Resuscitative thoracotomy

Resuscita)ve Thoracotomy

Michael Meyer, M.D., FACS COL, MC

Madigan Army Medical Center

Introduc)on

•  History •  Studies •  Review of CPG

Requisite Quotes

1883 Theodore Bilroth “The surgeon who should aMempt to suture a wound of the heart would lose the respect of his collegues.”

Requisite Quotes

1896 James Paget “Surgery of the heart has probably reached the limits set by nature to all surgery: no new method and no new discovery can overcome the natural difficul)es that aMend a wound of the heart.”

History

•  1649 Riolanus: First described pericardiocentesis

•  1829 Larrey: First successful pericardiocentesis for trauma

•  1896 Rehn: First successful human cardiac repair aXer a knife wound to the RV

•  1901 Igelsrund: First open cardiac massage for cardiac arrest

•  1902 Hill: First cardiorrhaphy in the US

History






History






History






Tromsø Amtsykehus

History






History

•  1927 Djanelidze: published detailed review of 535 cases of cardiac injuries

•  1939 Bigger: pericardiocentesis should be used both diagnos)cally and therapeu)cally; opera)on reserved as treatment for the unstable pa)ent

•  1946 Harken: Removal of missiles from the heart during WWII

•  1967 Barnard: First heart transplant

Trea)se on cardiac injuries, 1927

History





History





History





Lots of Papers •  Beall AC, Oschner JL, Morris GC Jr, et al. Penetra)ng wounds of the heart.

J Trauma 1961;1:195–207. •  Beall AC, Crosthait RW, Crawford ES, DeBakey ME. Gunshot wounds of the

chest: a plea for individualiza)on. J Trauma 1964; 4:382–389. •  Beall AC, Diethrich EB, Crawford HW, et al. Surgical management of

penetra)ng cardiac injuries. Am Surg 1966;112:686– 692. •  Boyd TF, Strieder JW. Immediate surgery for trauma)c heart disease. J

Thorac Cardiovasc Surg 1965;50:305–315. •  Sugg WL, Rea WJ, Ecker RR, et al. Penetra)ng wounds of the heart: an

analysis of 459 cases. J Thorac Cardiovasc Surg 1968; 56:531–545. •  MaMox KL, Feliciano DV. Role of external cardiac compression in truncal

trauma. J Trauma 1982;22:934–936. •  Millikan JS, Moore EE. Outcome of resuscita)ve thoracotomy and

descending aor)c occlusion performed in the opera)ng room. J Trauma 1984;24:387–392.

The Current Genera)on

•  Most data is from civilian studies •  Most data is retrospec)ve •  There is one major study looking at RT in the combat zone

•  Prospec)ve •  Analyzed mul)ple parameters as predictors of mortality – measured in the field, during transport, and upon arrival

•  Interven)ons included thoracotomy, sternotomy, or both, for resuscita)on and defini)ve repair of cardiac injury –  ED thoracotomy performed on all pa)ents arriving in cardiopulmonary arrest

•  Retrospec)ve review of 950 EDTs performed at a single regional Level I trauma center over 23 years

•  Evaluate the outcome based on the presence or absence of vital signs – At first contact by the paramedics and upon arrival at the emergency department

•  Overall survival 4.4%

•  Determine the main factors that most influence survival aXer EDT

•  24 studies, 4,620 cases, blunt and penetra)ng trauma

•  Primary outcome analyzed: in-‐hospital survival rate

•  Overall survival rate of 7.4% – Normal neurologic outcomes in 92.4%

•  Survival rates: 8.8% for penetra)ng and 1.4% for blunt –  16.8% for stab wounds –  4.3% for gunshot wounds –  19.4% if the heart was injured

•  SOL present on arrival: survival 11.5% •  SOL not present on arrival: survival 2.6%

•  Prospec)ve and retrospec)ve observa)onal study

•  Evaluate performance of EDT in order to improve treatment guidelines

•  Determine the outcomes of any survivors

•  All pa)ents undergoing EDT at a CSH in Iraq from November 2003 to December 2007

•  RT performed as a primary interven)on before the pa)ent leX the ER

•  101 pa)ents – 0.01% of total trauma admissions – 53 US military or civilian – 48 host na)onal pa)ents

CPG Review

Algorithms

•  Characterize the physiologic impact of aor)c balloon occlusion in a model of torso hemorrhage and shock

•  Compare the effec)veness of this technique to thoracotomy with aor)c clamping

References •  Rhee PM, Acosta J, Bridgeman A, et al. Survival aXer emergency department

thoracotomy. J Am Coll Surg. 2000;190(3): 288-‐98 •  Edens JW, Beekley AC, Chung KK, Cox ED, Eastridge BJ, Holcomb JB, Blackbourne

LH. Longterm outcomes aXer combat casualty emergency department thoracotomy. J Am Coll Surg. 2009;209:188-‐197

•  Moore EE, Knudson MM, Burlew CC, et al. Defining the limits of resuscita)ve emergency department thoracotomy: a contemporary Western Trauma Associa)on perspec)ve. J Trauma. 2011;70(2):334-‐9

•  Asensio JA, Berne JD, Demetriades D, et al. One hundred five penetra)ng cardiac injuries: a 2-‐year prospec)ve evalua)on. J Trauma 1998;44:1073–1082

•  Branney SW, Moore EE, Feldhaus KM et al. ' Cri)cal analysis of two decades of experience with pos)njury emergency department thoracotomy in a regional trauma center'. J Trauma 1998;45:87-‐95

•  White, JM, Cannon, JW, Stannard, A, Markov, NP, Spencer, JR, Rasmussen, TE. Endovascular balloon occlusion of the aorta is superior to resuscita)ve thoracotomy with aor)c clamping in a porcine model of hemorrhagic shock. Surgery 2011; 150(3):400-‐409

Health & Medicine

Resuscitative thoracotomy