Emergency physician credentialing for resuscitative thoracotomy for trauma

Objective: A low case incidence and variable skill level prompted the development of a credentialing programme and specific surgical training in resuscitative thoracotomy for emergency physicians at The Alfred, a Level 1 Adult Victorian Major Trauma Service. Methods: A review of the incidence of traumatic pericardial tamponade and the objectives of resuscitative thoracotomy were undertaken. Results: A training programme involving pre‐reading of a 17 page teaching manual, a 40 min didactic lecture and a 2 h surgical skills station using anaesthetized pigs were developed. The specific indication for resuscitative thoracotomy for this programme is ultrasound demonstrated cardiac tamponade secondary to blunt or penetrating truncal trauma in a haemodynamically unstable patient with a systolic blood pressure of less than 70 mmHg despite pleural decompression and intravenous volume replacement. Cardiac electrical activity must be present. The primary aims of resuscitative thoracotomy taught are release of cardiac tamponade, control of haemorrhage and access for internal cardiac massage. Conclusion: Emergency physicians working in high‐volume Trauma Centres are expected to diagnose cardiac tamponade and on occasion decompress the pericardium. Specific training in the procedure should be undertaken.     

Right ventricular rupture during closed-chest cardiopulmonary resuscitation after pneumonectomy with pericardiotomy: a case report.

SETTING: The collapse of a patient immediately after right pneumonectomy with right pericardiotomy resulted in closed-chest cardiopulmonary resuscitation, subsequent thoracotomy, and demise secondary to right ventricular rupture. Interventions: Closed-chest resuscitation with opened and closed chest tubes and medical and fluid interventions were inadequate, necessitating subsequent thoracotomy. MAIN RESULTS AND CONCLUSIONS: Right ventricular rupture during resuscitation was found during subsequent thoracotomy. This rupture and inadequacy of closed-chest resuscitation were felt to be associated with the operative pneumonectomy and pericardiotomy. Pathophysiology and the role of open-heart vs. closed-chest resuscitative measures are discussed.     

Iatrogenic postintubation tracheal rupture

Iatrogenic damage to the trachea in its intubation and during artificial lung ventilation ,is a rare, severe and commonly fatal complication in resuscitative care. The risk for tracheal damage increases in emergency, time shortage and hypoxia in a patient, while intubating with a double-lumen tube, using rigid mandrin guides without a safety limit stop, and having difficulties in intubating the patient due to his/her anatomic features. Fibrotracheoscopy is the principal diagnostic techniques that may cause tracheal rupture, which may be transformed to a therapeutic measure, by placing an intubation tube caudally at the site of tracheal rupture. Among 33 patients, only 6 underwent surgical defect suturing. When the trachea is ruptured, surgery is indicated for respiratory hemorrhage unstopped by inflating the cuff of an intubation tube and, perhaps, associated with the damage to a large vessel; for progressive gas syndrome, extensive rupture of the membranous part with the involvement of the tracheal bifurcation and main bronchus or with the interposition of paratracheal tissues; for a concomitant damage to the esophagus; for rupture of the tracheal membranous part during intubation before thoracotomy or for rupture detected during thoracotomy for another cause. Correct and timely care may eliminate this life-threatening iatrogenic complication, by yielding a good effect.     

Emergency department thoracotomy for trauma: a collective review

A decade of experience with resuscitative thoracotomy for the trauma victim in extremis has been gained since the pioneering efforts of Mattox and his associates in 1974. It appears, from a review of the various reports from different trauma centers, that there is an emergence of a consensus as to the best indications for the procedure. It is generally agreed upon that ERT is fruitless in the patient with severe head trauma or when vital signs were absent at the scene of the injury. In the absence of penetrating thoracic injuries ERT yields a very poor survival in patients without vital signs on admission to the emergency center. It is widely accepted that the best results for ERT are in patients with cardiac tamponade. The prognosis is hopeless in patients without vital signs after sustaining blunt trauma.     

Selective right-lung ventilation during emergency department thoracotomy

Surgeons are occasionally called on to manage patients with penetrating cardiac injuries who arrive at the ED in extremis. Immediate thoracotomy in the ED is associated with good resuscitative results in a select group of such patients, but cardiorrhaphy is often impeded by frequent inflations of the left lung during resuscitation. We investigated a technique for selective right-lung ventilation using a standard single-lumen endotracheal tube in cadaver and animal models. This technique is easily applicable, provides adequate oxygenation and ventilation for up to 60 min, and expedites cardiorrhaphy in the ED.     

Emergent pediatric thoracotomy following traumatic arrest

Objectives

Emergent thoracotomy is a potentially life-saving procedure following traumatic cardiac arrest. The procedure has been studied extensively in adults, but its role in pediatric traumatic cardiac arrest remains unclear. We aimed to determine the prevalence of survival following emergent resuscitative thoracotomy in children.

Methods

This was a retrospective cohort study that included consecutive patients < 18 years old who underwent emergent thoracotomy following traumatic cardiac arrest over a 15-year period. Factors previously associated with survival following thoracotomy in adults were measured.

Results

During the study period, 29 patients underwent emergent thoracotomy. Of these, 3 (10%, 95% confidence interval [CI]: 2–27%) survived to hospital discharge. All survivors sustained penetrating trauma to the heart and had signs of life on arrival of emergency medical services. Of the 13 patients who sustained blunt trauma, 0 (0%, 95% CI: 0–25%) survived, despite 69% (9/13) demonstrating signs of life on arrival of emergency medical services and 38% (5/13) having temporary return of spontaneous circulation.

Conclusions

Emergent thoracotomy is a potentially life-saving procedure for children following traumatic cardiac arrest. It appears most successful in children suffering penetrating trauma to the heart with signs of life on arrival of emergency medical services. Larger studies are needed to determine the factors associated with this survival benefit for emergent thoracotomy in children.     

Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture

Extracorporeal cardiopulmonary resuscitation (ECPR) followed by operating room sternotomy, rather than resuscitative thoracotomy, might be life-saving for patients with blunt cardiac rupture and cardiac arrest who do not have multiple severe traumatic injuries.A 49-year-old man was injured in a vehicle crash and transferred to the emergency department. On admission, he was hemodynamically stable, but a plain chest radiograph revealed a widened mediastinum, and echocardiography revealed hemopericardium. A computed tomography scan revealed hemopericardium and mediastinal hematoma, without other severe traumatic injuries. However, the patient's pulse was lost soon after he was transferred to the intensive care unit, and cardiopulmonary resuscitation was initiated. We initiated ECPR using femorofemoral veno-arterial extracorporeal membrane oxygenation (ECMO) with heparin administration, which achieved hemodynamic stability. He was transferred to the operating room for sternotomy and cardiac repair. Right ventricular rupture and pericardial sac laceration were identified intraoperatively, and cardiac repair was performed. After repairing the cardiac rupture, the cardiac output recovered spontaneously, and ECMO was discontinued intraoperatively. The patient recovered fully and was discharged from the hospital on postoperative day 7.In this patient, ECPR rapidly restored brain perfusion and provided enough time to perform operating room sternotomy, allowing for good surgical exposure of the heart. Moreover, open cardiac massage was unnecessary. ECPR with sternotomy and cardiac repair is advisable for patients with blunt cardiac rupture and cardiac arrest who do not have severe multiple traumatic injuries.     

T ERMINATION OF R ESUSCITATION IN THE P REHOSPITAL S ETTING FOR A DULT P ATIENTS S UFFERING N ONTRAUMATIC C ARDIAC A RREST

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.     

Societal opinions regarding CPR

Resuscitative measures are traditionally undertaken for most patients with cardiac arrest, unless an advance directive exists. This long-standing default presumption of patients' wishes to undergo resuscitation has never been proven. This study was undertaken to determine societal preferences of the general public regarding resuscitation. A cross-sectional survey was administered at community events to 724 volunteer participants over a 16-month period. For 6 hypothetical clinical scenarios (previously piloted and validated), respondents indicated personal preferences regarding resuscitation attempts for themselves. Most respondents indicated preferences for resuscitative efforts in a scenario depicting a young, healthy patient (96%), whereas few would desire resuscitative efforts for an elderly, debilitated patient (27%) (P <.01, Fisher's exact test). Nearly all (98%) respondents showed a trend (by scalogram analysis) toward refusal of resuscitative efforts in scenarios depicting more elderly, debilitated patients. Respondents had inaccurate perceptions of survival rates after cardiac arrest; the mean estimated survival rate was 50% (range 0%-100%). Although the majority of respondents had a personal physician (82%), only 10% of respondents had ever discussed death or resuscitation with their physicians. This study shows a trend in personal opinion among the general public toward refusal of resuscitative efforts in clinical scenarios with poor prognoses. Because so few patients have completed advance directives, physician awareness of such public opinions may be useful in decision-making in end-of-life care, particularly when caring for patients without advance directives. These public opinions support the feasibility of establishing societal consensus regarding resuscitation preferences, which may be useful in the development of federal and local guidelines and policies.     

Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling. PREHOSPITAL EMERGENCY CARE 2000;4:190-195     

Therapeutic hypothermia after prolonged cardiac arrest due to non-coronary causes

Mild resuscitative hypothermia has been shown to improve neurological outcome after cardiac arrest presenting with ventricular fibrillation (VF) due to cardiac causes. We describe the experience of inducing mild hypothermia in three patients with non-cardiac causes of arrest and long delays before a return of spontaneous circulation (ROSC). In one patient, extreme metabolic acidosis due to inadvertent oesophageal intubation complicated therapy, and the role of point-of-care diagnostics in the prehospital setting is briefly discussed. All patients survived to discharge from hospital, and neuropsychological examinations revealed good recovery. It is concluded that mild resuscitative hypothermia may be beneficial also in patients with obvious non-coronary causes for cardiac arrest.     

Development of a simple algorithm to guide the effective management of traumatic cardiac arrest

Background

Major trauma is the leading worldwide cause of death in young adults. The mortality from traumatic cardiac arrest remains high but survival with good neurological outcome from cardiopulmonary arrest following major trauma has been regularly reported. Rapid, effective intervention is required to address potential reversible causes of traumatic cardiac arrest if the victim is to survive. Current ILCOR guidelines do not contain a standard algorithm for management of traumatic cardiac arrest. We present a simple algorithm to manage the major trauma patient in actual or imminent cardiac arrest.

Methods

We reviewed the published English language literature on traumatic cardiac arrest and major trauma management. A treatment algorithm was developed based on this and the experience of treatment of more than a thousand traumatic cardiac arrests by a physician – paramedic pre-hospital trauma service.

Results

The algorithm addresses the need treat potential reversible causes of traumatic cardiac arrest. This includes immediate resuscitative thoracotomy in cases of penetrating chest trauma, airway management, optimising oxygenation, correction of hypovolaemia and chest decompression to exclude tension pneumothorax.

Conclusion

The requirement to rapidly address a number of potentially reversible pathologies in a short time period lends the management of traumatic cardiac arrest to a simple treatment algorithm. A standardised approach may prevent delay in diagnosis and treatment and improve current poor survival rates.     

Life‐threatening gastrointestinal bleeding from splenic artery pseudoaneurysm due to gastric ulcer penetration treated by surgical hemostasis with resuscitative endovascular balloon occlusion of the aorta: A case report

We report the case of a patient for whom surgical hemostasis of gastrointestinal bleeding due to a splenic artery pseudoaneurysm, which developed due to gastric ulcer penetration, was achieved with resuscitative endovascular balloon occlusion of the aorta without ischemia of organs including the spleen.     

Emergency Department Resuscitative Procedures: Animal Laboratory Training Improves Procedural Competency and Speed

Certain resuscitative procedures can be lifesaving, but are performed infrequently by emergency medicine (EM) residents on human subjects. Alternative training methods for gaining procedural proficiency must be explored and tested. OBJECTIVE: To test whether animal laboratory training (ALT) is associated with sustained improvement in procedural competency and speed. METHODS: After watching an educational videotape of saphenous cutdown (SAPH), thoracotomy (THOR), and cricothyroidotomy (CRIC), EM residents were randomized to receive either a tutored ALT session on live anesthetized pigs (Group A) or no ALT session (Group B). Residents were tested six months later by performing procedures on live anesthetized pigs. Videotaped procedures were evaluated by blinded examiners for the number of critical steps, complications, and procedure times. RESULTS: Group A (n = 10) achieved a higher number of critical steps compared with Group B (n = 8) for SAPH (15.4 +/- 0.7 vs. 9.0 +/- 1.8, p = 0.03) and THOR (17.4 +/- 0.6 vs. 12.3 +/- 1.6, p = 0.009), but not CRIC (18.1 +/- 0.4 vs. 16.2 +/- 1.0, p = 0.1). Group A completed procedures in less time than Group B for SAPH (Wilcoxon chi(2) = 4.0, p = 0.04) and THOR (chi(2) = 4.4, p = 0.04), but not CRIC (chi(2) = 0.9, p = 0.3). There was no difference in the number of complications for any of the procedures. CONCLUSION: Residents with animal laboratory training six months prior to testing demonstrated improved procedural competency and speed in the performance of resuscitative procedures.     

Emergency thoracotomy

Emergency thoracotomy is a valuable therapeutic modality for the moribund patient when trauma is the cause of the shock state. It is a procedure that requires an understanding of the technique and indications and should be instituted based on the indications listed above. There is probably no reason to do this procedure in the patient who is in extremis as a result of blunt trauma, because results have been universally dismal in these patients. In the patient with a rapidly expanding abdomen resulting from trauma and who is moribund, opening the chest and cross-clamping the aorta may be beneficial. Emergency thoracotomy does not take the place of volume replacement and definitive surgical care for the trauma patient.     

Spinal Cord Stimulation to Treat Postthoracotomy Neuralgia: Non–Small-Cell Lung Cancer: A Case Report

Surgery is the mainstay of therapy for resectable-type tumors associated with non–small-cell lung cancer. Today, thoracotomy and video-assisted thoracotomy are surgical options. The prevalence of chronic pain with neuropathic symptoms is relatively high after thoracotomy. Spinal cord stimulation to treat such pain has received limited attention in the literature. The aim of this article is to report on the use of spinal cord stimulation in a single case of neuralgia after thoracotomy with lobectomy to treat non–small-cell lung cancer. At 24 months after implantation of the spinal cord stimulation system, the patient reported >75% pain relief, an overall improvement in quality of life—described as less pain with breathing, and improved functional ability pertaining to arm movements—and improved sleep patterns. This detailed case presentation provides a qualitatively weighted investigation into spinal cord stimulation for postthoracotomy neuralgia against the backdrop of oncologic care. Further investigations relying on quantitative assessment tools are necessary to further explore this form of therapy in this patient population. In the single case reported here, the use of spinal cord stimulation suppressed intractable pain targeted at the T6 and T7 dermatomes of the chest wall in the manifestation of postthoracotomy neuralgia.     

Hyperkalemic cardiac arrest,prolonged heart massage and simultaneous hemodialysis

A 53 year old diabetic patient underwent CABG and aortic valve replacement in another institution and developed postoperative oliguric and hyperkalemic acute renal failure. Shortly after transferring to our unit a cardiac arrest occurred. Immediate resuscitative measures were ineffective. The serum potassium level was 10.2 mmol/l. Conventional arteriovenous hemodialysis was initiated while the patient was still undergoing cardiac massage. When the serum potassium level was lowered to 6.5 mmol/l, 90 min later, the heart began to beat. After hemodialysis was discontinued the patient was reactive and fully conscious. The use of simultaneous hemodialysis with prolonged mechanical heart massage as a reliable method for recovery in hyperkalemic cardiac standstill is stressed.     

Major pulmonary embolism

The scope and spectrum of pulmonary embolism (PE) that are likely to challenge the intensivist are dominantly confined to 2 scenarios; first, a patient presenting with undifferentiated shock or respiratory failure and, second, an established intensive care unit (ICU) or hospital patient who develops hemodynamically unstable PE after admission. In either scenario, the diagnostic approach and therapeutic options are challenging. Differentiating PE from other life-threatening cardiopulmonary disorders can be exceedingly difficult. This article will review a structured pathophysiologic approach to the diagnostic, resuscitative and management strategies related to PE in the ICU.     

Termination of Resuscitative Efforts for Out-of-hospital Cardiac Arrests

OBJECTIVE: To determine the rate of termination of resuscitative efforts for out-of-hospital cardiac arrest patients and whether variability exists among different base hospitals providing online medical control (OLMC). METHODS: This was an observational one-year study that included all adult patients in the city of Los Angeles with nontraumatic, out-of-hospital cardiac arrests with attempted resuscitative efforts by paramedics. OLMC was provided by 13 base hospitals. The main outcome measure was the incidence of termination of resuscitative efforts on scene as directed by OLMC. RESULTS: Of 1,700 patients, 151 (9%) had resuscitative efforts terminated on scene via direction by OLMC. Patients pronounced on scene were statistically more likely to be older, be found in an extended care facility, have an unwitnessed arrest, and present in asystole. Two base hospitals were more likely to terminate resuscitative efforts via OLMC than all others. Incidence at base hospital A was 37% (odds ratio, 18.6; 95% confidence interval = 11.7 to 30.0; p < 0.0001); incidence at base hospital B was 14% (odds ratio, 3.3; 95% confidence interval = 1.9 to 5.5; p < 0.0001), and incidence at all other base hospitals was 5%. Cardiac arrest patients handled by base hospital A were more likely to be found in ventricular fibrillation; those patients handled by base hospital B had shorter emergency medical services response times and were more likely to be found in an extended care facility. All other characteristics of cardiac arrest patients were not significantly different among the base hospitals. CONCLUSIONS: There is significant variability in Los Angeles, depending on the particular base hospital that provides OLMC, in pronouncement of death and termination of resuscitative efforts for medical cardiac arrest in the field. Given potential ethical, logistical, and economic concerns, efforts to assure consistency in the practice of discontinuing resuscitative efforts in the field is warranted.