Heroic Procedures You Should Know

Said Al-Mazroui

R5

Objectives

• Be aware of important procedures

• Indications and Contraindications

• Know yr limitations

Case I

• 31 yr old w h/o stab wound to the chest suddenly in the ER became unresponsive monitor is showing PEA

What is your action?

ER Thoracotomy

• Indications: • Penetrating chest trauma with recent loss ofvital signs • Blunt trauma with loss of vital signs in theED??????

• Survival rates were 5% for GSW and 33% for SW. Overall 18%

Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective.Molina EJ - Interact Cardiovasc Thorac Surg - 01-OCT-2008; 7(5): 845-8

• The goals of the procedure are to:- treat pericardial tamponade- control hemorrhage- perform open cardiac massage- temporarily occlude the thoracic aorta.

Contraindications

• Obvious signs of death• Penetrating chest trauma with no vital signs in

the field• BLUNT TRAUMA with or without vitals

Procedure:

• Open the chest• Deliver the heart• Open the pericardium• Plug the holes!• Cross-clamp the aorta• Open chest CPR /Defibrillation

Complications

( Complications are not significant when the alternative is death!!!)

• Iatrogenic laceration of surroundingstructures e.g. Lung, heart, vessels• Blood-borne disease transmission• Infection, never done under sterile conditions• Care should be taken to prevent injury to any

of the health care provider..

• A retrospective review of EDT experience was performed. Data collected included injury mechanism and location, presence of measurable ED vital signs, initial ED cardiac rhythm, GCS, method of transportation, and survival. Ninety-four of 237 patients presented penetrating cardiac injuries after EDT. Eighty-nine patients (95%) were males. Measurable ED vital signs were present in 15 patients (16%).

Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective.Molina EJ - Interact Cardiovasc Thorac Surg - 01-OCT-2008; 7(5): 845-8

Cont’d• Cardiac injuries were caused by GSW in 82

patients (87%) and SW in 12 patients (13%). Fifteen patients (16%) survived EDT and were taken to the operating room, while eight patients (8%) survived their entire hospitalization. All survivors were neurologically intact. Survival rates were 5% for GSW and 33% for SW. Mechanism of injury (SW), prehospital transportation by police, higher GCS, sinus tachycardia, and measurable ED vital signs were associated with improved survival..

• An overall survival of 18% suggests that ET is a life saving procedure. It is difficult to find good predictors of survival from logistic regression analysis. It should, for a trained trauma team, be a liberal attitude toward performing the procedure on the agonal patient.

Emergency thoracotomy saves lives in a Scandinavian hospital setting.Pahle AS - J Trauma - 01-MAR-2010; 68(3): 599-603

• Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable. METHODS: All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival. RESULTS

Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers.Seamon MJ - J Trauma - 01-DEC-2009; 67(6): 1250-7; discussion 1257-8

Cont’d

CONCLUSION: When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival

Case II

• 29 yo female G1P0, 34 wks pregnant, presents with chest pain.

• As you are interviewing the patient she suddenly collapses and is found to be in PEA.

• CPR is commenced.

What procedure should be considered at this stage?

Perimortem Cesarean SectionPerimortem Cesarean Section

Legal and Ethical Considerations

• Permission for the operation should be obtained from the family when possible but not at the expense of delaying the procedure.

• The emergency physician has the legal right and responsibility to provide the unborn fetus with every possible chance of survival when there is no hope of maternal survival.

• What is the minimum gestational age for performing Perimortem CS??

Infant survival

• Most literature involves only small numbers of cases.

• Emphasis mainly on successful cases so survival statistics difficult to ascertain.

• Survival rates range from 11-40%.

Indications

• Optimize maternal CPR

• PMCD must be considered in any woman who suffers irreversible cardiac arrest during 3rd trimester.

• Should be performed within 5 minutes of maternal demise.

Contraindications

• Prolonged CPR and fetus shows no sign of life

• Inability to adequately resuscitate the fetus after delivery

• Less than 24 wks of gestation

Equipment

• Scalpel with a No. 10 blade• Bandage scissors• Bladder retractor• Large retractors (2)• Forceps• Lap or gauze sponges• Hemostats (curved and straight)• Suction• Obstetric pack

• Using the scalpel, a midline vertical incision is made through the abdominal wall extending from the symphysis pubis to the umbilicus and carried through all abdominal layers to the peritoneal cavity.

The bladder is reflected inferiorly; if full it may be aspirated to evacuate it and permit better access to the uterus

approximately 5-cm, vertical incision is made through the lower uterine segment until amniotic fluid is obtained or until the uterine cavity is clearly entered

• The index and long fingers are then inserted into the incision and used to lift the uterine wall away from the fetus.

• A bandage scissors is used to extend the incision vertically to the fundus until a wide exposure is obtained

• The infant is then gently delivered, the nares and mouth suctioned, and the cord clamped and cut.

• Neonatal resuscitation should be carried out as necessary.

Maternal resuscitation

• CPR should be initiated on the mother at the time of cardiac arrest and continued throughout the procedure

• In rare instances relief of IVC compression improves maternal hemodynamics such that survival is possible, maternal pulses should be checked and CPR continued after delivery of the infant.

• Case report on 2003Perimortem cesarean delivery 30 minutes after a laboring patient jumped from a fourth-floor window: Baby survives and is normal at age 4 years

• Gynecology, and Obstetrics, University of Sassari, Sassari, Italy

• Perimortem Cesarean section in the helicopter EMS setting: a case report. - Kue R - Air Med J - 01-JAN-2008; 27(1): 46-7

Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training?Dijkman A - BJOG - 01-FEB-2010; 117(3): 282-7

• RESULTS: During the study period, 55 women had a cardiac arrest, 12 of whom underwent a PMCS. Before the introduction of the MOET course, four PMCSs were performed (0.36/year), compared with eight cases after its introduction (1.6/year, P = 0.01). No PMCS was performed within the recommended 5 minutes after starting resuscitation. Eight of the twelve women (67%) regained cardiac output after PMCS, with two maternal and five neonatal survivors. Maternal case fatality rate was 83%. Neonatal case fatality rate was 58%.CONCLUSIONS: Since the introduction of the MOET course, the use of PMCS has increased. Outcome, however, was still poor. An important factor to improve outcome is more timely application of this potentially life-saving procedure.

Case III

• A 37 yo man brought to the ED following an MVC.

• He had suffered significant damage to the left side of his face.

• On arrival, his GCS was 6. Shortly after intubation you notice the left eye is increasingly proptotic and noticeably firmer than the right.

What’s your diagnosis and what do you do next?

Retrobulbar hematoma

Diagnosis=

Orbital Compartment Syndrome

L a t e r a lL a t e r a l

C a n t h o t o m o yC a n t h o t o m o y

Other causes

• Iatrogenic: otolaryngic and ophthalmologic procedures e.g. endoscopic sinus surgery

• Spontaneous..

Pathophysiology of RBH

• The orbit is composed of 7 bones that enclose all but the anterior aspect. Here, the globe obstructs the opening to the bony orbit

• Following trauma, the presence of hemorrhage, foreign body or edema can increase retrobulbar pressure.

Pathophysiology (cont.)

• The orbit compensates through proptosis, but the medial and lateral canthal tendons, which attach the eyelids to the orbital rim limit the forward movement of the globe.

• As proptosis is restricted, the orbital pressure increases and impedes the optic nerve's vascular supply.

Pathophysiology (cont.)

• If IOP exceeds central retinal artery pressure, retinal ischemia results. In such situations, timely lateral canthotomy can save visual function

Indications 

• Decreased visual acuity • Intraocular pressure > 40 mm Hg • Proptosis

• Afferent pupillary defect

• Ophthalmoplegia

• Eye pain

Contraindication

• Globe rupture

Equipment

• Hemostat or needle driver

• Iris or suture scissors

• Forceps

The procedure

• The surrounding skin is preped with NS to improve visualization and reduce the risk of infection.

• If the patient is awake, an assistant should stabilize the head and maintain cervical immobilization.

• The procedure is no more painful than laceration repair, however, it can be visually disturbing for the patient.

Anesthetizing the lateral canthus

• 1-2 cc of 1%-2% lidocaine with epinephrine is injected into the lateral canthus.

• This provides both pain relief and hemostasis at the time of devascularization and incision.

Incising the lateral canthus

The area is cut laterally 1-2 cm in length

Cutting the inferior lateral canthal tendon

•Using the forceps, the

lower lid is pulled down to

visualize the inferior lateral

canthal tendon which is then

cut .

• After the inferior canthal tendon has been cut, intraocular pressure is reassessed with a tonometer.

• If IOP remains >40 mm Hg, then decompression is inadequate. The upper lid should be lifted and the superior lateral canthal tendon should be severed.

Case IV

• 48 yo male transferred from Sohar H. to SQUH where he presented with a stab wound to zone III of the neck.

• On arrrival, GCS 15, stable BP with no active bleeding from wound.

• After coming back from CTA neck, patient coughs and starts bleeding from wound.

• RSI attempted but fails. Patient develops a large expanding hematoma and his SpO2 is dropping to 60s.

What is the immediate management of this patient?

Surgical

Cricothyrotomy

Indications

• Failure of oral or nasal endotracheal intubation– Massive oral, nasal, or pharyngeal

hemorrhage– Massive regurgitation or emesis– Masseter spasm or clenched teeth – Structural deformities of oropharynx

Indications• AW obstruction

– Oropharyngeal edema

– Mass effect (cancer, tumor, polyp, web, or other mass)

– Foreign body

– Laryngospasm

Indications

• Traumatic injuries making oral or nasal endotracheal intubationdifficult or potentially hazardous

Contraindications

Tracheal transection

Laryngeal disruption/fracture

relative:

Age less than 8

Anterior neck hematoma

Previous cricothyrotomy

Tracheal tumor or mass

Coagulopathy

Equipment

• Scalpel with No. 11 blade

• Tracheal hook

• Tracheal dilator

• No. 4 or 5 Shiley cuffed tracheostomy tube with introducer and riser

A vertical incision is made after puncture through the membrane

The Procedure

Complications

• Thyroid gland damage

• Large vessel injury with hemorrhage

• Esophageal damage

• Infection

• Aspiration

Vertical or horizontal incision?

• Horizontal incision increases risk of tube misplacement

• Does not allow extension of incision if more exposure needed

• Increases risk of lacerating neck vessels with resulting hemorrhage

Pericardiocentesis

Indications:• Drainage of pericardial effusion causingacute tamponadeContra-indications:• No evidence of effusion

Complications:

• Bleeding• Infection• Solid and hollow viscus injury• Hemothorax• Pneumothorax• Lung laceration• Cardiac laceration• Arrhythmia• Air embolism

Ultrasound Assisted Technique:

• Perform basic echocardiographic views• Confirm the presence of life-threateningeffusion• Identify the safest access point throughleast tissue and largest target area• Place needle using ultrasound markedlocation• Place catheter through standard seldingertechnique• Drain effusion

Questions?