ED thoracotomy can be a dramatic, life-saving procedure. From the patient’s perspective, there is only an upside to performing it; without it there is 100% mortality. But to trauma professionals, there is considerable downside risk, including accidental injury, disease transmission and wasted resources. What is the societal risk/cost if ED thoracotomy is performed for weak indications?
The trauma group at Sunnybrook in Toronto looked at this question by retrospectively reviewing 121 patients who underwent the procedure over a 17 year period. They looked at appropriateness, resource use and the safety of the trauma professionals involved. They used the following criteria to determine appropriateness:
- Blunt trauma with an ED arrival time < 5 minutes
- Penetrating torso injury with an ED arrival time < 15 minutes with signs of life
Most of the patients were young men (avg age 30) with 78% penetrating injury and 22% blunt. About half (51%) underwent thoracotomy for inappropriate indications. The vast majority of inappropriate cases were for penetrating injuries with long transport times. Only 3 of the inappropriate thoracotomies were for blunt trauma, yet 24 of the “appropriate” procedures were done in the face of blunt trauma.
Resource use in the 63 inappropriate cases included 433 lab tests, 14 plain images and 9 CT scans (!!!?), 6 cases in the OR, 244 units of packed red cells and 41 units of plasma. Accidental needlestick injuries occurred in 6% of the inappropriate thoracotomies. None of the patients receiving inappropriate thoracotomy survived.
Bottom line: ED thoracotomy remains a very dangerous procedure. I’ve previously written about guidelines to determine which ones are appropriate (see link below). In this study, many of the procedures were performed on patients with blunt trauma. That means that the number of inappropriate thoracotomies would have been much higher if today’s standards had been applied. So use the guidelines and save your own health, safety and hospital resources. Is it really worth it if you know the patient will not survive?
Reference: Societal costs of inappropriate emergency department thoracotomy. J Amer Col Surg 214(1):18-26, 2012.
The patient impaled himself in the thigh while climbing over a wrought iron fence. A section of the fence (including him) has been carefully been separated, and it’s been secured while he is loaded into the ambulance. He’s just been dropped at your emergency department. What to do?
Trauma team activation? Yes! This should have been called in advance so the team could assemble prior to the patient’s arrival. This will definitely require a team, and the surgeon will be essential in planning further care.
Sedation? Definitely! If the embedded object is unwieldy or causes much discomfort, even consider electively sedating and intubating the patient for ease of management without causing more pain.
OR activation? Yes! Even before the patient arrives, the surgeon should call the OR to ready a room, since this will almost certainly require surgical attention.
ATLS guidelines? Yes! This case presents a perfect example of the Dang! factor (see below). Don’t let the team focus attention on the dramatic problem while ignoring his impending airway obstruction or some other major problem. A good physical exam of the involved part is essential to detect any subtle neurovascular symptoms that may give clues to deeper injuries.
Imaging? Maybe. Only if it will provide information that would help guide the extraction process. Just remember, it’s iron. Most radiographs and any MRI will be significantly degraded by so much metal.
The top left bar was in the groin crease, the middle left bar pierced the back of the thigh. There were no vessels or nerves involved.
Extraction in OR? Almost always! Only the smallest object embedded in the most benign areas can be removed in any place other than the OR. Depending on how close the foreign body is to any vital structure, the surgeon needs to decide whether to cut down on the object vs sliding it out and watching for the consequences (bleeding). Tourniquets may be used in more distal areas (not this case, though, due to how proximal it is).
In the last post, I discussed a patient who had impaled himself on top of a wrought iron fence.The questions revolved around proper management in the field. Here are my thoughts.
First of all, the patient stays impaled until delivered to the hospital. This will require a fair amount of creativity, as outlined by the comments by Medic97 in my last post. There are two main components: extrication and transport. The two are closely related.
Extrication will require some heavy equipment not carried by your typical EMS prehospital providers. The fire department or other agency can bring the equipment to the scene. I’ve actually seen rescue teams raid nearby construction trailers for tools!
It then boils down to finding the best spots to cut the fence while protecting the patient. Cutting equipment vibrates, gets hot, and can potentially cause abrupt movements of the fence. Shielding or bracing appropriate to the type of equipment being used is very important. Analgesia and sedation are encouraged. And once the piece of fence is detached, moving it and the patient in unison takes quite a few people.
The last challenging task is getting the patient into the rig (transport). Make sure that the section of fence removed will actually fit through the rear door while attached to the patient. If this is a problem, it’s easy to trim off sections at this point to allow a fit. The other difficulty is securing the patient for the ride, mainly because they may not be able to assume the usual supine position. I’ve seen patients who had to be transported on their side or even prone because of the orientation of the foreign object. Once again, creativity is the key!
Finally, call ahead and notify the emergency department. This will allow them to plan ahead for positioning and imaging needs, and will let them get an OR ready for eventual removal of the object.
The fence posts went over and under the right femur, with the lower one impaling the posterior thigh and the upper one resting on the groin.
Tomorrow, I’ll finish with some tips you can use once the patient arrives at the hospital.
The first part of this post is for my prehospital colleagues. We’ve probably all seen one of these at least once. Someone decides that want to take the short cut. Over a wrought iron fence. Alcohol is usually involved. They get to the top, but just before they can get over, they slip. The top of the fence impales their thigh!
This example comes from a TV news site in Los Angeles.
Let’s say you are one of the first responders at the scene. What do you do? Pull him off or leave him impaled? What equipment do you need? How do you avoid further harm? How do you fit him into your rig? How do you even secure it? Tweet you answers or leave comments below.
I’ll share some of my ideas on Monday, as well as the xray. Then we’ll talk about the in-hospital management piece.
Most orthopaedic injuries are very handily fixed by our friendly neighborhood orthopaedic surgeons. But occasional patients have bony injuries so severe that they challenge even the best of them. Think motorcycle crashes, mangled extremities and bone loss.
Researchers at universities in Edinburgh and Southampton have developed an experimental product that may facilitate rebuilding these challenging injuries. They created a plastic polymer that is honeycombed with small holes. These holes allow blood to flow through it, enabling stem cells from the bone marrow to take up residence and rebuild bone. Once new bone has formed, the plastic slowly degrades, leaving only the patient’s own tissues.
This image show proteins from skeletal stem cells that have been cultured on a plastic scaffold
This new product has been tested successfully in animals, and work is underway to get approval for human testing.
Bottom line: Although many years away, this product may increase the number of limbs salvaged after mangling type injuries to the extremities.
Reference:Discovery and Evaluation of a Functional Ternary Polymer Blend for Bone Repair: Translation from a Microarray to a Clinical Model. Advanced Functional Materials ePub Jan 25, 2013.