ED Thoracotomy?

[Orange Julius]

Is it ever indicated in blunt trauma? If so, when?

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[SLUser11]

Is it ever indicated in blunt trauma? If so, when?

Short answer is no.

Long answer is very rarely, and with marginal benefit.....less than 2% survive, and the neuro function is a whole other issue.

If I were in an oral boards situation, I would not crack a chest for blunt trauma.

Here's a fun read if you get a chance. I think I've linked it before, but still quite comical.

 

[Dr.LeoSpaceman]

I thought the ATLS teaching was ED thoracotomy for blunt trauma if the patient arrests in the trauma bay (as opposed to the field).

EDIT: On second thought, it may not be ATLS. I'd have to actually crack the book to be sure. In any case, that's what we're taught at my program.

And a further addendum:

http://www.ncbi.nlm.nih.gov/pubmed/21307731

Collectively, the WTA multicenter experience suggests that resuscitative thoracotomy in the ED is unlikely to yield productive survival when patients (1) sustain blunt trauma and require >10 minutes of prehospital CPR without response, (2) have penetrating wounds and undergo >15 minutes of prehospital CPR without response, or (3) manifest asystole without pericardial tamponade (Table 5). However, there will invariably be exceptions to these guidelines in the recorded literature. In fact, there are reports of survivors with functional neurologic recovery exceeding these thresholds.10,18–20 On the other hand, these data provide further evidence that the National Association of EMS Physicians and ACSCOT guidelines are excessively restrictive. Our responsibility as members of the academic trauma community is to assimilate our contemporary experience along with a critical analysis of the current literature to generate what we believe are rationale guidelines for resuscitative thoracotomy in the ED in the appropriate setting.

 

[Smurfette]

At my program, we cracked the chest if they coded in the trauma bay after blunt trauma....got one back long enough to get up to the OR, too.

Since I just got my ATLS book 3 days ago (renewing this month), I looked it up. Basically, for blunt trauma it says it's not indicated if they arrive pulseless, but doesn't specifically address if they become pulseless in the trauma bay. All it says is thoracotomies are "rarely effective" for blunt trauma after it gives the general benefits of doing an ED thoracotomy (i.e. tamponade, etc.). So no clear "book answer" for this one...

 

[JackADeli]

...Since I just got my ATLS book 3 days ago (renewing this month), I looked it up. ...it gives the general benefits of doing an ED thoracotomy (i.e. tamponade, etc.)...

Haven't looked in awhule, but was told they reference ED thoracotomies but do not go over and/or teach technique during ATLS anymore. Is that true?

 

[ESU_MD]

Ed thoracotomy is pretty theatrical, maybe everyone should do a few.. However, rarely effective and very, very dangerous to the providers.

A good way to catch aids or hepatitis

 

[droliver]

If you aren't an experienced thoracic surgeon, doing a rapid thoracotomy is kind of a tricky manuever. Not many people are going to be salvaged by your average surgery resident (much less your average ER resident) attempting this

 

[HNANAL]

at my institution, we crack almost any chest, even blunt

 

[Orange Julius]

Thanks guys. I know that chests are cracked for blunt trauma. I've done a few myself. Total nonsense IMHO.

However, I'm really just trying to find what is the boards answer. I see different things in different sources.

So is it, Blunt trauma + ED arrest = ED thoracotomy
or
Blunt trauma = never ED thoracotomy


??????????

 

[HNANAL]

Thanks guys. I know that chests are cracked for blunt trauma. I've done a few myself. Total nonsense IMHO.

However, I'm really just trying to find what is the boards answer. I see different things in different sources.

So is it, Blunt trauma + ED arrest = ED thoracotomy
or
Blunt trauma = never ED thoracotomy


??????????

you need more information....
If the patient loses vitals on the table, AND you know there is bleeding in the chest, e.g. a thoracic pseudo aneurysm, then it is reasonable to crack the chest and control the bleeding. There needs to be a surgical source that can be treated. Also after blunt trauma, say you saw possible chest hemorrhage on a CXR, this is also reasonable to do an EDT

 

[Smurfette]

Haven't looked in awhule, but was told they reference ED thoracotomies but do not go over and/or teach technique during ATLS anymore. Is that true?

Will find out in a couple weeks if they still teach it or not...

OJ: Realistically, on the boards, you are not going to get that question outright. you'll get a trauma scenario and other interventions will fail, and then your patient will code, and you will be left trying to figure out what you missed (if anything....sometimes they let your patient die to see how you handle it and the family). If you've tried everything and want to try a "hail mary" ED thoracotomy, they'll let you do it....but that is not generally an answer or end point they are looking for. They want you to be systematic at trying to find the likely cause of the patient's demise given the information they've provided and just want to know how you think. i.e. if not A-->B, if not B-->C, etc.

 

[SLUser11]

at my institution, we crack almost any chest, even blunt

So just to go over things a little more in detail, the article from JACS I mentioned is from LA County/USC, where all patients without pulse in the trauma bay get a thoracotomy, regardless of mechanism of injury. They had an overall "survival to discharge" rate of 1.9%, or 5/263. One of those was a blunt trauma (6-story fall with multiple fractures), or 1/263.

There's also an article in the February 2011 Journal of Trauma that discusses thoracotomy, where 9% of survivors to discharge were blunt traumas, and the majority of survivors being from stab wounds to the heart or GSWs to the lung. Only one of the blunt trauma survivors presented in asystole, and I don't think the article even mentions how many thoracotomies were actually performed. 18% of survivors had "moderate to severe anoxic brain injury."

This mostly has to do with the amount of diffuse damage that occurs to organs in blunt trauma. The sort of blunt trauma that would cause pulseless aortic transection or cardiac injury is usually unsalvageable....most pulmonary injuries would be as well....remember that the survivability for pneumonectomy in trauma is 0-50%.

Of course, we have to remember that neurologic outcomes can be very poor, but this is less of an argument for blunt trauma, since hypothetically those patients would be without perfusion for a shorter period of time.

So, in summary, resuscitative thoracotomy for blunt trauma is extremely unsuccessful and rarely indicated, while thoracotomy in the appropriate penetrating trauma is effective and could be life-saving.

If a blunt trauma presents in asystole, I won't crack the chest. If a reliable person says they lost vitals in the parking lot, I will look for tamponade and cardiac activity with ultrasound...if both are missing, I will not crack the chest.

One okay indication that hasn't been discussed much would be a patient exsanguinating from multiple fractures who needs aortic cross-clamping. That I might do.....

 

[NJA61479]

practice, practice, practice

so that when an isolated stab wound in the box comes in you have some practice with the maneuvers to achieve the reported 40% success rate.

 

[JackADeli]

Ed thoracotomy is pretty theatrical...However, rarely effective and very, very dangerous to the providers...

If you aren't an experienced thoracic surgeon...Not many people are going to be salvaged by your average surgery resident (much less your average ER resident) attempting this

That has been my general take.... alot of drama and alot of high five for no real results.... just makes everyone feel cool.

at my institution, we crack almost any chest, even blunt

practice, practice, practice...

That's the problem. It is more likely NOT practice, rather simple hack/butcher for ~entertainment/excitement. Most places I know doing an ED thoracotomy has little to no good technical oversight or Q&A. They may occassionally discuss at M&M. The dramaa is often used as an excuse for poor technique.

Some states require automatic, in depth ME review of ED thorocotomies. This results in a rapid decline in the numbers... cause, ME looks at chart and dings if the indication does not match current published standards. Then, ME looks at the autopsy for specific morbidities.... esoph injury? phrenic injury? etc, etc?

 

[SLUser11]

practice, practice, practice

so that when an isolated stab wound in the box comes in you have some practice with the maneuvers to achieve the reported 40% success rate.

Your opinion might be a little biased....I won't go into why for the sake of anonymity. But I didn't calculate 40%.

Also, if it's clearly not indicated, I think as a family member I would be apalled to discover my loved one had his/her chest cracked open for "practice" without consent. If we really need more practice, then we should do it on cadavers/pigs/whatever.

Anyway, here's a position statement from the ACS Committee on Trauma that seems to be against resuscitative thoracotomy for blunt trauma (page 4), and even hints that most places that boast a high survival rate might have performed unnecessary thoracotomies to get those numbers, i.e. patients would have survived without the big whack.

Also, although I didn't find an ATLS handbook, I did find literature discussing the 8th edition of ATLS, that says "patients sustaining blunt injuries who arrive pulseless but with myocardial electrical activity are not candidates for resuscitative thoracotomy."

It's obviously a hot topic, and an issue that is unresolved with some grey area.....still, I would argue against doing it for the sake of practice....and I would also argue against doing it in an attempt to harvest organs.

 

[HNANAL]

blunt EDT is no doubt unpopular. However I come from a progressive institution where we see more than most. It can be argue that this sort of things needs to be done to push the envelope. Won't know unless it is done. EDT no matter the mechanism is infrequently successful. Thus any success is a freebie. Yes blunt EDT is very poor, but we are comparing sucky to suckier here. This is giving it your all. It is not such a bad idea....but the part about the injuries is true.

 

[HNANAL]

Your opinion might be a little biased....I won't go into why for the sake of anonymity. But I didn't calculate 40%.

Also, if it's clearly not indicated, I think as a family member I would be apalled to discover my loved one had his/her chest cracked open for "practice" without consent. If we really need more practice, then we should do it on cadavers/pigs/whatever.

Anyway, here's a position statement from the ACS Committee on Trauma that seems to be against resuscitative thoracotomy for blunt trauma (page 4), and even hints that most places that boast a high survival rate might have performed unnecessary thoracotomies to get those numbers, i.e. patients would have survived without the big whack.

Also, although I didn't find an ATLS handbook, I did find literature discussing the 8th edition of ATLS, that says "patients sustaining blunt injuries who arrive pulseless but with myocardial electrical activity are not candidates for resuscitative thoracotomy."

It's obviously a hot topic, and an issue that is unresolved with some grey area.....still, I would argue against doing it for the sake of practice....and I would also argue against doing it in an attempt to harvest organs.

books are not exactly uptodate or the best place to look. The best people to ask would be from institutions where these sorts of things are done everyday, i.e. jackson memorial, lac, memphis, etc.

as for consent, how you do suggest one get a consent? Trauma is about life and death decisions within minutes to seconds sometimes. I'm not suggesting that consents are not a good idea, just that it's not practical in this case.

 

[JackADeli]

practice, practice, practice

so that ...to achieve the reported 40% success rate.

...that most places that boast a high survival rate might have performed unnecessary thoracotomies to get those numbers, i.e. patients would have survived without the big whack...

Yep, that was what I was going to say... high rate of unnecessary.... in the wrong direction! "Success" with ED Thorocotomies, while requiring a decent ED team is still very, very dependent on physician independent variables. This includes but not limited to patient protoplasm and field recovery.

There are a significant number of patients, that by nature of the type/s of injuries appropriate for ED thorocotomy have very poor baseline protoplasm to survive the physiologic embarassment of first the injury and then the treatment. Remember, a penetrating wound in "the box" is generally not a random act upon just anyone. So, to have any meaningful numbers, you would have to be drawing from these populations.

Then, the specific populations more prone to such acts of violence are often in regions to which EMS dispatch is delayed. Further confounding is the "witness" information to provide appropriate "timeframe" for treatment. Presuming EMS gets to the scene promptly, it is all too common for "witness" to claim "he/she just got stabbed 2 minutes ago...". When in actuality, it may have been 20+ minutes ago. So, EMS transports with an erroneous timeline, treatment is undertaken, patient dies.... there goes your high success rate average!

In general, a procedure that's "success" is so dependent on adverse ~environmental factors in order to achieve "high success rate" numbers would likely need to be skewed so as to NOT perform said procedures on all appropriate candidates and hedge the bet to perform it on healthier, thereby less appropriate candidates.

As I mentioned earlier, very, very poor Q&A at many institutions that perform these procedures to any significance. A place that boasts a 40% success rate, I would like to see a clear post procedure analysis of the injuries to determine if the procedure was beneficial, not beneficial, and/or confounding. Also, I would want to see a close analysis of all such trauma patients declined said treatment to ascertain a selection biasis for denial of care that enhanced the numbers....

...as for consent, how you do suggest one get a consent? Trauma is about life and death decisions within minutes to seconds sometimes. I'm not suggesting that consents are not a good idea, just that it's not practical in this case.

Correct, fast and decisive. However, the physician needs to be completely honest as "you" are now assuming a deciding role in the patient's care. The "no harm cause would have died, but maybe this "Hail Mary" might save, but it won't do any harm..." argument in the ED/Hospital is innappropriate. I have watched too many ED "autopsies" couched in that argument with a "wink, wink, nod, nod". The only people that should be making "Hail Maries" are those that have the deepest understanding of what they are about to undertake and accurate understanding of appropriate indications. Many die. But, not everyone needs to die with a thorocotomy. Going to the ED does NOT automatically mean donating your body to student/resident/etc... education!

 

[SLUser11]

blunt EDT is no doubt unpopular. However I come from a progressive institution where we see more than most. It can be argue that this sort of things needs to be done to push the envelope. Won't know unless it is done. EDT no matter the mechanism is infrequently successful. Thus any success is a freebie. Yes blunt EDT is very poor, but we are comparing sucky to suckier here. This is giving it your all. It is not such a bad idea....but the part about the injuries is true.

That's sort of a weak argument. You can be progressive without doing a bunch of unnecessary and dangerous procedures.

books are not exactly uptodate or the best place to look. The best people to ask would be from institutions where these sorts of things are done everyday, i.e. jackson memorial, lac, memphis, etc.

as for consent, how you do suggest one get a consent? Trauma is about life and death decisions within minutes to seconds sometimes. I'm not suggesting that consents are not a good idea, just that it's not practical in this case.

I agree books aren't the best place to look. The literature is the best place to look, where there's evidence or lack thereof. I definitely disagree with the above-mentioned institutions being the best place to look...they would be loaded with bias.

As far as consent, I never insinuated that it's needed to emergently treat a dying patient. My point was pretty straightforward, which was that if something is not indicated, and it is purely educational, then consent should be obtained. If it doesn't benefit the patient, it shouldn't be done without consent.


I also wanted to mention that in the Journal of Trauma article, the oldest survivor was 64....so we definitely shouldn't be cracking the chests of elderly traumas....

 

[JackADeli]

...My point was pretty straightforward, which was that if something is not indicated, and it is purely educational, then consent should be obtained. If it doesn't benefit the patient, it shouldn't be done without consent...

...I also wanted to mention that in the Journal of Trauma article, the oldest survivor was 64....so we definitely shouldn't be cracking the chests of elderly traumas....

Yeh, that would be wonderful, septuagenarians/octagenarians with blunt trauma... go straight to ED thorocotomy at "witnessed arrest"

 

[Buzz Me]

Remember there's also a difference between "signs of life" and "vital signs."

 

[Hometown Diego]

The accepted indication for ED thoracotomy in blunt trauma is loss of vitals in the trauma bay. That being said survival is dismal, and you have to way the risks. If a blunt trauma pt shows up who has had cpr for >5min, in asystole with no tamponade on FAST that pt is DOA.

 

[dpmd]

ATLS no longer teaches how to perform the ED thoracotomy. It is basically because for the majority of the people they are trying to educate ED thoracotomy is in no circumstance appropriate (remember ATLS originated out of a need to educate people who are not dealing with trauma every day, and who may not have rapid access to surgeons-if you can't have a surgeon there pretty damn fast you have no business opening the chest). I went to USC, and I understand why they do what they do. They have a lot of patients with short transport times, they have in house attendings who supervise the procedure to improve technique, the patients are typically younger, and using blood products on these patients doesn't overly strain the system. It isn't generalizable. At my institution we are pretty conservative. If they are down more than 10 min most of us won't do it regardless of the mechanism. And I won't stick around if they decide to "practice" ACLS and lines/tubes etc on those pts. I document DOA, plead my case to the ED attending (since ours aren't in house the ED attending has to agree to stop resus for it to happen), and if they refuse to call it I walk away. We have to call the attending on every full arrest and they will typically support this sequence.

 

[45408]

The sort of blunt trauma that would cause pulseless aortic transection or cardiac injury is usually unsalvageable....most pulmonary injuries would be as well....remember that the survivability for pneumonectomy in trauma is 0-50%.

You just reminded me of a young college student who had that happen when I was doing trauma in med school. Mechanism was a crushing chest injury (pinned against an SUV by a semi). I wasn't there when she came in, but she coded a few different times, went into PEA when the CT surgeon was opening, etc. She actually had a really good outcome, but she dodged quite a few bullets along the way. They featured her story in the news a few times, and our chief trauma surgeon considered her his star patient. It's nice to know we pull off some incredible saves once in a while.

 

[SLUser11]

ATLS no longer teaches how to perform the ED thoracotomy. It is basically because for the majority of the people they are trying to educate ED thoracotomy is in no circumstance appropriate (remember ATLS originated out of a need to educate people who are not dealing with trauma every day, and who may not have rapid access to surgeons-if you can't have a surgeon there pretty damn fast you have no business opening the chest). I went to USC, and I understand why they do what they do. They have a lot of patients with short transport times, they have in house attendings who supervise the procedure to improve technique, the patients are typically younger, and using blood products on these patients doesn't overly strain the system. It isn't generalizable. At my institution we are pretty conservative. If they are down more than 10 min most of us won't do it regardless of the mechanism. And I won't stick around if they decide to "practice" ACLS and lines/tubes etc on those pts. I document DOA, plead my case to the ED attending (since ours aren't in house the ED attending has to agree to stop resus for it to happen), and if they refuse to call it I walk away. We have to call the attending on every full arrest and they will typically support this sequence.

Just when I think this topic is dead, someone cracks its chest and brings it back to life.....


j/k....anyway, while ED thoracotomy is a hot topic, I'm a little more interested in the recent trend to move away from normal saline and toward whole blood resuscitation in the trauma bay....it's amazing how the pendulum swings back and forth over time....

It's also nice to see the big players vocalizing the fact that we leave way too many abdomens open these days when we could probably close them....

 

[dpmd]

Were you at the TCCACS meeting too?

I liked the part about trying to get the FDA to take normal saline off the market.

 

[HNANAL]

That's sort of a weak argument. You can be progressive without doing a bunch of unnecessary and dangerous procedures.

I agree books aren't the best place to look. The literature is the best place to look, where there's evidence or lack thereof. I definitely disagree with the above-mentioned institutions being the best place to look...they would be loaded with bias.

As far as consent, I never insinuated that it's needed to emergently treat a dying patient. My point was pretty straightforward, which was that if something is not indicated, and it is purely educational, then consent should be obtained. If it doesn't benefit the patient, it shouldn't be done without consent.

I also wanted to mention that in the Journal of Trauma article, the oldest survivor was 64....so we definitely shouldn't be cracking the chests of elderly traumas....

Why talk about consents when it clearly doesn't apply in this case?
I mentioned these large institutions because if anything is going to come out, it's going to come out there where there are volumes high enough to even do such a study. There are only a handle of places that can do these sort of studies - fact

 

[ESU_MD]

hell, I havent given a crystalloid bolus in almost 3 yrs now. blood or albumin, maybe hespan.

SLU- I have always felt that alot of people just leave the belly open out of convenience. when in reality, its NEVER convenient for the guy who has to do the closure at the end of the elective schedule the next day. Plus pts just dont do as well with an open belly.... barring the subset who really can benefit from open abd.

how long does it really take to close even a trauma lap incision?

 

[dpmd]

blunt EDT is no doubt unpopular. However I come from a progressive institution where we see more than most. It can be argue that this sort of things needs to be done to push the envelope. Won't know unless it is done.

You can argue that, but that doesn't mean that every institution should follow suit. I don't argue that the places that are doing one every day should start doing them less. I just don't think some everyone should start doing more. It is institution dependent.

Don't discount the downside. Two of my three sharps injuries were during ED thoracotomies. Once as an assistant, and once as the primary. Things can be a zoo during any resuscitation. Add in a bunch of sharps, plus extra hands wanting to be involved, and it is a recipe for disaster. The better thing would be to practice it in a controlled setting (hell, if you could set things up to where you get consent from the recently expired person's family it would probably be great-but I just don't see that becoming an acceptable practice). Fresh cadavers at the coroner's office would be another. In reality though, when it came time for me to do my first I just remembered what I had read and did it (our attendings aren't in house so it wasn't like I had much supervision, the ED attending was helpful but not a surgeon). When more senior people showed up they didn't find a bunch of stuff wrong (and nothing that contributed to the failure to reanimate).

 

[ESU_MD]

the places that are doing one every day

where are these places doing one a day? Even the well known "busy" trauma centers occasionally have days when they don't do a real trauma operation, let alone an EDT. one a day is ALOT

what types of injuries do you see when you open the chest?
What difficulty are encountered trying to operate in the chest through a possibly suboptimal exposure, poor light/instruments? I'm not sure if doing 100 EDT's will prepare anyone to be better vs. knowing what to do in elective cardiovascular/thoracic repairs

or is it to just xclamp the aorta to staunch abdominal bleeding? (btw, thoracic aortic xclamp is not totally easy in a pulseless patient as a blind move) I have seen trauma surgeons clamp the aorta with kelly-type clamps.

 

[dpmd]

I wasn't being literal about the every day.

When I was a student at USC my trauma rotation was 3 wks long and I was present for 6 (I can't remember how often we took call, probably q3 since that was when our team was on).

At my present institution we had one every call night for my first three calls, then I wasn't involved in any more until I was night float. Have done 3 myself. Only one made it to the OR and that one had a bleeding injury to the R lung that I found after clamshelling. Controlled with some big clamps and got vitals back, but had a hilar injury that we had to do a pneumonectomy for. Died shortly after reaching the ICU. Even though we got vitals back in the ED, the admission labs told me the patient was unlikely to survive. I proposed not going to the OR, but it is hard to stop the train at that point.

One is memorable because of how things went. Cut my finger while opening the skin (the one holding counter traction on the skin didn't move as fast as the other). Kept on going anyway, then the f'ing rib spreader is assembled backwards. Got a new set opened up and the damn crank isn't there. Decided to just grab and pull which opened up just enough for me to shove my hand in and do some cardiac massage (noting the lack of tamponade, and minimal amount of blood). Someone had reassembled the rib spreader by now so I placed that and had the intern do some cardiac massage while I took a few seconds to rinse my hand, pour some betadine on, and put on intact gloves, then I finished up (cross clamped, open up the pericardium just to be sure and to pour some warm fluids on the heart). The chest tube on the right didn't have much blood either so I didn't have much thought that I was going to bring this one back (they had exsanguinated at the scene and en route I think) so I don't think the pause to address my hand factored in. Just goes to show how things don't always go as planned.

 

[HNANAL]

You can argue that, but that doesn't mean that every institution should follow suit. I don't argue that the places that are doing one every day should start doing them less. I just don't think some everyone should start doing more. It is institution dependent.

Don't discount the downside. Two of my three sharps injuries were during ED thoracotomies. Once as an assistant, and once as the primary. Things can be a zoo during any resuscitation. Add in a bunch of sharps, plus extra hands wanting to be involved, and it is a recipe for disaster. The better thing would be to practice it in a controlled setting (hell, if you could set things up to where you get consent from the recently expired person's family it would probably be great-but I just don't see that becoming an acceptable practice). Fresh cadavers at the coroner's office would be another. In reality though, when it came time for me to do my first I just remembered what I had read and did it (our attendings aren't in house so it wasn't like I had much supervision, the ED attending was helpful but not a surgeon). When more senior people showed up they didn't find a bunch of stuff wrong (and nothing that contributed to the failure to reanimate).

I never suggested nor expected other institutions to do what we do. It's a last ditch effort to save someone. I've done 5. The accidents happen because speed is necessary, but there are often times too many people around. Only need 1 person to crack the chest. The assistant should just hand over instruments, sutures, foley and suction as necessary.

 

[SLUser11]

Were you at the TCCACS meeting too?

I liked the part about trying to get the FDA to take normal saline off the market.

I wasn't, but I read the syllabus. I've also listened to several audio digest lectures recently where the evils of normal saline and the wonders of whole blood were discussed.

I think it's all really interesting, and it exposes how much the pendulum swings in trauma care. Five years from now, it could be completely different.

Why talk about consents when it clearly doesn't apply in this case?
I mentioned these large institutions because if anything is going to come out, it's going to come out there where there are volumes high enough to even do such a study. There are only a handle of places that can do these sort of studies - fact

It does apply when you are talking about a procedure that is not indicated, but is purely educational. However, I'm not going to discuss it anymore because we're going in circles.

I don't necessarily agree that there's only a "handle" of places that can do the studies. The best literature has come from a collaborative effort between 18 instutitions (Western Trauma Association)....the procedures should be treated as a rare event, and the guidelines have to be widely applicable.

hell, I havent given a crystalloid bolus in almost 3 yrs now. blood or albumin, maybe hespan.

how long does it really take to close even a trauma lap incision?

Of course, it would be easy to discuss the cons of giving albumin and hespan, especially with recent news that the Hespan guru fabricated most of his studies.

I do agree that some bellies are left open out of convenience...when it actually is necessary, I am a firm believer in the Wittman patch. What do you guys think about that? I know the literature isn't too strong, although it's included in some of the more successful published algorithms. Also, I believe there's an old article from the Journal of Trauma that mentioned that it's a helluva lot harder to close the belly if you don't get it done in the first 7 days.

I never suggested nor expected other institutions to do what we do. It's a last ditch effort to save someone. I've done 5. The accidents happen because speed is necessary, but there are often times too many people around. Only need 1 person to crack the chest. The assistant should just hand over instruments, sutures, foley and suction as necessary.

How many of those 5 thoracotomies were for blunt trauma? Did any of the 5 make it out of the hospital? If so, you deserve some major props.

Anyway, nobody is arguing that ED thoracotomies should be abandoned altogether, just that the surgeon use good judgment and have a good knowledge of the literature. There are not too many other procedures that we perform that boast a 2% survival, and for other situations (e.g. pan-gut ischemia) with horrible outcomes we have the good judgment to decide not to cut on the patient.

 

[HNANAL]

I wasn't, but I read the syllabus. I've also listened to several audio digest lectures recently where the evils of normal saline and the wonders of whole blood were discussed.

I think it's all really interesting, and it exposes how much the pendulum swings in trauma care. Five years from now, it could be completely different.



It does apply when you are talking about a procedure that is not indicated, but is purely educational. However, I'm not going to discuss it anymore because we're going in circles.

I don't necessarily agree that there's only a "handle" of places that can do the studies. The best literature has come from a collaborative effort between 18 instutitions (Western Trauma Association)....the procedures should be treated as a rare event, and the guidelines have to be widely applicable.

Of course, it would be easy to discuss the cons of giving albumin and hespan, especially with recent news that the Hespan guru fabricated most of his studies.

I do agree that some bellies are left open out of convenience...when it actually is necessary, I am a firm believer in the Wittman patch. What do you guys think about that? I know the literature isn't too strong, although it's included in some of the more successful published algorithms. Also, I believe there's an old article from the Journal of Trauma that mentioned that it's a helluva lot harder to close the belly if you don't get it done in the first 7 days.

How many of those 5 thoracotomies were for blunt trauma? Did any of the 5 make it out of the hospital? If so, you deserve some major props.

Anyway, nobody is arguing that ED thoracotomies should be abandoned altogether, just that the surgeon use good judgment and have a good knowledge of the literature. There are not too many other procedures that we perform that boast a 2% survival, and for other situations (e.g. pan-gut ischemia) with horrible outcomes we have the good judgment to decide not to cut on the patient.

Shouldn't even have mentioned consents in the first place. And how can EDT be purely educational? That doesn't make any sense; It's just wrong. Outside of someone family members showing up to the ER before the pt comes, there isn't a scenario where a consent is possible or practical. Should we stop care and consult the local ethical board? The other possibility is when family is already there and patient codes in the ICU and you think an EDT is needed, in which case it would have been a good idea to have spoken to family in the first place. I've done that also. I had to perform an ICU thoracotomy for blunt trauma because we've done everything else outside of surgery and it was the last resort. And yes he died.... so? Maybe we should deny surgery for end stage cancer pt with peritonitis too while we are at it.

you focused on the specific institution I cited but missed my point. You need data points. You need these big institutions. Like it or not they will be involved. Of course studies from multi-institutions are going to be higher powered - DUH!

The Op's question have pretty much been answered. EDT for loss of vitals in field. EDT for blunt loss of vitals near or at ER, and institution dependent. He asked, "is it ever indicated?" Besides, asking a controversial topic is going to give controversial answers.

 

[SLUser11]

Shouldn't even have mentioned consents in the first place. And how can EDT be purely educational? That doesn't make any sense; It's just wrong.

If a procedure is not indicated, then you generally shouldn't do it. My junior residents need plenty of practice, but if a patient comes in with an unsurvivable injury, I'm not subjecting the patient to unnecessary mutilation while simultaneously exposing the health care team to unnecessary risks....just for "maximal resident benefit."

It's a question of ethics, and you are taking the more utilitarian approach. Like I said, we're arguing in circles. You're not going to change your mind, and you definitely haven't convinced me, so I think we should drop it.

 

[LucidSplash]

So if we're shouldn't be cracking chests in the ED, when do you think residents should learn those maneuvers in case they need them in an OR setting?

So here's a scenario that happened recently on our Emergency GS service (not trauma). A guy came in on transfer. The OSH told us they though he had ruptured bowel based on their read of their CT scan. When we got a look at the images when he arrived, it was pretty obvious to everyone (even moi the lowly intern) that they guy had a belly full of blood. I won't draw it out but basically the guy had PAN and what they found when they opened him was blood under tension from a ruptured splenic artery aneurysm. How was this guy alive still on transfer? Hell if I know.

Anywho, with blood coming up like geyser, they are desperately trying to get control. Another of our EGS/trauma attendings scrubs in with the attending and the chief to help out but they just can't see anything - suction is insufficient and they are struggling to clamp the aorta in the abdomen. The best the attending can do is put his finger on the aorta but based on the blood and the anatomy they can't get it clamped and anesthesia basically says "if you can't stop the bleeding right now to help us catch up we can't do anything." So they cracked his chest, EDT style, in the OR to get to the thoracic aorta and got the clamp on there. Long story short, guy has protracted hospital course but walks out at the end of it.

Its not like we have a case like this coming in every day, so its not like as residents we're going to learn those maneuvers on patients like this. But obviously my attendings learned how to do this kind of thoracotomy based on doing it in the trauma bay.

I'm not trying to be a smarmy intern. I'm genuinely asking - even though cases where this maneuver needs to be done might be rare, we still need to learn to do it, right? So if you object to them being done on blunt injury patients in the trauma bay, when/how should it be done? Just on cadavers? Or do you think that the one month or whatever I will spend on CT as a 4th year would be sufficient to do what my attendings did in this situation?

 

[SLUser11]

So if we're shouldn't be cracking chests in the ED, when do you think residents should learn those maneuvers in case they need them in an OR setting?

Nobody said we should never crack a chest....I'm not sure where you're getting that from. We should only crack the chests of patients that have a chance of benefitting from it.

As far as your example goes, I'm not sure why they couldn't just get supra-celiac control/compression by dividing the gastrohepatic ligament and entering the lesser sac....you can do it blindly, and it would probably be a lot faster than opening the chest.

I also don't think the CT surgery month will be too helpful, unless you're putting the trauma patient in right lateral decubitus position and going for a posterolateral thoracotomy.


I just don't think "residents needing practice" is an acceptable reason to subject a patient to a unnecessary procedure. There are plenty of rare things we never do anymore that we may need to do emergently, e.g. foregut surgery for an upper GI bleed, but we don't do them on patients purely for the practice. You may need to do an emergent burr hole in the trauma bay, but we don't drill into every dead patient's head. There's a thousand more examples.

Anyway, I think you'd be singing a different tune if you cut yourself on a dead patient with HIV and/or Hepatitis.

 

[LucidSplash]

Nobody said we should never crack a chest....I'm not sure where you're getting that from. We should only crack the chests of patients that have a chance of benefitting from it.

Fair enough - my question stemmed from my perception of the tone of many posters which seemed to suggest that because the rate of survival was SO low, it was pretty much never indicated.

As far as your example goes, I'm not sure why they couldn't just get supra-celiac control/compression by dividing the gastrohepatic ligament and entering the lesser sac....you can do it blindly, and it would probably be a lot faster than opening the chest.

I can't answer that. I was only in the room for part of the case, I wasn't scrubbed and I'm just an intern. The case was presented a few weeks later and the general consensus favored the actions taken in the OR that day. I mention it here only because this was the case that came to my mind while reading the thread.

I also don't think the CT surgery month will be too helpful, unless you're putting the trauma patient in right lateral decubitus position and going for a posterolateral thoracotomy.


I just don't think "residents needing practice" is an acceptable reason to subject a patient to a unnecessary procedure. There are plenty of rare things we never do anymore that we may need to do emergently, e.g. foregut surgery for an upper GI bleed, but we don't do them on patients purely for the practice. You may need to do an emergent burr hole in the trauma bay, but we don't drill into every dead patient's head. There's a thousand more examples.

Anyway, I think you'd be singing a different tune if you cut yourself on a dead patient with HIV and/or Hepatitis.

Actually, I did do that during my 4th year forensic pathology elective in medical school. A month of triple therapy is no joke and neither is the nerve-wracking nature of the follow-up bloodwork.

I'm not arguing AGAINST you in my post. I agree we shouldn't be doing things "just for the practice." I was asking, from a position of inexperience, how residents should get experience in rarely performed maneuvers in a population that has an extremely high mortality rate despite the maneuver in question.

Thanks for taking the time to answer my post. I always value your contributions to the threads on this board and appreciate your moderate approach to discussing controversial topics.

 

[Smurfette]

I did an EDT on a patient who turned out to have HIV. And the whole thing was a mess---while I didn't cut myself, I got blood on both my arms (between the gown and gloves....cuz the gloves available were too big and folded up on my wrists). The family immediately told us his HIV status (of course, a non-compliant patient off his meds, being a typical trauma victim), so I had half the trauma service tracking me down to let me know once they found out, especially as they saw how bloody it had been and how covered I was. I was lucky to not have cut myself...very lucky. Those ribs were sharp.

The thing is, EDT are generally a cluster and TOO MANY people are doing things to the patient simultaneously. More than just cutting yourself with a scalpel, getting yourself on a sharp rib edge or other sharp object IS a big risk, or getting stuck by someone doing something else to the patient.

There are *some* patients who *could* benefit from it in the right setting. We had an occasional (chest stab wound) patient make it out of the hospital, but this was very much the exception to the rule in a high volume trauma center with high penetrating trauma rates. But I think what everyone here is saying, is that it is not without risks---if you can't justify doing it for a reason OTHER than "practice", because the patient has no chance, you shouldn't be doing it.

 

[JackADeli]

Going to comment a little on your post and/or follow up on SLuser's comments:

So if we're shouldn't be cracking chests in the ED, when do you think residents should learn those maneuvers in case they need them in an OR setting?

ED thorocotomy is not the place to learn how to perform a OR thorocotomy. I referenced issues with teaching, quality control, etc. earlier; but, I won't belabor the point. Bottom line it just isn't the way you teach OR technique.

...So here's a scenario ...A guy came in on transfer...had a belly full of blood...opened him...a ruptured splenic artery aneurysm...

Another of our EGS/trauma attendings scrubs in...they are struggling ...The best the attending can do is put his finger on the aorta...So they cracked his chest, EDT style, in the OR to get to the thoracic aorta...

I am just really not impressed. In fact, somewhat disapointed. My general surgery residency program director would have had that case up for M&M and roasted the case for 90 minutes... So, some points:
1. I personally hate the "crack chest" statement for a thorocotomy that is performed well. The cracked chest really is either a sternotomy or you broke ribs with your thorocotomy.... Maybe they did given their "struggle".
2. One of the most common operative injuries we dealt with, I dare say all major trauma centers deal with, is major splenic injuries. During residency, we had plenty of splenic avulsions, etc... We never found ourselves so blinded. Hell, we had penetrating injuries directly to the aorta!
3. On vascular surgery rotation, we had aortic (i.e. not no little splean) ruptures with bellies full of blood. The only reason we went in the chest would be because the aneurysm was up there too...

Long and short, if TWO trauma attendings can not get control of splenic artery abdominal bleeding IN THE ABDOMEN, IMHO there is a real problem. Sounds like another wonderful drama story. But, it is one I would never brag about, never discuss in a more informed audience, and not plan on using in the boards......

So if we're shouldn't be cracking chests in the ED, when do you think residents should learn those maneuvers in case they need them in an OR setting?...we still need to learn to do it, right?...

Honestly, probably not. If you aren't doing trauma surgery you really don't need to be doing ED thorocotomies. Yes, you can practice on a cadaver. But, seriously, if your in a small community hospital, how many indicated trauma cases are coming accross your doorstep? And, keep in mind, it ISN'T INDICATED if you lack the facilities/services/capacity to provide the next step of care. You do NOT perform ED thorocotomy to transfer! Finally, so you do 1, 2, 5, or 10 ED thorocotomies over 5 years of general surgery. Great. Now, you are back in the small community hospital and have done none for 1, 2, 5, 10 years! What was the point.

So, no, most surgery residents do not need to perform an ED thorocotomy. You can learn the anatomy and study the procedure from a number of text sources to get through your boards. There are numerous procedures of which you will be questioned and never have seen or assisted or performed the procedure...

...I just don't think "residents needing practice" is an acceptable reason to subject a patient to a unnecessary procedure. There are plenty of rare things we never do anymore that we may [need to know about for our boards]...

...EDT...if you can't justify doing it for a reason OTHER than "practice", because the patient has no chance, you shouldn't be doing it.

... PS: I added the bold bracket point in the quote from SLuser above.

 

[LucidSplash]

I am just really not impressed. In fact, somewhat disapointed. My general surgery residency program director would have had that case up for M&M and roasted the case for 90 minutes... So, some points:
1. I personally hate the "crack chest" statement for a thorocotomy that is performed well. The cracked chest really is either a sternotomy or you broke ribs with your thorocotomy.... Maybe they did given their "struggle".
2. One of the most common operative injuries we dealt with, I dare say all major trauma centers deal with, is major splenic injuries. During residency, we had plenty of splenic avulsions, etc... We never found ourselves so blinded. Hell, we had penetrating injuries directly to the aorta!
3. On vascular surgery rotation, we had aortic (i.e. not no little splean) ruptures with bellies full of blood. The only reason we went in the chest would be because the aneurysm was up there too...

Long and short, if TWO trauma attendings can not get control of splenic artery abdominal bleeding IN THE ABDOMEN, IMHO there is a real problem. Sounds like another wonderful drama story. But, it is one I would never brag about, never discuss in a more informed audience, and not plan on using in the boards......Honestly, probably not. If you aren't doing trauma surgery you really don't need to be doing ED thorocotomies. Yes, you can practice on a cadaver. But, seriously, if your in a small community hospital, how many indicated trauma cases are coming accross your doorstep? And, keep in mind, it ISN'T INDICATED if you lack the facilities/services/capacity to provide the next step of care. You do NOT perform ED thorocotomy to transfer! Finally, so you do 1, 2, 5, or 10 ED thorocotomies over 5 years of general surgery. Great. Now, you are back in the small community hospital and have done none for 1, 2, 5, 10 years! What was the point.

So, no, most surgery residents do not need to perform an ED thorocotomy. You can learn the anatomy and study the procedure from a number of text sources to get through your boards. There are numerous procedures of which you will be questioned and never have seen or assisted or performed the procedure...... PS: I added the bold bracket point in the quote from SLuser above.

Thanks for your response JAD - I appreciate your insight which is obviously sourced in experience. In truth, I'm sorry if the way in which I communicated the specific scenario came across as "bragging." That's not really my style, especially in the setting of an internet forum, and I'm confident that my posting history would support that. It was simply the case that was at the forefront of my mind when reviewing what others have been posting over the last few days/weeks. I'm definitely not qualified to discuss the specifics of the case and who knows - you may be correct in your assessment but I think its tough to really assess the case based on a short retelling on an internet forum, provided by an intern who wasn't even directly involved. It was discussed at M&M (not for 90 minutes but for most of the hour we allot). I'm at a Level 1 center and we do see our share of blunt and penetrating trauma (obviously nothing like where I went to medical school but still, Level I) and I got the impression this was someone different than the usual stuff. But as I've made clear, I'm only an intern and I acknowledge that I'm not particularly qualified to discuss the case in depth or analyze it in any fashion. I'm definitely not trying to derail the thread just by mentioning the case.

Thanks again for your post. Given the controversy over EDT, I'm just trying to get a bit more educated on the various positions people hold on the subject.

 

[SLUser11]

Thanks for your response JAD - I appreciate your insight which is obviously sourced in experience. In truth, I'm sorry if the way in which I communicated the specific scenario came across as "bragging." That's not really my style, especially in the setting of an internet forum, and I'm confident that my posting history would support that. It was simply the case that was at the forefront of my mind when reviewing what others have been posting over the last few days/weeks. I'm definitely not qualified to discuss the specifics of the case and who knows - you may be correct in your assessment but I think its tough to really assess the case based on a short retelling on an internet forum, provided by an intern who wasn't even directly involved. It was discussed at M&M (not for 90 minutes but for most of the hour we allot). I'm at a Level 1 center and we do see our share of blunt and penetrating trauma (obviously nothing like where I went to medical school but still, Level I) and I got the impression this was someone different than the usual stuff. But as I've made clear, I'm only an intern and I acknowledge that I'm not particularly qualified to discuss the case in depth or analyze it in any fashion. I'm definitely not trying to derail the thread just by mentioning the case.

Thanks again for your post. Given the controversy over EDT, I'm just trying to get a bit mI ore educated on the various positions people hold on the subject.

I think you are being too apologetic. You are a surgical resident and your opinion is valued. This is an anonymous message board and there's no real hierarchy. Btw this is my first attempt at sdn posting from my phone.....

 

[ESU_MD]

Who knows, maybe trauma surgeons will have problems controlling a splenic artery bleed. Take a scenario.... Some dude from a marginal training program comes with shaky skills, then wants to be a "trauma" surgeon, so they become an icu jockey for a year (no operating). Then off to some nonop trauma job as staff and do appys and gallbladders. A spleen comes in, the IR guy is out of town and poof... Uncontrollable bleeding from a vessel that can almost be controlled with a bovie.

Btw.... I loved the wittman patch. Underutilized and alot nicer than the iv bag closure

 

[JackADeli]

Thanks for your response...I'm sorry if the way in which I communicated the specific scenario came across as "bragging."...

I think you are being too apologetic. You are a surgical resident and your opinion is valued. This is an anonymous message board and there's no real hierarchy. Btw this is my first attempt at sdn posting from my phone.....

I agree with SLuser... you are being too apologetic. You did not come accross as bragging. My statement in that regards was not an accusation but a warning. We all have or have had dramatic case observations and/or experiences. They become fuel for our "war story" moments. As you move up in your training, you may find yourself looking silly/slapped down when you pull out a war story.

The experienced/knowledgeable folks in the room will immediately zero in on the critical point failures, i.e. two trauma attendings unable to get control of splenic artery bleed by the abdomen, thus they employ ~complete abdominal/gut ischemia..... The board examiners may ask you to "tell us about a particularly interesting case....". Be very careful not to be distracted/tempted into pulling a "drama case" out your butt.

Again, you are correct, neither you nor I were present. There may have been some "unique anatomy" situation or equipment failure requiring entry into the thorax. Keep in mind the old tradition.... "new surgeons always seem to encounter unique anatomy....". My suggestion to you, as you progress in training, is to ask "why"? Always put the drama aside and consider if the approach/plan made sense or represented a "panic maneuver"? You should consider what the "normal expectation of competence" is in such a scenario? i.e. any decent, SOLO trauma surgeon at a level 1 center should be able to get control of isolated abdominal splenic bleeding. Remember, "we" often see patients with multiple intra-abdominal organ injury and hemorrhage, i.e. kidney/s, liver, splean, etc., etc... That is what four quad packing and damage control is all about. On top of that, vascular, arguably is were you see the most dramatic abd bleeding when you salvage a AAA rupture.

So, put the drama excitement of the specific case (often emphasized by the story teller to distract from failings) aside at M&Ms and ask yourself, is this reasonable? is it normal? is there a standard/reasonable alternative? how would I handle it in the future now that I have heard such a story? That is critical analysis and what makes you a better surgeon then the presenter....

 

[45408]

Do the board examiners usually ask you to tell about an interesting case? I've never heard about this before.

 

[Smurfette]

Do the board examiners usually ask you to tell about an interesting case? I've never heard about this before.

I've never heard of that either (may be too subjective for the boards examiners...there's no algorithm for them to follow with this), but I suppose it's a possible "extra" question in a room if you've already passed the 4 scenarios in the room and have time left....

 

[JackADeli]

Do the board examiners usually ask you to tell about an interesting case? I've never heard about this before.

Yes, it is not uncommon from my single experience and experiences of colleagues. It is not universal. However, it is not a unique or unheard of practice. It sometimes goes something like this, "Dr. tell us about an interesting operative case, why it interested you and how you handled...". At least, that's how it was posed to me and similarly to my colleagues.

Sometimes they let you tell the story or simply allow you to open a dorr for them to proceed questioning a particular subject. One colleague was asked, he started to speak about a teenager girl that was pregnant.... the questioning apparently veered to cover both the "ethics questioning" as well as what do you do with a breast lump in pregnancy. Others have told me of getting excited and into story telling and all but walked down to the chopping shed when the entire scenario was butchered because of reported details appeared to represent poor management.

 

[ESU_MD]

Do the board examiners usually ask you to tell about an interesting case? I've never heard about this before.

Thank god I have not encountered this in my one and only first hand experience either. I do not have first hand information that this really has ever occured, but anything is possible with 3 people in a hotel room. (in many circumstances, not just the boards............)


one of my examiners gave me a question involving a standard trauma scenario as a 4th question that evolved to getting into very detailed specifics about left heart bypass, heparin doses, flow rates etc... i think this was all gravy at the end, but it still was fun in retrospect and goes to show.. anything goes.

 

[JackADeli]

...one of my examiners gave me a question involving a standard trauma scenario as a 4th question that evolved to getting into very detailed specifics about left heart bypass, heparin doses, flow rates etc... i think this was all gravy at the end, but it still was fun in retrospect and goes to show.. anything goes.

That's a wonderful question to get cause it almost universally means you passed that room!