All posts by TheTraumaPro

ED Thoracotomy Part 2: The Heart

Once the chest is open, the first item of business is to check the heart. In some patients, the inferior pulmonary ligament may prevent you from pushing the lung laterally and superiorly, out of the way. This ligament is a piece of pleura that attaches the lower lobe to the medial diaphragm and mediastinum. Locate it with your fingers and carefully cut it (blindly) with your scissors.

Now look at the heart. What is the rhythm? Put your hands around it. What is the patient’s volume status? If there is the possibility of a penetrating injury, open the pericardium. This structure is tough, and if tamponade is present it will be stretched tight. I find it very difficult to grab the pericardium with forceps and make the initial incision with scissors. Toothed forceps may work, but I just make a very small nick, carefully and directly, with a scalpel. The incision should be placed anterior to the phrenic nerve and vessels, which are usually plainly visible. See the picture on the left, above. The color of the pericardial fluid will immediately indicate whether a cardiac injury is present.

Next, extend the incision (parallel to the bed) to the top and bottom of the ventricle and eviscerate the heart. This will allow careful inspection of all but the atria. If an injury is present, a finger can be used to occlude it until preparations for a repair are made.

Holding the heart is both diagnostic and potentially therapeutic. The “fullness” of this organ is an excellent indicator of the volume status, and if a finger is being used to plug a hole, the temperature of the blood and infused fluids can be determined quickly. All volume resuscitation in this situation should be warmed fluids. And if need be, open cardiac massage is very effective for augmenting circulation.

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Image from my personal archive. Not treated at Regions Hospital.

ED Thoracotomy Part 1: Getting In

Performing a proper emergency thoracotomy is more difficult than you think. There are lots of details to consider, and the learning curve is steep. I’m going to split the process into three parts: getting in, dealing with the heart, and clamping the aorta.

The most important part of getting in is setting up your team. Someone has to be assigned to make sure the chemical and volume resuscitation part is carried out, because the person actually doing the thoracotomy is going to be busy. The most experienced person in the room will actually perform the procedure, or assist the physician who will be learning the procedure.

Next, protect yourself! This is a dangerous procedure. Emotions run high, and people are holding sharp objects. You don’t know where your patient has been or what is circulating in the little blood they may have left, so be careful and make sure you are wearing your personal protective equipment.

Finally, make the incision. This is usually placed along the fifth intercostal space, which is just under the nipple in men. Don’t start too close to the sternum, or you may cut the internal mammary artery. This won’t bleed until circulation is restarted, but it takes some effort to stop it later. Some people prefer a straight incision down toward the table, but I prefer a curved incision that follows the ribs, as illustrated.

Use the scalpel to incise skin, subcutaneous tissue and muscle. However, stop short of the pleura while you are incising the intercostal muscles. If you try to cut through the pleura with the knife, it’s alarmingly easy to injure the lung, or even the diaphragm. Use scissors instead.

Now it’s time to insert the retractor. I prefer to place it with the handle pointing down toward the feet so it doesn’t get jammed against the arm. This is not nice, polite thoracic surgery. You don’t open it a few turns and wait, trying to avoid rib fractures. Open it fast and all the way. Ribs will break, so be careful from this point onward so you don’t cut yourself on their sharp edges.

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Tomorrow, I’ll describe what you need to do with the heart.

Image from my personal archive. Not treated at Regions Hospital.

ED Thoracotomy: Practice Management Guideline

I still encounter a quite a bit of confusion about ED thoracotomy: when to do it, when to stop. A nice set of guidelines was developed by the Subcommittee on Outcomes of the American College of Surgeons Committee on Trauma about 10 years ago. And really, things haven’t changed very much since then.

In general, the literature on this topic has been all over the place. Most studies are retrospective with very little statistical validation. But there’s a lot of it out there. The subcommittee used fairly standard methods to evaluate the literature and come up with some recommendations.

The overall survival rate for all comers was 8% (11% for penetrating, 1.6% for blunt). About 15% of survivors (no breakdown of blunt vs penetrating) suffered from neurologic impairment. Penetrating cardiac injury had the best survival (31%). In the 4 studies on children, the survival numbers paralleled the adults.

Because of the relatively weak quality of the data, only level II recommendations were given. They were:

  • Don’t consider ED thoracotomy in blunt trauma patients unless the patient arrests in front of you. Otherwise, meaningful survival is almost nonexistent.
  • Consider ED thoracotomy for penetrating chest injury if there were witnessed signs of life and a short transport time (5-10 minutes max, in my opinion). Look for pupillary response, spontaneous respirations, palpable pulse, or a narrow complex cardiac rhythm.
  • ED thoracotomy for penetrating abdominal injuries has a low survival rate, but can be considered if the injury may involve the chest.
  • Consider thoracotomy for suspected abdominal vascular injury, but survival is also very low.
  • The guidelines above apply equally to children.

Practical tips: ED thoracotomy is a seldom used and dangerous procedure. There are many opportunities for injury to trauma professionals, so be selective and take precautions. Assign someone to run the chemical code while the surgeons open the chest. Watch out for broken ribs and scalpels gone wild!

I’ll post pictures and specific pointers over the next three days.

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Reference: Practice management guidelines for emergency department thoracotomy. JACS 193(3):303-309, 2001.

Trauma Care And HIPAA Demystified

HIPAA

There is a lot of confusion and misinformation out there regarding HIPAA (Health Insurance Portability and Accountability Act). This law was enacted in 1996 with the intent of protecting the health insurance benefits of workers who lose or change their jobs, providing standards for electronic health care transactions, and protecting a patient’s sensitive health information. This last part has caused much grief among trauma professionals.

It is commonplace for a trauma patient to require the services of many providers, from the initial prehospital crew, doctors and nurses at the initial hospital, yet another ambulance or aeromedical crew, professionals at a receiving trauma center, rehab or transitional care providers, and the patient’s primary physician to name a few. Unfortunately, because there can be significant financial penalties for violating the HIPAA privacy guidelines, providers are more likely to err (incorrectly) on the side of denying information to others outside their own institution.

All of the people mentioned above are considered “covered entities” and must abide by the HIPAA Privacy Rule. This rule allows us to release protected information for treatment, payment and “health care operations” within certain limits. The first and last items are the key provisions for most trauma professionals.

Treatment includes provision, coordination and management of care, as well as consultations and referrals (such as transferring to a trauma center). Think of this as the forward flow of information about your patient that accompanies them during their travels.

Health care operations include administrative, financial, legal and quality improvement activities. These quality improvement activities depend on the reverse flow of information to professionals who have already taken care of the patient. They need this feedback to ensure they continue to provide the best care possible to everyone they touch.

Bottom line: Trauma professionals do not have to deny patient information to others if they follow the rules. Obviously, full information must be provided to EMS personnel and receiving physicians when a patient is transferred to a trauma center. But sending information the other way is also okay when used for performance improvement purposes. This includes providing feedback to prehospital providers, physicians, and nurses who were involved in the patient’s care at every point before the transfer. The key is that the information must be limited and relevant to that specific encounter.

Feedback letters and forms, phone conversations and other types of communications for PI are fine! But stay away from email, which is not secure and is usually a violation of your institutional privacy policies.

Always consult your hospital compliance personnel if you have specific questions about HIPAA compliance.

Reference: HIPAA Privacy Rule

Distracted Driving In Police Officers

A lot has been written about the hazards of distracted driving. Now, there is new information about the impact of distraction on police officers! A public safety administration class at St. Mary’s University here in Minnesota analyzed 378 crashes involving police cars from 2006 to 2010. The results are intriguing!

Key findings included:

  • Most crashes occurred during non-emergency responses
  • Crashes occurring during emergency responses were the most expensive
  • Distracted driving caused 14% of all crashes
  • Half of distracted driving crashes were due to the use of squad car computers
  • Average insurance claim was $3,000 per crash. However, if the crash was due to distracted driving it doubled to $6,000. If the crash was due to squad car computer distraction the average cost was $10,000!

This study is interesting, but it’s only a partial snapshot of this type of crash in one state. It did not include some of the larger police departments, such as St. Paul and Minneapolis.

Bottom line: It’s safe to assume that distracted driving is just as dangerous to police (and prehospital providers, too). And with growing dependence on advanced technology for law enforcement, this problem is just going to get worse. It is imperative that everything be done to improve safety for our law enforcement colleagues. Potential solutions include training to increase awareness of distractions within the car, simulator testing of driving while using cockpit technology, and ergonomic studies to maximize field of view from within the car.

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