[DDET What are the most feared procedures in Emergency Medicine? (Click for answer)]
1) Perimortem C-Section
This is actually the number 1 answer, a truly nerve-jangling experience for all involved, and sure to leave a deep mental impression. There are some great posts about this topic over at EMCrit, StEmlyns and Broome Docs that cover this topic, and I’d recommend you view all of them, twice…
2) Manual faecal disempaction
Isn’t this what medical students are for?
3) ED Thoracotomy
Like the peri-mortem C-section, this is a rarely encountered, invasive procedure that you may never need to do, but you must know how to, just in case, one day, you’re the one holding the Finochietto. Haven’t had to do one yet? Worried you’ll bugger it up when your turn comes? Then hopefully this post will help you overcome some of that fear.
Read on as we watch others go elbows-deep in the thorax, in real-time, and critique their performance from the comfort of our armchairs, so that if and when we are faced with this situation, we remember how to do it right.
We’ll use the plus/delta method of critiquing, which is a great way to do succinct, rapid feedback on a scenario.
WARNING: All of the following videos contain graphic material, intended for medical professionals only.
VIDEO 1: “Slow is smooth, smooth is fast”
This is a classic “amateur thoracotomy”, video but it still contains useful learning points (and is one of my all time favourite movie scenes…)
Click on the Plus/Delta below for the feedback/critique.
- “Slow is smooth, and smooth is fast”. The slow, steady hand movement and calm concentration meet the Scott Weingart recommended mode for performing any difficult procedure: “Slow is smooth, and smooth is fast” is a mantra from Scott’s Crack to Cure talk that I use all the time, at home and at work. What you think is slow in these settings, is actually very fast due to the time distorting effects of adrenaline. If you rush you will cut yourself or your assistant, or make a big mistake.
- Complete evacuation of the pericardium. In real-life, you don’t want to remove the heart entirely to inspect it for injuries, but it is important to remember that the pericardium may appear externally normal despite the presence of tamponade, so if you are opening the chest, you are opening the pericardium and delivering the heart.
- Ensure patient meets indications for thoracotomy. These are still debated, but my indications are:
- Cardiac tamponade in haemodynamically distressed patient with blunt or penetrating truncal trauma
- Defined as SBP < 70mmHg (which is the pressure needed for coronary perfusion in diastole) despite pleural decompression & IV fluid replacement
- Traumatic cardiac arrest:
- Blunt: Arrests in the ED/Dies in front of you
- Penetrating: Arrested but has “signs of life”
- Pupil reaction
- Gag reflex
- Electrical activity on monitor (includes PEA)
- Cardiac motion on echo/ultrasound
- Work on sterile technique. There’s not point getting an output back if the patient dies or has major complications from a wound infection. Pour the betadine on. Sterile gloves. Sterile tray of instruments.
VIDEO 2: A “successful” thoracotomy
In this video you see a chest get cracked, with return of ROSC, which is technically a “success”, but there are many learning points here – the “Delta” section is longer than the “Plus”…
- Finichietto placed the correct way, handle DOWN. This means you can extend to a “clamshell” thoracotomy by extending the incision across to a right sided thoracotomy. NB To do this you need to cut through the sternum with a special device (options include a Lebsche knife/chisel, a Gigli saw, a pneumatic or battery powered sternal saw, or good ol’ trauma shears – see below). Clamshell is indicated if you find a cardiac injury, or the left thoracotomy is negative and you have large volume blood loss from the right chest ICC.
- Right side of chest decompressed with ICC. This is a must. If you do a left thoracotomy, but don’t find tamponade, the cause of the arrest may be in the right chest. Decompress with finger then tube thoracostomy. Ideally this would have already been done, but of it hasn’t, you need to do it.
- Where do we start? OK, not to be too critical, as stated this is in the top 3 most stressful things you can ever do in your career, and it’s easy when you’re not the one in the hot-seat, but there’s some important things that should not be replicated in this video.
- Stop the CPR: I lost count how many times the guys with the knife/scissors nearly cut their own or someone else’s fingers off. Whilst it may theoretically give some small volume of cardiac output, if you think about the physiology here – ie heart can’t pump because it can’t fill, because the pericardium full of blood is squashing it – then CPR is useless, and very, very dangerous. It also makes the rib spreaders fall out at one point. Ideally you’ll have the chest open, and pericardium incised in under 2 minutes in a patient who is intubated and receiving 100% oxygen. The best thing you can do for their brain is open the chest, and it’s very hard to do this while it’s bouncing up and down.
- Personal protective gear: This is a bloody, messy procedure with sharp things (including pointy fractured ribs) flying everywhere. Full length gown, with sterile double-gloves pulled over the cuffs, with eye protection and a mask is the minimum.
- Right equipment. At the 22-second mark you hear someone say “he needs a bigger knife”. If you see how it’s done in videos 3 and 4, you’ll see a non-CPR chest with a large scalpel, and it doesn’t take that many cuts to get where you want.
- Indication: Blunt trauma with pre-hospital arrest – prognosis close enough to zero to not warrant the risk. Remember, indication for thoracotomy in blunt trauma = DIES IN FRONT OF YOU, IN THE ED.
Video 3: In contrast…
Contrast this with video 2, in particular the general atmosphere in the room, and the technique of the operator.
- Setup: Wide application of antiseptic (“baptised with betadine”), giving a wide sterile field, good lighting, assistant holding retractor and a nice big scalpel.
- Technique: 4 cuts and he’s into the chest. A quick run up and down with the scissors and the rib spreader’s in. From scalpel touching skin to heart being exposed is under a minute and a half. Slick.
- Not much to criticise here. Lack of face shield.
- Hard to see how the pericardium is opened, however it’s apparently not a big deal as they get ROSC.
Video 4: Cadaveric demonstration video
The producers of the following video have very generously given us permission to use their videos in our course manual, so if you sign up to the ETM Course, you’ll get this video and some other procedure videos from the same team that you can watch, in your manual, in iBook format!
- Good scalpel technique – long, slow, deliberate but firm strokes, with assistant’s hand well out the way and providing retraction of breast tissue.
- Identifies phrenic nerve before incising the pericardium. They use the word “above” in the commentary, but I think they mean above as in “toward the ceiling” (which is medial), rather than above meaning superior. If you go as far toward the sternum as you can reach to make the incision, you’ll avoid the phrenic nerve.
- Could possibly have extended the incision in the intercostals a bit more posteriorly, as it seems he has trouble getting the rib spreaders in.
So there you have it, an armchair critique of a few ED resuscitative thoracotomies. I think it’s really important to use this video critique method, and to watch these videos several times, visualising how you’d perform this procedure. As you can see, it doesn’t need to be a situation defined by panic or fear. Knowing who to do it on, how to do it methodically and calmly, and what to do once you’re in there are key to mastering this rarely performed procedure.
If you want more practical tips on thoracotomy in the ED, I can’t recommend Scott Weingart’s Crack to Cure talk enough. It’s the definitive talk on ED thoracotomy, and is full of practical tips and tricks.