgical scissors in and that's okay if there's a big tamponade because the heart is protected but you don't want the scalpel blade to be down towards the heart where you might lacerate it if it's not a tense tamponade or you don't even see a tamponade you're still going to open the pericardium so you still you will pick it up with your Spencer Wells and then put your scissors in if you if you can and then what I do is I use my non-dominant index finger to guide the scissors up to the top of the heart and your finger will automatically stop where you hit the reflection around the great vessels then that way you know you've opened right up to the top and you're not going to leave a little flap which is going to obstruct outflow later you then come back down to the bottom so in this yellow dotted line you've cut up the front you go back to the bottom and then you cut cut one side and then the other.

Running down the side of the heart is the phrenic nerve. It looks like a little white shoelace. You could look at it. We shouldn't be anywhere near it, to be honest, if we don't cut that far back.

But you just want to open the pericardium so that you can look at the front and the back of the heart. If you've had a through and through wound, you might not get a tamponade because it would have decompressed already. So it doesn't mean there's not a cardiac wound if you haven't got tamponade.

So have a good look at the front and the back of the heart, looking for your wounds. And think at the same time about whether this heart has actually got volume in it or whether it's empty and communicate that to your team, because that will then allow them to get some blood ready if they need it. It will also signal to you if the heart's empty that you're probably going to need to do a aortic occlusion as well. So now you've opened the pericardium, you're hopefully going to find a wound. And we'd like it if it was right on the front of the heart, partly because it's easier to suture.

I think I've covered all this. And the reason. to actually say why the heart is empty or full you tamponade and exsanguination have two different treatments so for the tamponade you might actually get rosk straight away once you release the tamponade and close the hole the exsanguination we're going to need to do a autoclusion give some volume etc so different treatment priorities for the two pathologies so how are you going to close the hole well the first thing you do is put your finger on it while you have a quick think and a chat with your colleague and tell them what you want If you're very close to hospital, you're in hospital and there's a cardiac surgeon coming, you might just keep your finger on the hole if you've got ROSC, but actually you can probably close the hole if it's not too big.

Your options are generally a handheld silk needle or a stapler in the emergency department. We don't tend to use needle holders because it just adds extra sort of faff to the process. And the handheld silk allows you to control the depth and the width of your suture. You can also do running suture if it's a bigger wound to save time because every knot you tie takes a bit of time to do. Staples are also good.

They're particularly good for left ventricular wounds because it's quite a meaty chamber and obviously the edges are likely to be closer together. They're a bit of a challenge to use on the right ventricle if the heart is empty because you can't get the edges together. The staples are obviously a set depth and width so you can't adjust your sort of bite like you can with a suture. So there's pros and cons to both types of closure.

And it's worth having a practice with both so you can decide what you want to use on a particularly given cardiac wound. So once you close the wound, you've then got to do check the back of the heart, make absolutely sure there's no wounds that you've missed. Once you close the wound, you've got to then restart the heart. We're going to assume this patient is still in a rest.

So oxygenation is important. Hopefully someone's managed the airway that's been delegated and that's been done well. You've then got to decide whether the patient needs volume. You've made that assessment by looking at the heart and also from your initial assessment of the patient about their volume status. That might involve giving blood products.

If you do give blood products, ideally you want to give them in a one to one ratio, which pre-hospital would probably be Paxils and plasma. In hospital, you can probably add in other products shortly after arrival. And you should also give tranexamic acid. We give two grams to our code red patients. The protocol in most parts of the country is still to give one gram at the moment.

That certainly gives some tranexamic acid as soon as you can. And then just to remind you, so we're looking at the heart and you want to know what the status of this patient is. And actually now you've got to decide you're going to give some volume.

If the heart is empty, you really want to put aortic occlusion on. We don't advise that you do an aortic clamp unless you're a surgeon, you absolutely know what you're doing. But manual aortic compression like you can see in this picture, someone's hand with a long glove, ideally a glove that's up to the elbow, with their hand in behind the left lung, pushing against the left hand side of the spinal column.

People think they're going to feel a tube when they put their hand in. You will not feel aorta. It feels like a flat piece of squid and they're just going to put their palm down, hand in the back.

and just push down at the side, the left-hand side of the spine of the vertebra and against the back of the chest. It won't be total aortic occlusion, but it should be enough to improve the coronary and hence the cerebral circulation with some volume going in through whichever access has been achieved before. And ideally you want that access to be above the diaphragm. So it can be external jugular, subclavian central line. antecubital fossa access so that should all be happening hopefully while someone's doing this procedure.

So oxygen volume you may now have to do internal massage there's no point doing cardiac massage on a heart that is empty because you'll damage the conducting system and the valves so you want some volume going in and then you what you'll do is you put your hands on the heart take you back to this picture and you want to keep the heart lying flat in its bed. So one hand underneath the heart and one on front. We do massages with two flat hands, none of this using your thumb.

Some people have put their thumb through the front of the heart, so you want to have your heels of your hands together around the apex and then you're effectively just doing systole by compressing the whole heart from the bottom to the top. You need to give it time to fill and then you allow, then you support it in emptying. You don't go at 100 a minute.

You start very slow, allowing it to fill, and then the rate can gradually increase as the heart fills and starts to improve. Up to now, we haven't mentioned monitoring, so you don't need any monitoring on in particular at this point. And actually, it may be a hindrance to your incision if there are defib pads or monitor leads in the way.

But now it would be quite helpful to put particularly end tidal CO2 monitoring because it's going to allow you to adjust your contract. your internal massage to get the best end tidal CO2 you can. You have to do massage a little bit harder than you might imagine.

So you really got to get your hands around the heart and you can have a bit of an internal competition with yourself by getting the end tidal CO2 as high as you possibly can. Other things to think about temperature. When you do a thoracotomy, patients cool really, really quickly. You may, particularly if you're outside in the winter, you might have to tip some warm saline into the chest cavity to get the heart to restart. You can microwave a bag of IV fluids, if there's a microwave somewhere to hand for 60 seconds, give it a shake.

And then you can tip it into the chest cavity. Or if you're in a hospital, you may actually have a cabinet with warm saline. Other things to think about for restarting the heart are electrolytes and also VF.

So it's likely if your patient's been in a rest for a little while or they've had a blood transfusion that their potassium may go up. We treat this with boluses of 10 mils of 10% calcium chloride. You may not give the 10 straight away. If they're peri-arrest, it might be 5 mils repeated.

If you're in hospital, you'll have access to insulin and dextrose in a blood gas machine. And you may have to give boluses rather than infusion of insulin and dextrose to get the potassium under control. Calcium is often low in major trauma patients, particularly those who've had transfusion. And again, we use calcium chloride. It has better bioavailability than gluconate.

And you need three times the volume of gluconate for the same effect. If you need to do... just keep massaging until you're ready to shock. Pre-hospital, we don't carry internal defib pads.

In a hospital, 10 joules would be the first shock. Out of hospital, we just use an AED. We take the metalwork out of the chest, close the chest down, and then shock with the defib pads in the standard position. And then once the shock's delivered, open the chest, get back on with massage unless you've got spontaneous sinus rhythm. So the doctor, just going back to the actual roles, the doctor...

hopefully will be ready to do this procedure whether they're pre-hospital or NED. Just a bit of advice about PPE, double glove, it's worth wearing your standard rubber gloves with surgical gloves on top. If you're pre-hospital wearing a pencil headlight will help and then eye protection and standard kit and if you're in hospital you can wear a gown. There's a few important things pre-hospital.

You need to make it very clear what you're about to do. So everyone understands you need to have hands out of the way. So saying something like we need to open the chest and making sure that all other activity on the chest stops, such as CPR. And just remember when you're doing this, you're going to start as a surgeon. Then you're going to turn into a physician when you troubleshoot why you can't start the heart.

Think carefully about the pathology. and the order of intervention. So if you've just had a tamponade, the patient's heart isn't empty, they may not need aortic compression, they may not need blood products.

Equally, if they've exsanguinated, you may not have a cardiac wound to suture, but actually you have to focus on getting aortic occlusion and volume in and really good massage. Whoever's assisting has got a lot of work to do, they won't be doing the actual procedure. But certainly pre-hospital, making sure you're doing it in the right space with 360 degree access, making sure you've got additional equipment as listed and actually being a strong advocate and supporting running the scene is really important.

And then leading the packaging and getting going to an MTC. And of course, reminding the doctor to do the blue call because they're probably a bit maxed out by now. So pitfalls, I'm going to run through these super fast. There's quite a few. I know you'll have access to the slides that later and I've covered most of them.

But. I'm not really going to apologise for having quite a few slides on this because this is where people really go wrong. So just a little note, some of the US guidelines say that asystole, fixed dilated pupils and more than a 10 minute downtime is futility and you shouldn't start the procedure.

As I mentioned at the beginning, we've got survivors who fall into this group, which would be deemed futile in the States. So none of these things are against starting the procedure, certainly in the UK. 360 degree access is really important make your space as much like an operating theatre as you can you know if you've got a trolley get the patient at the right height have suction ready and get the lighting the best you possibly can I've talked a lot about the landmarks and surface anatomy that's really important because if you don't get into the right place and get good access yes you're not going to be able to fix the problem you If you don't extend the incision posteriorly, the chest just won't open, you'll have to go back and do something again, which just delays everything. And as I said at the beginning, time to actually solving the problem, relieving the tamponade or getting an aortic occlusion on is what's going to make a difference and hopefully get a survivor. If you don't open the pericardium, you can't inspect the heart.

You might miss that wound at the back and the chance to close a hole. You might get ROSC. Once you've got ROSC, you'll then get further bleeding, which is harder to fix with a beating heart. So just have a really good look. And as I said, make sure you extend the pericardium superiorly to prevent any outflow obstruction.

Talked about that. Try and close the hole quite quickly. Don't let the patient lose more blood than they need to.

So get your finger on the hole. and then have a quick think about what you're going to do. Some courses teach you to do things like use pledges. You just don't need to do that as an emergency. Just close the hole and then someone else with more surgical technique can fix it in theatre and use some pledges.

If you have a wound that's very close to a coronary artery, you might have to do a mattress suture just to dive underneath it so you don't actually occlude the coronary artery. And if a patient goes into VF just after you've put a stitch in your coronary artery, you probably just, you know, cause that deliberately. So just cut it out and then have another go.

Remember to include the aorta. It's sort of your best friend. Because effectively. reducing the circulating volume um and you know don't forget the aim is to resuscitate the brain and coronary arteries um i mentioned i wasn't going to talk about what's going on around the procedure but it's really important someone does allocate getting iv access is an important task as i mentioned there's various options um but you do want someone to have some blood product ready if that heart is empty and some access to allow you to start filling the heart before you do internal massage so it's all about prioritization and getting things you done and lined up so that they're ready when you need them.

I talked about the importance of good don't delegate this to someone who has no idea what they're trying to do. It needs to be slow to start with and you need to have take this bit like bagging a patient you need to be able to feel how much the heart needs and support the heart until you get a good ROSC and as I said have that sort of competition with yourself about how good you can get the end tidal CO2. If you can't start the heart it's probably because it's too empty you too cold, too acidotic, potassium's through the roof, or you haven't managed to get them out of the air. So try and troubleshoot those problems as early as you can. Little note for pre-hospital, when we package a patient, if we're going to hospital, we tend to put them the wrong way around in the ambulance.

So the right way on the scoop, and then the scoop loaded in upside down or back to front, if you like, so that patient's head is near the back. door. That's so that you can actually kneel down next to the patient's left hand side and either do massage or a aorta conclusion.

And then when we get to hospital, if we've still got a aorta or we're doing massage, we would load the patient end to end rather than side to side on the bed. When you hand over, it's normally quite stressful because there'll be a lot of people. So if you're a team leader, be kind and patient to the people handing over. And if you're the person handing over, just try and get your breath.

Probably the most important thing in the handover is to actually mention the important times and what procedures have been done. Debriefs are important as well. These procedures are sort of normal in London, which is a bit sad, but not everywhere else. So it's worth just remembering that seeing the inside of a chest is not a normal activity for most police officers, ambulance service personnel or even ED nurses. So if this does happen, someone's probably made a fairly heroic decision to do it.

and just make sure that everyone gets a chance to do both a hot and a cold debrief. Notes are really important as well, partly for research purposes. And also, if you've been unlucky enough that the patient hasn't survived, it will be a coronial inquiry.

So just to make sure that your notes are really good. So the patient will then move on to theatre, hopefully, if you have got ROSC, which is good news. They often don't do very much. They never close the pericardium.

They often don't take our sutures out and they'll probably just wash out the chest. because although we try and do it aseptically obviously there's a potential risk of contamination they will probably place two or four chest drains and then close the chest up and the patient will go to intensive care but hopefully if you've done a good job your patient will be awake and chatting to you in a couple of days time saying thank you. Our trauma anesthetist use this little acronym based for how they manage the patient in theatre thinking about the same things acid-based status electrolytes. blood product ratios, thinking about time, temperature and correcting electrolytes.

So I promised to do a few quick tips. I know I'm running short of time. But this is really just to acknowledge all the people that have helped teach me in the first place, then support me and who also teach on the PERC course that I mentioned before, the whole mixture of surgeons, emergency physicians here. And you'll recognize some famous faces, but I asked all of them probably about 18 months ago to give me their top tips. which are just summarised on the next couple of slides.

I've covered most of them in the talk, but it's interesting that even though these people are all very experienced and have done many, many thoracotomies, they still go back to the basics. They still check the positioning of their incision. They always open the pericardium. They always do cardiac massage from the patient's left hand side and start slow. And with suturing, they do good anecdote as much as is needed, but as little as possible.

every knot you have to tie is a delay to getting the heart started so just do as much as you need to close that hole and then if you're a team leader these are top tips is it the right thing to do make sure you've got your team wearing ppe flatten the hierarchy you need other people listening out and looking for pitfalls get them to speak up so all really good advice but all quite basic stuff that we can all do you So hopefully you've got a better understanding now, or if you're some of you, and I've seen a couple of people in there who I know that can do thoracotomy very well. But hopefully it's just giving you a bit of an idea about where we are now. Certainly with the London's Air Ambulance and our data. If you still want to learn a bit more, I would go and have a cup of coffee with your local friendly trauma surgeon and just talk it through. Ask them for their top tips.

There's some quite good online resources. Rebel EM has got a good explanation of how to do a clamshell. They do it the same as us. And actually East Midlands Emergency Medicine, Education and Media have got some really good sort of preset drills that you can do in your emergency room with your nursing staff with very simple kit that will just get everyone in the same sort of...

mind space if you like so what I'd advise you to do if you've never done this before you think you might be put in this situation just perhaps later tonight when you just have a quiet moment shut your eyes imagine you're in your ED or in your ambulance and by the way don't do this in ambulance take them out of the back of the ambulance if you've got to do it but just think it through think about what you do what kit you need what you'd say what order you're going to do things in and then when the patient presents himself hopefully you'll feel more competent than you might have done at half past seven this evening. And I hope this has helped. I've rushed through a little bit because I have loads of slides, but I hope it's been useful.

And if anyone wants to get in touch, you can drop me an email. OK, thanks very much, everyone.

Transcript for:Emergency Resuscitative Thoracotomy Webinar Notes

Transcript for:
Emergency Resuscitative Thoracotomy Webinar Notes