27 y/o man delta tta at 2225 pedestrian struck by suv in cardiac arrest on arrival king airway...
TRANSCRIPT
![Page 1: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/1.jpg)
27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy, 2
U PRBC, IC epinephrine with ROSC Aorta crossclamped Taken immediately to OR
![Page 2: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/2.jpg)
Question #1 Midlevel
Describe the steps of a resuscitative thoracotomy
![Page 3: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/3.jpg)
Question #2 chief
Describe the indications of a resuscitative thoracottomy
![Page 4: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/4.jpg)
Question #3 Intern
Why do we clamp the aorta?
![Page 5: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/5.jpg)
In OR, multiple rounds of IC epinephrine, cardiac massage
Laparotomy performed Ventricular fibrillation arrest Pupils fixed and dilated Resuscitative efforts terminated at
2256
![Page 6: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/6.jpg)
Question #4 Last- Chief resident
State reasons for NOT doing a thoracotomy
![Page 7: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/7.jpg)
Indications for ED thoracotomy
Salvageable postinjury cardiac arrest Witnessed penetrating trauma with <15 min
prehospital CPR Witnessed blunt trauma with < 5 min
prehospital CPR
Severe postinjury hypotension due to Cardiac tamponade Hemorrhage, air embolism
![Page 8: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/8.jpg)
Contraindications
Penetrating trauma CPR >15 min and no signs of life
(pupillary response, respiratory effort, motor activity)
Blunt trauma CPR >5 min and no signs of life,
asystole
![Page 9: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/9.jpg)
Steps
Anterolateral incision through 4th intercostal space, sternal border to midaxillary line
Heavy scissors to cut intercostal mm Insert rib spreader, handle down Open pericardium anterior to phrenic n
Mobilize lung Control pulmonary hilum Crossclamp aorta Open cardiac massage/defibrillation
![Page 10: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/10.jpg)
![Page 11: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/11.jpg)
![Page 12: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/12.jpg)
• AIM: identify injury patterns consistent with survival after ED thoracotomy
•To define limits of resuscitative thoracotomy to enable development of rational guidelines to withold or terminate efforts
•Prospective multicenter study, 18 institutions representing Western Trauma Association, 6 year period
![Page 13: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/13.jpg)
Results
56 patients surviving hospital discharge 30% survivors = stab to ventricle 16% GSW lung 9% after blunt trauma 34% underwent prehospital CPR 7 patients survived with asystole at ED
arrival 18% had moderate-severe anoxic brain
injury
![Page 14: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/14.jpg)
![Page 15: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/15.jpg)
![Page 16: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/16.jpg)
![Page 17: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/17.jpg)
Conclusions
WTA multicenter experience suggests unlikely EDT survival when Blunt trauma with > 10 minutes
prehospital CPR Penetrating trauma with > 15 minutes
prehospital CPR Asystole without tamponade
Mechanism alone is not a discriminator of futility
![Page 18: 27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy,](https://reader030.vdocuments.mx/reader030/viewer/2022033105/56649ee65503460f94bf7373/html5/thumbnails/18.jpg)
Take home points
Resource-intensive procedure High risk for personnel Precise indications remain to be
defined Consider duration of prehospital
CPR Consideration for blunt trauma
victims supported in literature