Time Critical Procedures Part II

Kane Guthrie

Last Talk

This Talk

•Emergency Resuscitative Thoracotomy

•Pericardial Tamponade

•Tension Pneumothorax

•Peri-Mortem C section

Case 1

•22 male

•Fight over girl

•Stabbed to L chest

•Goes into PEA

6 Killer Chest Trauma

•ATOM-FC

•Air obstruction - disruption

•Tension pneumothorax

•Open pneumothorax

•Massive haemothorax

•Flail chest

•Cardiac tamponade

Emergency Resuscitative Thoracotomy

Indications•Penetrating thoracic injury

•Traumatic arrest - previously SOL

•Unresponsive hypotension (BP <70)

•Blunt thoracic injury

•Unresponsive hypotension (BP <70)

•Chest tube output >1500ml

Allows us to

•Evacuation pericardial tamponade

•Direct control intrathoracic haemorrhage

•Control massive air embolism

•Open cardiac massage

•Cross clamp aorta

Relative Indications

•Traumatic arrest without witnessed cardiac activity!

Contraindications

Survival Rates

•Penetrating > 9-12%

•Some institutions achieved >38%

•Blunt trauma > 1-2%

Risky Business

Factors associated with survivors!

Equipment

Opening the Chest

•Left anterolateral incision

•Scissor through muscle, periosteum, pleura

•Rib spreaders 6th ribs

•May need to move the lung

Once Inside

•Relieve tamponade

•Look for bleeding source

•Suture

•Cross clamp

•IDC

Internal Cardiac Compressions

•2 handed technique

•Compress heart between:

•2 flat hands

•Hinged clapping motion

Defib the Cracked Chest

•Internal paddles

•Paddles each side of heart

•Low joules 15-30

•No internal paddles?

•Close chest- standard defib!

Case 2

•60 male

•Hx lung ca on chemo

•Progressive SOB

•Now:

•Hypotensive/shocked

Pericardial Tamponade

•is defined as the critical compression of the heart by accumulation of blood in the pericardial space.

Beck’s Triad!

•Distended neck veins

•Hypotension

•Muffled heart sounds

•Only occurs 40% of time!

Use the Probe!

Pericardiocentesis

•

Handy Hints

•Pericardial blood doesn’t clot

•Intracardial blood does clot

Some Pearls

•Only 100ml of blood can cause it

•Early Dx is key -ECHO

•Best manage in OT

Complications

•Myocardial perforation

•Bleeding

•Pneumothorax

•Arrhythmia

Pericardiocentesis Fails!

•Open thoracotomy

•Pericardio window

Case 3

•24 male

•Fell from roof

•SOB, hypotensive, agitated

Signs of Tension PTX

•Anxiety, agitation, distress

•Tachycardia-hypotension

•Neck vein distention

•Decreased chest movement

•Tracheal deviation

•Decreased breath sounds

Should be found clinically!

Managing Tension PTX

•Give high flow O2

•Immediate:

•Needle thoracentesis

•Finger thoracostomy

•Proceed to:

•Intercostal catheter

Needle Thoracentesis

•14g inserted

•2nd ICS

•Aim relive Tension PTX!

Needles Don’t Work

•Don’t reach target in 65% cases

•Prone to:

•Kinking

•Occluded

•Compress

A better spot

•5th ICS in AAL

•Less failure rate (16%)

• Caution on the L side!

Finger Thoracostomy

•Chest tube insertion w/o chest tube

•Use prehospital- arrest situations

Indications

•PTX in PT undergoing ventilation

•Actual/near traumatic cardiac arrest

•Shocked state - no apparent cause

Advantages

•The lung can be felt/seen to re-expand

•Pt deteriorates lung can be “re-fingered”

•Avoids blockage/kinging chest drain system

Trouble getting ICC in?

Case 4

•29 Female

•MVA -cardiac arrest

•Bun in the oven!

Determining Gestation

•Hard to do!

•No magic number >20weeks

•If fundal height above umbilicus great

Peri-mortem C-section

•Ability for 200% mortality

Timing

Get as much help as possible

•Obstetrician

•Paediatrician

•Midwife

•NICU

Remember

•PMCS is a resuscitative intervention for the mother!

Equipment - Mum

•Scalpel

•Surgical scissors

•Towels

•Cord clamps

Equipment -Baby

•Baby warmer

•Neonatal BVM

•Intubation kit

•IO

•First line drugs

Procedure

Neonatal Resuscitation

Questions

Take Home Points

•These are once in a career cases!

•Your own adrenaline is the enemy

•Be cognitive ready

•Know your equipment

•Hardest part is making the decision to do it

Thankyou