Tag Archives: thoracotomy

Thorax

How Safe Is ED Thoracotomy?

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A few weeks ago, I opened a survey to find out common practices regarding performing emergency thoracotomy (EDT) in the emergency department. This procedure is performed at one time or another in most higher level trauma centers. It’s very invasive and is performed in an area that is not really set up for major operative cases. Furthermore, the atmosphere can be chaotic, and stress levels run high.

How safe is this situation? How does personal safety balance out with saving your patient? There are many, many opportunities for injury during this procedure, with significant exposure to blood and other bodily fluids.

A recently published multi-center study examined the potential for exposure during EDT at 16 US trauma centers over a 1.5 year period (14 Level I, 2 Level II). The study was prospective and observational, and was based on questionnaires filled out by all personnel involved in each procedure. A total of 1360 providers submitted information on 305 EDTs.

Here are the factoids:

  • Mechanism was penetrating in 77% of patients, who were predominantly young and male (91%)
  • 15 patients survived (5%), and 4 had residual neurologic impairment
  • Only 56% of respondents wore full personal protective equipment (PPE)
  • There was a 7% exposure rate per EDT(22 incidents), and 1.6% rate per participant in the case
  • The majority of those exposed were trainees (68%) who were injured by something sharp (scalpel 39%, fracture 28%, needle 17%, scissors 3%)
  • There was a strong correlation with PPE use and no exposure during the procedure
  • Only 92% followed their hospital’s occupational exposure protocol if injured (!!!)

Bottom line: Emergency thoracotomy will always be a dangerous procedure. Things happen quickly, there is little time to properly prepare and sharp, pointy things are everywhere. But according to this paper, the actual exposure rate is low. Factoring in the risk of disease transmission, the risk to an individual provider of contracting HIV is 1 in a million, and for hepatitis C is 3 in 100,000. 

The most distressing part of this study, to me, was the sense of invulnerability of a few of the participants. How can anyone justify not wearing full PPE during an emergency thoracotomy? I believe this represents a very casual attitude toward wearing PPE in any resuscitation. But this study clearly shows a large decrease in exposure rate when full PPEs are worn. Even more disturbing? The fact that 8% chose not to protect themselves by following their own institution’s occupational exposure protocol. Unforgivable!

The main takeaway messages are: always wear your PPE to a trauma resuscitation because you never know when you’ll need to get invasive (and won’t have time to dress up then), and be careful!!

Reference: Occupational exposure during emergency department thoracotomy: A prospective, multi-institution study. J Trauma 85(1):78-84, 2018.

Procedures

ED Thoracotomy Survey: Read The Answers! (Rest of the World)

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Last time, I posted summary info for ED thoracotomy on US trauma centers. Here’s a rundown of the answers provided by international respondents. A few duplicates from the same hospitals have been merged into single answers for them. The total number of international centers for the tables below is now 43.

Level of trauma center (or equivalent)

Level I 22
Level II 8
Level III 6
No level 7

 

How many ED thoracotomies are performed per year at your hospital?

A few per year (<6) 30
About every month (6-15) 6
A couple of times a month (16-30)4 4
About every week (31-52) 2
Not specified 1

 

What type of trauma do you perform ED thoracotomy for?

Both blunt and penetrating 22
Penetrating 17
Blunt 4

 

Do you use a practice guideline for ED thoracotomy?

Yes 17
No 16
I’m not sure 10

 

Do you use REBOA in your ED?

No 32
Yes 9
I’m not sure 2

 

And now for the questions you’ve been waiting for!

Who could perform ED thoracotomy at your hospital? (n=149)

Surgeon 39
Emergency physician 25
Surgical resident / fellow 15
Emergency medicine resident 7
Intensivist 1
ED intern / medical officer 1
No one 1

 

Who usually performs ED thoracotomy at your hospital? (n=149)

Surgeon 32
Emergency physician 15
Surgical resident / fellow 9
Emergency medicine resident 1
Thoracic surgeon on call 1
Trauma team leader 1
Never done one 1

 

Survey

Take This Survey On ED Thoracotomy At Your Hospital

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Hello all! I’d like to invite you to participate in a brief survey regarding ED thoracotomy at your hospital. I’m curious about who can and does perform the procedure. The survey is very short and should only take a minute or two to complete.

Please take a moment to participate by clicking here to take the survey. Although entering your center name is optional, I do require the city,  state/province, and country so I can eliminate duplicates.

The survey will officially close in 2 weeks, so please fill it in soon! I’ll publish the results in a post shortly afterwards.

Thanks!
Michael

Click here to take the survey

General

The Societal Cost of ED Thoracotomy

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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?

Related posts:

Reference: Societal costs of inappropriate emergency department thoracotomy. J Amer Col Surg 214(1):18-26, 2012.

General
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Emergency Thoracotomy Video

I did get a lead on a decent video of an emergency thoracotomy that combines most of the principles I laid out last week. It shows a nicely done thoracotomy with exposure of the heart. Aortic crossclamping is not performed, but overall it’s pretty good. All narration is in Thai, so many of you may not be able to follow the conversations.

(Source: https://www.youtube.com/)