Tandem resuscitative hysterotomy and thoracotomy in peripartum cardiomyopathy-mediated cardiac arrest

[SpacemanSpifff]

A case report published in this month's Annals: young, pregnant woman arrives at an academic center after being intubated for hypoxemic respiratory failure at a referring facility. Arrests on/shortly after arrival. They deliver the fetus, crack mom's chest... both leave the hospital within 3 weeks, without significant deficits. Full details in the original article. This is just insanity, of the best kind.

The authors state that both the thoracotomy and hysterotomy were performed by emergency physicians without specialist assistance. Hysterotomy is a procedure I've been trained on. Thoracotomy, not so much. What programs out there are having EM trained residents/attendings cracking chests? Any attendings doing this in the community? Obviously a rare procedure filled with risk, but undeniably life-saving in certain situations.

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[Birdstrike]

What programs out there are having EM trained residents/attendings cracking chests?

In my residency the experience consistent of doing a few on cadavers combined with whatever we saw/did on surgical rotations which was slim to none. You'll do more of these at a gun n' knife club residency. In 10 years in the ED, the only time I ever came close to doing one was on a kid who had been shot through the heart, but he was beyond the time window that there's any chance of survival, so I didn't do it.

Any attendings doing this in the community?

Yes, but rare. This is why it's a case report as opposed to routine. You're better off having your surgeon on call doing it. That being said if you have to try it on a dead person, keep in mind you can't hurt a dead person. At the same time, I've never seen an EM physician criticized for not doing an ED thoracotomy.

 

[Groove]

Our residency was somewhat of a knife and gun club (only tertiary trauma center in the state). I assisted with 2 during residency that I can remember (aside from cadavers). I did one on my own about 2 years out of residency on a 18yo male who jumped in front of his sister/cousin to protect her from assailant (reportedly), KSW sub xiphoid that went through his right ventricle. He arrested minutes after we dragged him from his car and got him into the resus bay. It was rather textbook and in spite of the statistical unlikelihood of survival after ED thoracotomy I still think it was the right decision. He had tamponade and a large lac to the right ventricle that I couldn't plug with a foley and couldn't whip stitch fast enough before he bled out in front of me.

You need a surgeon present or on board and if you anticipate beginning one, make sure you have someone call in GS or CT surgery. I put a call in to both as we were coding the pt and they were bringing thoracotomy tray to the room. CT did not think I should do it (futile statistics and we are not a trauma center) but was on his way. GS was on board and said he would come assist. I made the call to do it and GS arrived to help halfway through. CT showed up at the end of the case. It was the right call given the circumstances but if you're going to have the slightest chance of survival you need surgery next door as well as an attached OR and all the resources of a level 1 trauma center. The closest we had to survival in residency was a guy that made it up the elevator to the OR and then re-coded and died.

 

[Nik Theyyunni]

Hey! I'm one of the authors. Our residents generally get a little experience with thoracotomy at one of the trauma centers in our system, but most of them will have experience mostly in cadaver lab and sim. For resuscitative hysterotomy I think most of our physicians are familiar with it only in sim. I've done or assisted on a reasonable number of thoracotomies and a handful of hysterotomies.

The senior author is an attending with just a huge amount of experience, and it was absolutely his experience and leadership of the case that made this go anywhere nearly as well as it did. However I'll say that as with many rare procedures in emergency medicine, the most difficult part of the procedure was the decision to perform it.

To be clear, we were very much at a large academic hospital. One thing that's hard to get across in print is how BIG a team helped with this. over the course of the resuscitation at least 3 ED attendings, 4 awesome senior residents, at least 5 nurses and multiple other health care team members including respiratory therapy were involved. If we had more time quite definitely neonatalogy, obgyn, and surgery would have been involved. They were called, but the acuity of the case didn't allow time to wait for consultants. All were involved, and extremely helpful in the ongoing resuscitation.

I don't and haven't worked in the community. I have the greatest of respect to someone who would have to do this in a setting with fewer resources. My experience with this has made me really focus on discussing the decision making and performance of these rare procedures with trainees as often as possible.

 

[miacomet]

Hey! I'm one of the authors. Our residents generally get a little experience with thoracotomy at one of the trauma centers in our system, but most of them will have experience mostly in cadaver lab and sim. For resuscitative hysterotomy I think most of our physicians are familiar with it only in sim. I've done or assisted on a reasonable number of thoracotomies and a handful of hysterotomies.

The senior author is an attending with just a huge amount of experience, and it was absolutely his experience and leadership of the case that made this go anywhere nearly as well as it did. However I'll say that as with many rare procedures in emergency medicine, the most difficult part of the procedure was the decision to perform it.

To be clear, we were very much at a large academic hospital. One thing that's hard to get across in print is how BIG a team helped with this. over the course of the resuscitation at least 3 ED attendings, 4 awesome senior residents, at least 5 nurses and multiple other health care team members including respiratory therapy were involved. If we had more time quite definitely neonatalogy, obgyn, and surgery would have been involved. They were called, but the acuity of the case didn't allow time to wait for consultants. All were involved, and extremely helpful in the ongoing resuscitation.

I don't and haven't worked in the community. I have the greatest of respect to someone who would have to do this in a setting with fewer resources. My experience with this has made me really focus on discussing the decision making and performance of these rare procedures with trainees as often as possible.

Sounds like it might be tough in a solo coverage shop....

 

[Groove]

As far as hysterotomy, I don't ever remember being trained for it. I have some vague recollection of being taught how to do vertical hysterotomy somewhere but I'm not sure where I learned or read about it. I've watched enough youtube videos over the years that I think I could do one just fine if the circumstances called for it but man...I really don't ever want to be in the position where I need to do one of those.

Watch this dude on Youtube perform an emergent c-section at warp speed. Most impressive.

 

[GonnaBeADoc2222]

Hey! I'm one of the authors. Our residents generally get a little experience with thoracotomy at one of the trauma centers in our system, but most of them will have experience mostly in cadaver lab and sim. For resuscitative hysterotomy I think most of our physicians are familiar with it only in sim. I've done or assisted on a reasonable number of thoracotomies and a handful of hysterotomies.

The senior author is an attending with just a huge amount of experience, and it was absolutely his experience and leadership of the case that made this go anywhere nearly as well as it did. However I'll say that as with many rare procedures in emergency medicine, the most difficult part of the procedure was the decision to perform it.

To be clear, we were very much at a large academic hospital. One thing that's hard to get across in print is how BIG a team helped with this. over the course of the resuscitation at least 3 ED attendings, 4 awesome senior residents, at least 5 nurses and multiple other health care team members including respiratory therapy were involved. If we had more time quite definitely neonatalogy, obgyn, and surgery would have been involved. They were called, but the acuity of the case didn't allow time to wait for consultants. All were involved, and extremely helpful in the ongoing resuscitation.

I don't and haven't worked in the community. I have the greatest of respect to someone who would have to do this in a setting with fewer resources. My experience with this has made me really focus on discussing the decision making and performance of these rare procedures with trainees as often as possible.

Amazing. Great work.

 

[namethatsmell]

If I ever had the misfortune of receiving such a case and then had the blessing of a similar outcome to what was described...I'd think hard about retiring from EM...there's no way to exit the game more on top than this...


Is anybody able to post the full report?

 

[TooMuchResearch]

As far as hysterotomy, I don't ever remember being trained for it. I have some vague recollection of being taught how to do vertical hysterotomy somewhere but I'm not sure where I learned or read about it. I've watched enough youtube videos over the years that I think I could do one just fine if the circumstances called for it but man...I really don't ever want to be in the position where I need to do one of those.

Watch this dude on Youtube perform an emergent c-section at warp speed. Most impressive.

We practiced it in sim (hysterotomy). I know where the kit should be in the tertiary center ED, but I think you really only need a few tools.

I was in the room and somewhat hands on for 1-2 thoracotomies in residency, also got some cadaver and sim practice.



OP, your ability to do some of these things out of residency is more dependent on where you work rather than where you do residency. Could I do a resuscitative hysterotomy at one of the rural places I work? Absolutely, and we have OB and other people on call to help afterwards. Thoracotomy? I don't even know if we have a kit. I can transport these patients to the trauma center faster than I can muster enough people to staff the OR, but I suspect they wouldn't survive transport. Maybe I'd do it in a very young person with the right injury, but again not even sure there is a kit.

 

[Groove]

Thoracotomy? I don't even know if we have a kit. I can transport these patients to the trauma center faster than I can muster enough people to staff the OR, but I suspect they wouldn't survive transport. Maybe I'd do it in a very young person with the right injury, but again not even sure there is a kit.

Most of the time in the worst case scenario your hospital should have the thoracotomy tray in the OR and can send it down (assuming you have CT surgery there). One thing we've started doing is creating mobile "trauma" and "difficult airway" carts that can be moved around the ED and has all the tools already in it. Prior to that, if I had an occasional GSW come in with chest wounds, I'd call in advance for the thoracotomy tray (just in case) and it took exactly 6 minutes to get to the ED from the OR which isn't bad, especially if you call in advance. Stabilizing and flying to your local major trauma center is always best but if you can't get them stable for transport... That being said, the opportunity to do these things in community practice is exceedingly rare.

 

[Zebra Hunter]

I performed or assisted on about 10 thoracotomies in residency with a trauma and EM attending supervising. They are easy enough to perform, but almost never have a good outcome. I think the data is significantly biased towards good outcomes, or possibly other centers are seeing way more stabbings than GSWs.

Never seen a peri-mortem c-section, and most EM docs will never see one in their career, but we should always be ready to do one regardless of whether you have surgical back up or not (unlike thoracotomies).

As far as the case in OP. I'm having a very hard time understanding their reasoning for cracking the pt's chest. I understand that they were getting inadequate end tidal CO2 but I really don't see why the need to go to thoracotomy rather than possibly adjusting chest compressions. It is an amazing case and an incredible outcome, but I guess I'm just missing the logical leap that made them decide thoracotomy was necessary.

 

[RoyBasch]

As far as the case in OP. I'm having a very hard time understanding their reasoning for cracking the pt's chest. I understand that they were getting inadequate end tidal CO2 but I really don't see why the need to go to thoracotomy rather than possibly adjusting chest compressions. It is an amazing case and an incredible outcome, but I guess I'm just missing the logical leap that made them decide thoracotomy was necessary.

Because one of the study authors @Nik Theyyunni is in the thread, maybe they can elaborate; however, I am with Zebra, why was a thoracotomy performed here? Seems like major morbidity with no therapeutic benefit. I understand why the peri-mortem C section/hysterotomy was done.

 

[SpacemanSpifff]

If I ever had the misfortune of receiving such a case and then had the blessing of a similar outcome to what was described...I'd think hard about retiring from EM...there's no way to exit the game more on top than this...
Is anybody able to post the full report?

Attached.

Because one of the study authors @Nik Theyyunni is in the thread, maybe they can elaborate; however, I am with Zebra, why was a thoracotomy performed here? Seems like major morbidity with no therapeutic benefit. I understand why the peri-mortem C section/hysterotomy was done.

If you've seen some of the work that Felipe Teran has been championing, closed chest compressions can be downright counterproductive in some cases - specifically if over the LVOT (prompting TEE guided compressions). Changing the area of maximal compression may have been previously attempted. My thought: in the case of several data points suggesting inadequacy of close chest compressions, in a young, otherwise healthy patient with a reversible condition, the morbidity of an thoracotomy scar seems outweighed by a small possibility of achieving ROSC. Certainly can see the contrary point of view as well

 

[TooMuchResearch]

Most of the time in the worst case scenario your hospital should have the thoracotomy tray in the OR and can send it down (assuming you have CT surgery there). One thing we've started doing is creating mobile "trauma" and "difficult airway" carts that can be moved around the ED and has all the tools already in it. Prior to that, if I had an occasional GSW come in with chest wounds, I'd call in advance for the thoracotomy tray (just in case) and it took exactly 6 minutes to get to the ED from the OR which isn't bad, especially if you call in advance. Stabilizing and flying to your local major trauma center is always best but if you can't get them stable for transport... That being said, the opportunity to do these things in community practice is exceedingly rare.

Tertiary care center has a thoracotomy tray in the ED.
Teeny tiny places I also work don't have CT surgery.

 

[deleted109597]

Thoracotomy was done because the hysterotomy did not result in adequate resuscitation, and closed chest CPR wasn't working.

After delivery, the mother remained in cardiac arrest. End-tidal capnography demonstrated acceptable waveform but poor amplitude, at only 4 mm Hg despite appropriate chest compressions and administration of 2 mg of intravenous epinephrine. Given the low capnographic readings, CPR generated poor perfusion. Combined with the short duration of arrest in addition to favorable patient age and baseline comorbidities, our team thought that the mother might benefit from open-chest cardiac massage. The lead emergency physician—without surgical assistance—performed a left lateral thoracotomy and immediately evacuated more than 1 L of serous fluid. There was no pericardial effusion and we deferred pericardiotomy. We then performed direct cardiac massage, with increase in capnography amplitude to greater than 30 mm Hg within 2 minutes.

The only thing I've learned from my many many "tacticool" courses is that LLT is not as effective as a clamshell. As John Hinds said, if you can't fit your head in there, the hole isn't big enough.

 

[Rendar5]

So is the future of cpr going to be everyone gets a thoracotomy for open chest compressions if closed ones don’t work?

 

[SpacemanSpifff]

So is the future of cpr going to be everyone gets a thoracotomy for open chest compressions if closed ones don’t work?

The closing statement of the article suggests considering opening the chest in select cases with “poor objective predictors of ROSC”, a potentially reversible cause presumably amenable to the intervention, and all the other caveats (young enough, previously healthy enough, surgical support available, etc.).

 

[deleted109597]

So is the future of cpr going to be everyone gets a thoracotomy for open chest compressions if closed ones don’t work?

Or ECMO, obv