Podcasts about Thoracotomy

What if the future of heart surgery didn't involve massive scars and long recovery times? On this episode we'll visit the pioneering world of minimally invasive cardiac procedures through the eyes of Dr. Allan Stewart, Medical Director and Chief of Cardiovascular Surgery at HCA Florida Mercy Hospital. A leading cardiac surgeon, his journey from childhood started with an understanding of mechanics that led to groundbreaking medical innovations. His path is nothing short of inspiring. Dr. Stewart shares the pivotal moments that led him to transform the field, including a captivating Nova episode on pediatric heart transplants, and his many years of practice using minimally invasive techniques. Ever wondered how surgeons tackle the complexities of myocardial bridges? Dr. Stewart takes us on a compelling journey through his unexpected dive into this challenging area while at Columbia University. He explains the intricacies of diagnosing and treating these conditions, and the critical decision-making involved in whether to perform surgeries on a beating heart or with a pump. From ensuring precision to avoid catastrophic complications like cutting the artery, to the difficulty of accurate diagnosis, this segment shines a light on both the art and science of cardiac surgery. Finally, we'll delve into the crucial importance of thorough and precise surgical intervention. Incomplete arterial surgeries can lead to devastating consequences, including the need for complex redo surgeries. Dr. Stewart emphasizes the necessity of proper techniques to prevent complications and stresses the importance of educating both patients and cardiologists about the risks associated with myocardial bridges and inappropriate stent use. Join us for this enlightening conversation, and on a lighter note, I look forward to a future bike ride together in South Florida. Don't miss this episode with one of the field's most innovative minds. To reach Dr. Stewart a voice mail or text message was suggested as best. 917-748-7836 To learn more about Dr. Stewart click on the link: Dr. Allan Stewart Episode Highlights (00:17 - 00:40) Becoming a Leading Cardiac Surgeon (03:55 - 05:37) Assessing Candidates for Thoracotomy (09:50 - 11:27) Minimally Invasive Approach in Surgery (14:20 - 15:46) Advanced Imaging Technology in Cardiology (18:58 - 19:57) Robotic vs Full Heart Surgery (23:01 - 23:52) Successful Artery Surgery Examination (31:15 - 33:04) Traveling for Specialized Medical Procedures Chapter Summaries (00:00) Cardiac Surgeon Discusses Minimally Invasive Procedures Dr. Stewart shares his journey to becoming a pioneer in less invasive cardiac surgeries, emphasizing the importance of minimizing trauma and improving cosmetic outcomes. (05:39) Advances in Myocardial Bridge Diagnosis My journey into addressing myocardial bridges began serendipitously and involves challenges such as diagnosis and surgical techniques. (19:59) Cardiac Surgery Complications and Stress Relief Proper surgical techniques and education are crucial in preventing complications and misdiagnosis of arterial bridges in heart surgery. (33:43) Importance of Complete Artery Surgery Nature's arterial bypass and stent surgeries, complications from incomplete procedures, and importance of thorough intervention.  

In this Care Plan episode, the focus is on thoracotomies, both open and video-assisted, commonly performed for thoracic or cardiovascular issues. The discussion goes into preoperative considerations, emphasizing optimizing patients' respiratory health and utilizing double-lumen tubes for one-lung ventilation (OLV). Detailed insights into the challenges posed by patient positioning, the effects of OLV on pulmonary blood flow, and the significance of hypoxic pulmonary vasoconstriction are covered. Anesthetic considerations, including anesthetic choice and ventilation strategies during OLV, are outlined, along with meticulous postoperative care strategies focusing on pain management and chest tube management.To connect with Rhea and Sachi, check them out on Instagram @crna_scientist and @thecrnaclub. Also, be on the lookout for the launch of their new company featuring basic and clinical science education for the nurse anesthesia community.Support the showTo access all of our content, download the CORE Anesthesia App available here on the App Store and here on Google Play. Want to connect? Check out our instagram or email us at info@coreanesthesia.com

In this session we will examine the latest research to emerge from Zane Perkins and Mike Christian around Resuscitative Thoracotomy (RT). The research has been led by Zane and Mike examined over 600 retrospective thoracotomy cases from the LAA database spanning 20 years, looking at the survivors, the pathology (exsanguination versus tamponade), the pre-arrest rhythms, the morbidity and mortality, the time of intervention versus outcome as well as other markers. I wanted to explore the results of this research and the potential implications on practice. Zane Perkins is a consultant Trauma and General Surgeon at the Royal London Hospital, a consultant Physician for London's Air Ambulance, and an Honorary Senior Lecturer at the Centre for Trauma Sciences, Queen Mary's University London. Current thinking on Thoracotomy practice Examine the research in more detail from primary & secondary outcomes Survival rates - Who are the current survivors? What are the main domains of pathology Exsanguination: Results of outcome and pre-arrest rhythms What it shows around intervention and decisions around exsanguination Tamponade: results of outcome and pre-arrest rhythms What it shows around intervention and decisions around tamponade Differentiated decision making and prospective changes to SOP Final thoughts and take-home messages. The study has yet to be published but we will publish the results as they are published. My thanks to Zane for an engaging and insightful interview.

Contributor: Jared Scott, MD Educational Pearls: Immediate resuscitative thoracotomy can be performed in the ED to gain rapid access to the thoracic cavity in cases of traumatic cardiac arrest Western Trauma Association Society Criteria for ED thoracotomy Blunt trauma +

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A trauma patient rolls into the bay.  CPR started 10 minutes ago.  They are pulseless, the entire trauma team is looking to you for leadership, and the thoracotomy tray is prepped and ready.  Do you pick up the knife and cut?   Welcome back to the BIG T TRAUMA series.  Join Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill for a high-level discussion on the one surgical procedure that trumps them all – the ED thoracotomy.  This is episode 2 of 2.  In episode 1 we discussed who should get an ED thoracotomy.  Today, we cover how to do it.    Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

A trauma patient rolls into the bay.  CPR started 10 minutes ago.  They are pulseless, the entire trauma team is looking to you for leadership, and the thoracotomy tray is prepped and ready.  Do you pick up the knife and cut?   Welcome back to the BIG T TRAUMA series.  Join Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill for a high-level discussion on the one surgical procedure that trumps them all – the ED thoracotomy.  This is episode 1 of 2.  In episode 1 we discuss who should get an ED thoracotomy and in episode 2 we cover how to do it.    Listen to learn about the guidelines, signs of life, ultrasound, survival, and when NOT to do an ED thoracotomy.    EAST: https://www.east.org/education-career-development/practice-management-guidelines/details/emergency-department-thoracotomy  WTA: https://www.westerntrauma.org/wp-content/uploads/2020/08/Resuscitative-Thoracotomy_FINAL.svg  WakeMed Blunt Pulseless Trauma Resuscitation Guideline: https://www.wakemed.org/assets/documents/general-surgery-guidelines/trauma-guidelines/blunt-pulseless-arrest.pdf  Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Dr. Jeremy Levin and Dr. Megan Quintana discuss Resuscitative Thoracotomy (RT) with Dr. Ronnie Mubang and Dr. Adam Nelson.  They dive into patient selection, application of ultrasound, different institutions' criteria, the clamshell, and some less tangible benefits of RT besides survival.  Additionally, hear their opinion about select patient scenarios and special populations.  And ALWAYS wear your PPE! Supplemental material: Joseph B, Khan M, Jehan F, Latifi R, Rhee P. Improving survival after an emergency resuscitative thoracotomy: a 5-year review of the Trauma Quality Improvement Program.Trauma Surg Acute Care Open. 2018 Oct 9;3(1):e000201. doi: 10.1136/tsaco-2018-000201. PMID: 30402559; PMCID: PMC6203136. 

We discuss the following paper and its impact on our prehospital management.  Prehospital narrow pulse pressure predicts need for resuscitative thoracotomy and emergent intervention after trauma Schellenberg M, Owattanapanich N, Getrajdman J, et al. J Surg Res. 2021;268:284-290.

There are recent updates about the management of lung metastases in osteosarcoma and deciding thoracotomy vs VATS is our topic for today. At the recent 2021 Pediatric Surgery Update Course, Dr. Anusua "Roshni" Dasgupta reviewed the latest literature. And now we're giving you the highlights in this video.Hosted by: Rod Gerardo, Ellen Encisco, Todd Ponsky

There are recent updates about the management of lung metastases in osteosarcoma and deciding thoracotomy vs VATS is our topic for today. At the recent 2021 Pediatric Surgery Update Course, Dr. Anusua "Roshni" Dasgupta reviewed the latest literature. And now we're giving you the highlights in this video. Hosted by: Rod Gerardo, Ellen Encisco, Todd Ponsky

Podcast summary of articles from the July 2021 edition of the Journal of Emergency Medicine from the American Academy of Emergency Medicine.  Topics include ED thoracotomy, pediatric sedation, babesiosis, low back pain, lumbar punctures, and Crotalid Envenomation.  Guest speaker is Dr. Spencer Greene.

It’s the JournalFeed Podcast for the week of Apr 12-16, 2021. We cover emotional intelligence, the best antibiotic for diverticulitis, SpO2 targets for COPD, return rates after giving opioids in the ED for back pain, and resuscitative thoracotomy - clamshell vs left anterolateral approach.

We're joined by Drs. Greg Winter and Scott Herskovitz to discuss the second episode of "Code Black." The show did one thing right - it was a great example of the way doctors in teaching hospitals actually have to teach. Having an ER resident perform a laparoscopic  surgery unassisted? That's less accurate. Greg recommended a book called "The Knife and Gun Club," which can be found on Amazon at https://amzn.to/3bTLCWE

In this follow-up episode to our discussion with Dr. Scott Weingart of EMCrit, we review the indications for performing a resuscitative thoracotomy, together with the potential application of a circulation first resuscitation strategy, and some intricacies regarding performing a surgical cricothyroidotomy.

All things chest crackin'

IT'S THE HALLOWEEN SPECIAL, PART TWO! Ralph & Dr. Barker are joined by Dr. Daniel Liesen, who is here to discuss thoracotomies in the emergency department. Remember:1. Know your indications and contraindications and ensure back up is available and on their way.2. Prepare your equipment3. Incise and gain entry also intubate right mainstem and know how to use your spreaders!4. LOOK!!! 5. Control hemorrhage that is visible and open pericardium-control direct cardiac bleeding6. Clamp the aorta above the diaphragm- Time is ticking.....7. Open cardiac massage/defibrillation8. Avoid further air embolism if any present9. Got ROSC and adequate vital signs————-> To the OR10. Always be careful please!Below are some great instructional links and evidence based articles. https://emj.bmj.com/content/22/1/22https://www.facs.org/-/media/files/quality-programs/trauma/publications/thoracotomy.ashxhttps://litfl.com/resuscitative-thoracotomy/https://www.east.org/education/practice-management-guidelines/emergency-department-thoracotomyhttps://rebelem.com/if-youre-going-to-do-the-thoracotomydo-a-clamshell/https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiHnNHUzdvsAhWriK0KHcJ_B-UQwqsBMAF6BAgFEAM&url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3D924t8kpW-p4&usg=AOvVaw170N7m070KxjSCUWwAJRKYhttps://www.uptodate.com/contents/resuscitative-thoracotomy-techniquehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802990/

IT'S THE (EARLY) HALLOWEEN SPECIAL, PART ONE! Ralph & Dr. Barker are joined by Dr. Daniel Liesen, who is here to discuss thoracotomies in the emergency department.Remember:1. Know your indications and contraindications and ensure back up is available and on their way.2. Prepare your equipment3. Incise and gain entry also intubate right mainstem and know how to use your spreaders!4. LOOK!!! 5. Control hemorrhage that is visible and open pericardium-control direct cardiac bleeding6. Clamp the aorta above the diaphragm- Time is ticking.....7. Open cardiac massage/defibrillation8. Avoid further air embolism if any present9. Got ROSC and adequate vital signs————-> To the OR10. Always be careful please!Below are some great instructional links and evidence based articles. https://emj.bmj.com/content/22/1/22https://www.facs.org/-/media/files/quality-programs/trauma/publications/thoracotomy.ashxhttps://litfl.com/resuscitative-thoracotomy/https://www.east.org/education/practice-management-guidelines/emergency-department-thoracotomyhttps://rebelem.com/if-youre-going-to-do-the-thoracotomydo-a-clamshell/https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiHnNHUzdvsAhWriK0KHcJ_B-UQwqsBMAF6BAgFEAM&url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3D924t8kpW-p4&usg=AOvVaw170N7m070KxjSCUWwAJRKYhttps://www.uptodate.com/contents/resuscitative-thoracotomy-techniquehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802990/

ED Thoracotomy Article ED Thoracotomy Quick Summary A look at an article on ED thoracotomy and factors associated with survival after ED thoracotomy.

Podcast summary of articles from the December 2019 edition of the Journal of Emergency Medicine from the American Academy of Emergency Medicine.  Topics include NOACs vs vitamin K antagonists for intracranial  hemorrhage, dabigatran reversal, post contrast acute kidney injury in PE studies, ED thoracotomies and board review on iron deficiency anemia.  Guest speaker is Dr. Megan Bennett.

REBOA, ECMO, Thoracotomy? Where should we be focussing our attention in the world of Pre-hospital care? We were lucky enough to be invited to the London Trauma Conference on the Prehospital Day supported by the Norwegian Air Ambulance Foundation. The day focussed on the areas we can make a real impact to the outcomes of our pre-hospital critical care patients. We grabbed a few minutes time of the following speakers to hear their thoughts; Introosseous Access; Jerry Nolan Pre-hospital Blood products; Jostein Hagemo Communication under pressure; Dr Stephen Hearn Pre-hospital Critical Care - what should the near future look like? Dr Stephen Rashford Have a listen and as always we’d love to hear any thoughts or comments you have on the website and via twitter, and take a look at the references below to draw your own conclusions. We'll be back in the new year with monthly episodes of Papers of the Month and Roadside to Resus; have a great Christmas and New Year and we'll speak to you soon! Enjoy! Simon, Rob & James

Here we tackle the evolving SAQ type - you start with something that tests your 'basic approach' and then takes an abrupt turn for the worse and challenges you.  We take the approach of an undifferentiated scenario that eventually makes it's way to Thoracotomy in the ED.  

There are few surgical interventions more dramatic than the thoracotomy - a desperate last-ditch effort to save a failing heart by manual compression. The history of the procedure is a fascinating one, dating back to the 19th century. This became the procedure of choice when a heart stopped, typically during surgery, but was eventually replaced by what we now call CPR. The history of the development of CPR is also covered, and of course, we'll take some interesting tangents. 

I had such a fun time chatting on the phone with Dan about medicine.  Total recorded time was 2 hours that I had to edit down to this current episode.  His story from childhood to how he became one of the administrators for a surgical group in one of the biggest hospital systems in California is enriching.  He is a true inspiration.  Thanks Dan! Physician Assistant Stats:* Physician Assistants practice medicine on teams with physicians and other healthcare workers. They examine, diagnose, and treat patients autonomously and as part of a team in all various specialties of medicine.   2017 Median Pay: $104,860 per year ($50.41 per hour)   Educational Degree: Masters Degree   Number of US jobs in 2016:106,200   10 Year Job Outlook: 37% growth, much faster then avg.     *Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Physician Assistants, (visited August 5, 2018).     Terms Covered in Episode Navy A School   Corpsman - Enlisted medical specialist   Lipoma - Overgrowth of adipose tissue (fat) creating a benign tumor often located between skin and muscle layer.   Eugene Stead Jr. MD   CT Surgery - Cardiothoracic surgery deals with issues of the thorax, generally the heart and lungs.   Trauma Surgery - Surgical field dealing with acute traumatic injuries such as falls, motor vehicle crashes, gunshots, blunt and penetrating injuries, etc.   ICU (Intensive Care Unit, Critical Care Unit, or Intensive Therapy/Treatment Unit) - Part of the hospital with the sickest patients requiring the most intervention from both staff and equipment.  May consist of intubated, sedated, and ventilated patients.   Call - To be available on your “off time” for phone calls, patient visits, surgeries, emergencies, etc that varies by job.   Open Surgery - Traditional way of surgery going through the layers of the body to operate.   Endoscopic Surgery - Surgery utilizing cameras, smaller openings and temporary ports in the body to pass through instruments in a tight space allowing for less pain and quicker recovery.   Vein Harvest - Generally endoscopic removal of a vein to replace a coronary artery (cardiac bypass)   Bypass - Surgical procedure to restore blood flow to the heart after an obstruction occurs.   Cardiac Graft   BP (Blood Pressure) - Force of blood against the arterial walls.   Recovery - Phase after surgery when anesthesia is wearing off and patient is being monitored before being sent home with family or admitted to the hospital.   Punch Biopsy - Small round biopsy (cut) taken to identify the cause of abnormal tissue.   Hernia - Bulging of an organ (intestines) through an abnormal opening.   ENT Surgery - Ear, Nose, and Throat.  Various procedures involving the head.   MBA - Masters of Business   UCSF Neuroscience   Medicare - Government provided healthcare insurance to those over 65, young people with disabilities, and people with end stage renal disease.   401k - Retirement plan.   Western Governors University   Bedside Manner - approach or attitude towards a patient.   Neurosurgery - Surgery dealing with the Nervous System (brain and spine).   Trauma LVL 1 Center - Hospital able to provide total care for every aspect of injury.  Large facility with all types of staff including Residents.   Cerebral Stenosis - When artery inside the brain that becomes blocked by plaque or disease.   TPA (Tissue Plasminogen Activator) - Protein involved in the breakdown of blood clots.   Aneurysm - Ballooned and weaker area of an artery.   CVA (Cerebral Vascular Assault) - Stroke.  Damage to the brain from a loss of blood flow.   Ischemic CVA - loss of blood flow from a blockage.   Hemorrhagic CVA - loss of blood flow from a blockage a ruptured aneurysm.   Elective Surgery - Nonemergent scheduled surgery   Discectomy - Surgical removal of whole or part of a intervertebral disc.   Fusions - Surgery to join two or more vertebrae together.  Done for fractures, deformities, instabilities, slipped vertebrae, or herniated disk.   ACDF (Anterior Cervical Discectomy & Fusion) - Discectomy of the cervical spine (neck) with fusion to decompress the spinal cord and nerve roots of the cervical spine.   Neuroaxis (Neuraxis) - Central Nervous System   Tumor - Abnormal growth of cells   Resection - to surgically remove   Spine Stabilization - Surgery to stabilize the spine with more flexible materials then traditional fusion.   Angio - technique used to visualize inside blood vessels.   MRI (Magnetic Resonance Image) - Medical Imaging using magnets to see deep layers of the body.   Space Occupying Lesion - abnormal mass in the brain usually due to cancer, but may be abscess (infection) or hematoma (blood).   Glioblastoma - Rare very aggressive and fatal cancer of the brain or spine.   Code Yellow - Phrase used over PA system of hospital when Trauma Patient is coming to the ER.  To alert the hospital to assemble the Trauma Team and support staff to receive the patient.   Hypotensive - lower then normal blood pressure.   Chest Tube - tube placed in the chest cavity to evacuate blood, pus, or air.   Central Line - Larger then an traditional IV placed into a main vein of the body. Thoracotomy - Opening into the chest wall.   Finochietto (Rib Spreader) - Used to get a better window/view into the chest cavity the pushes the ribs aside.   Pericardial massage - Manually pumping the heart with a hand in the chest cavity.   Each and every episode of Maybe Medical is for educational purposes only, not to be taken as medical advice.  The opinions of those involved are of their own and not representative of their employer.

Author: Dylan Luyten, MD Educational Pearls:   Resuscitative thoracotomies are most commonly used for treatment of cardiac tamponade and to selectively perfuse the brain and heart in setting of hemorrhage control. Resuscitative thoracotomies are indicated in patients with penetrating injuries who lose vitals in the ED or those who had vitals within the last 10 minutes. Do not perform resuscitative thoracotomies on patients who have no signs of life on scene, asystole as their presenting rhythm, or no vitals  > 10 minutes. Resuscitative thoracotomies are not indicated in patients with blunt trauma  unless vitals are present in ED. Do not perform CPR on trauma patients.   References: Karmy-Jones R, Namias N, Coimbra R, et al. (2014).Western Trauma Association critical decisions in trauma: penetrating chest trauma. Journal of Trauma Acute Care Surgery. 77:994. Seamon MJ, Shiroff AM, Franco M, et al. (2009) Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. Journal of Trauma. 67:1250.

Author: Aaron Lessen M.D. Educational Pearls:   Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient. Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%. Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure. A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure.   References: K. Inaba et al, “FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation” Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320

Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.

  Details of the surgical skills course mentioned in the podcast can be found here: https://wmstc.co.uk/portfolio/phem-ess/ The Sydney HEMS Traumatic Cardiac arrest operating procedure can be viewed on their website, and there are a number of useful references within the document: Policies and Procedures An excellent ‘how to do it’ paper, published in 2005, by … Continue reading Episode 14: Thoracotomy

Dr. David Harpole, Duke University Medical Center, compares traditional open thoracotomy with video-assisted thorascopic surgery, highlighting the advantages of the newer approach.

Dr. David Harpole, Duke University Medical Center, compares traditional open thoracotomy with video-assisted thorascopic surgery, highlighting the advantages of the newer approach.

Dr. David Harpole, Duke University Medical Center, compares traditional open thoracotomy with video-assisted thorascopic surgery, highlighting the advantages of the newer approach.

Traumatized children need your full attention. Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more.   Two main reasons:  Children have specific injury patterns  Their physiologic response to trauma is unique.   Crash course in pediatric anatomy and physiology in trauma When you think of trauma in children, think of Charlie Brown. Large head, no neck, his chest and abdomen form an underdeveloped, amorphous shape. Alternatively, think of children as apples – they are rounder than they are tall, with a large increased surface area. Apples don’t have a hard shell or thick rind to protect them. If you drop them, you may not see any evidence of damage to the outside, but there can be considerable bruising just under the surface. A child has thin skin, less subcutaneous deposits than an adult, and a non-calcified, pliable thorax that deforms more than it protects or shields. The child’s abdominal muscles are not yet developed. There is less peritoneal fat to cushion a blow, and so traumatic forces transmit readily into internal organs, often without external bruising. The child’s large surface area also causes him to dissipate heat more quickly. He may be wet from urine or blood, and in a major trauma, this faster cool-down predisposes him to coagulopathy. Case A 5-year-old boy who was playing with his older brother in front of their home when the ball rolled into the street. He ran after it, and was struck by a sedan going approximately 30 mph. This is the so-called Wadell’s triad that occurs in a collision of auto versus pedestrian or auto versus bicycle. The initial impact is the greatest, and will vary depending on the child’s height and what part of his body reaches up to the bumper of the car. Depending on the height of the child and the height of the car, the initial impact will cause a femur fracture, a pelvic fracture, or direct abdominal trauma. The second impact happens as the child is flung onto the grill or the hood of the car, causing usually thoracic trauma. The third impact can be the coup de grace – to add insult to major injury, the child is then propelled forward, worsening the two previous impacts’ injuries and adding a third – severe blunt head trauma. Intubation Pearl #1: If your patient has any subtle change in mental status, intubate early. In pediatric trauma, we need to be proactive. Hypoxia is our enemy. Intubation Pearl #2: Thankfully cervical spine injuries in children are uncommon, and when they do occur, they typically occur at the child’s fulcrum, which is at C2. Compare this with an adult’s injury pattern with our fulcrum at C7. Be careful and minimize manipulation of the cervical spine, but do what you must to visualize the chords and place the tube. Keep the neck midline, and realize that the child’s usual decrease respiratory reserve is even more affected by trauma. Preoxygenate and pass that tube quickly. Chest Tube Pearl #1: Chest tube sizing in pediatrics is straightforward if we remember that the traditional chest tube size is 4 x the ETT size. Chest Tube Pearl #2: Try using a pigtail catheter. Safety Triangle Lateral edge of the pectoral muscle Lateral edge of the latisimus dorsi Line along the fifth intercostal space at the level of the nipple. It’s roughly where you would put on a generous dose of deodorant. Insertion here minimizes the risk of damage to nerves, vessels and organs. Resuscitative Thoracotomy in Children In a 40-year review of ED thoracotomy, Moore et al. analyzed 1,691 patients who received ED thoracotomy. Overall all-cause adult survival was 6.1%. In children ? 15 years of age, overall all-cause survival was considerably less, at 3.4%. In a large case series and review of the literature for pediatric ED thoracotomy, Allen et al. found a survival rate in penetrating trauma of 10.2%, with a much lower survival rate in blunt pediatric arrest, at 1.6%. Adolescents had more penetrating injuries, and younger children had more blunt trauma. To synthesize, the rarity of ED thoracotomy in children is due to the fact that: Traumatic full arrest in children is uncommon. It is most often blunt trauma. Blunt traumatic arrest in children is mostly non-survivable. REBOA If you have access to resuscitative endovascular balloon occlusion of the aorta or REBOA, this may be an option to temporize the child to get him to the relative control of the operating room. REBOA involves accessing the common femoral artery, passing a vascular sheath, floating a balloon catheter to the appropriate section of the aorta, and inflating the balloon to occlude blood flow. Brenner et al. described a case series of 6 patients from two Level I trauma centers. They used REBOA for refractory hemorrhagic shock due to either blunt or penetrating injury. After balloon occlusion, blood pressure improved sufficiently to take the patient either to interventional radiology or to the OR. Four patients lived, two died. The AORTA trial is underway to investigate its use in trauma. Summary: Children are like Charlie Brown – large head, no neck, amorphous, underdeveloped and unprotected thorax and abdomen. Or, if you like, they’re like, apples – they have a large surface area and are easily internally bruised, often without overt signs of external bruising. Chest tubes for children are very similar to the adult procedure – the traditional chest tube size is 4 x the child’s ETT size. Try to use smaller pigtail catheters, available in commercial kits, whenever possible. They’re easy, safe, and effective. Resuscitative thoracotomy is for penetrating trauma with signs of life wthin 10-15 minutes of arrival. Find the correctable surgical cause of the arrest. Resuscitative thoracotomy for blunt trauma has a dismal prognosis in children. Selected References Allen CJ, Valle EJ, Thorson CM, Hogan AR, Perez EA, Namias N, Zakrison TL, Neville HL, Sola JE. Pediatric emergency department thoracotomy: a large case series and systematic review. J Pediatr Surg. 2015 Jan;50(1):177-81. American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pediatric Emergency Medicine Committee; National Association of Ems Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics. 2014 Apr;133(4):e1104-16. Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7. Moore HB, Moore EE, Bensard DD. Pediatric emergency department thoracotomy: A 40-year review. J Pediatr Surg. 2015 Oct 19. Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869-72. Pediatric Trauma on WikEM   This post and podcast are dedicated to Dr Al Sacchetti, MD, FACEP. Thank you for promoting the emergency care of children and for spreading the message that you don’t need subspecialty training to take good care of acutely ill and injured children. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

John Hinds shows us why he will be so dearly missed in this superb talk from SMACC Chicago. This is about resuscitative thoracotomy but really so much more.

Episode 45: ED Thoracotomy - Brand New Guidelines

Trauma is a significant cause of mortality worldwide, especially amongst children and young adults, with the majority of deaths occurring shortly after arrival in hospital.

Pain after thoracic surgery can be severe and, in the acute phase, contribute to perioperative morbidity and mortality. Unfortunately, patients also incur a significant risk of chronic pain. Although there are guidelines for postoperative pain management in these patients, there is no widespread surgical or anesthetic best practice. Here, we review the recent literature on techniques specific to perioperative pain control for thoracic patients, including medical management, neuraxial blockade, and other regional techniques, and suggest an algorithm for developing a multimodal pain management strategy.   To view the article, click here.

Weingart does thoracotomy.

In this episode, Dr Erik Beuker discusses trauma thoracotomy. After listening to this episode, learners will be able to: • Describe the basic steps in trauma thoracotomy • List indications and contraindications to trauma thoracotomy • List outcomes from trauma thoracotomy

Right sided thoracotomy anyone? As a bonus to Episode 30 on Emergency Procedures, Pearls & Pitfalls, Tips & Tricks Dr. Jamie Blicker tells his Best Case Ever of a trauma patient who goes sour after a chest tube insertion. In the related episode dedicated to emergency procedures pearls and pitfalls, tips and tricks, Dr. Jordan Chenkin & Dr. Jamie Blicker take us step by step through how best to perform surgical airways and pericardiocentesis, as well as place central lines and intraosseous lines. They explain the various methods for surgical airways including the bougie-assisted surgical airway. They review the indications, contraindications, and complications for all of these life saving procedures, and give us some amazing tips and tricks on what to do when things aren't going as expected. The post Best Case Ever 15: Right Sided Thoracotomy appeared first on Emergency Medicine Cases.

Crack to cure; in the right circumstances you may save a life. ER thoracotomy--do it improperly and you put you and your team at risk.

Background and Objective: Our objective was to report on the design and essentials of the Etoricoxib protocol-Preemptive and Postoperative Analgesia (EPPA) Trial, investigating whether preemptive analgesia with cox-2 inhibitors is more efficacious than placebo in patients who receive either laparotomy or thoracotomy. Design and Methods: The study is a 2 x 2 factorial armed, double blinded, bicentric, randomised placebo-controlled trial comparing (a) etoricoxib and (b) placebo in a pre- and postoperative setting. The total observation period is 6 months. According to a power analysis, 120 patients scheduled for abdominal or thoracic surgery will randomly be allocated to either the preemptive or the postoperative treatment group. These two groups are each divided into two arms. Preemptive group patients receive etoricoxib prior to surgery and either etoricoxib again or placebo postoperatively. Postoperative group patients receive placebo prior to surgery and either placebo again or etoricoxib after surgery (2 x 2 factorial study design). The Main Outcome Measure is the cumulative use of morphine within the first 48 hours after surgery (measured by patient controlled analgesia PCA). Secondary outcome parameters include a broad range of tests including sensoric perception and genetic polymorphisms. Discussion: The results of this study will provide information on the analgesic effectiveness of etoricoxib in preemptive analgesia and will give hints on possible preventive effects of persistent pain.