Futile Thoracotomies . . .

[Tiger26]

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So after getting a trauma alert today saying a guy had been shot in the chest coming in with poor or no vitals and the paramedics doing CPR en route, there was some palpable excitement about the prospect of doing a ED thoracotomy.

Regardless, he was PEA upon hitting the trauma bay and they called it within a minute or so. Obviously it was a legitimate call since he had no previously witnessed cardiac activity and had been PEA for the 30 min or so between when the call was made to EMS and when he got to the ED.

So the question is, in a situation like this, what is the likelyhood of doing a thoracotomy at your institutions anyway since you "can't make him any more dead" (I read this phrase doing a little thread searching before deciding to post)?

Medico-legally, I suppose you could be opening yourself up to undue litigation for somehow "killing" the patient (as the lawyer could say), especially since the likelihood of success is minimal at best. With that said, for educational purposes (and the minuscule off-chance of lifesaving), could it be worth it for the residents to get enough experience so that they're a little more prepared when they get a pt in the future who has a classic indication for the procedure?

 

[pseudoknot]

...Is there any other kind?

 

[WilcoWorld]

Patients with penetrating chest trauma are often not model citizens, and, although I don't have any data to support this, probably have a less than negligible rate of Hep C or HIV. ED Thoracotomies are by definition crash procedures which carry a non-negligible rate of body fluid exposure. Do you want to risk contracting HIV or Hep C because you "can't make him any more dead"?

I don't.

 

[Jeff698]

It really depends on where you are. At our 'big house' academic center with residency the indication for ED thoracotomy gets stretched a bit. MRB and all (maximum resident benefit).

In my community ED, it just ain't gonna happen. Even if we got 'em opened up, we wouldn't have anyone else to work on them from there. My thought is that if you're going to have to turn right around and transfer them as soon as you cut them, you probably shouldn't be cutting to begin with.

Take care,
Jeff

 

[roja]

Patients with penetrating chest trauma are often not model citizens, and, although I don't have any data to support this, probably have a less than negligible rate of Hep C or HIV. ED Thoracotomies are by definition crash procedures which carry a non-negligible rate of body fluid exposure. Do you want to risk contracting HIV or Hep C because you "can't make him any more dead"?

I don't.

Here, Here! Not only that, the survival rate is low, although better if you are at a major trauma center, staffed with trauma surgeons. Although still pretty crappy, and only if you do them within the strict guidelines associated with it.

Needlesticks and exposures are high during this procedure. If you haven't had to take preventive therapy, or know anyone who has, find someone and talk to them.

 

[bartleby]

All good points above. The other reason to avoid doing gratuitous thoacotomies is that if you have someone is not a good candidate (people with prolonged down time) you always take the risk of resuscitating someone who is almost guaranteed to have a bad functional/neurological outcome.

 

[xaelia]

I saw one good outcome during my one month of trauma surgery at Harbor-UCLA for an ED thoracotomy; they lost pulses in the department, the cardiac injury was apparently obvious, and they had him rolling upstairs immediately. I could not believe I sent the guy home a week later.

 

[edinOH]

...Is there any other kind?

That was my thought. Kind of redundant.

 

[diphenyl]

Even if it is indicated it a community hospital unless you have an OR w/ a surgeon ready its pointless.

 

[deleted109597]

...Is there any other kind?

For blunt trauma, thoracotomies aren't useful because the injury can't be fixed (aortic transection, other great vessel tears). For gunshot wounds, if the injury is to the heart, you likely aren't going to be be able to repair it.
However, if the injury is a stab to the box, and you lose pulses, it likely isn't due to irreparable damage. Usually pulses are lost due to tamponade physiology, and this particular subgroup has a greater than 50% survival of thoracotomy at the appropriate center.
The rest are usually just academic though.

 

[droliver]

As a practical point, most people other then thoracic surgeons will struggle with these cardiac manuevers under any circumstance, much less an emergent one. I did maybe 2-3 emergency thoracotimes during my surgery residency (with some signifigant experience in doing them electively during other services) and I came to the conclusion that I was as likely lacerate/tear the heart into shreds (or cover a room in fountains of blood) as I was likely able to actually control an injury.