The history of resuscitative thoracotomy is really the early history of cardiac surgery

1. Resuscita)ve
Thoracotomy
Michael
Meyer,
M.D.,
FACS
COL,
MC
Madigan
Army
Medical
Center

3. Introduc)on
• History
• Studies
• Review
of
CPG

4. Requisite
Quotes
1883
Theodore
Bilroth
“The
surgeon
who
should
aMempt
to
suture
a
wound
of
the
heart
would
lose
the
respect
of
his
collegues.”

5. Requisite
Quotes
1896
James
Paget
“Surgery
of
the
heart
has
probably
reached
the
limits
set
by
nature
to
all
surgery:
no
new
method
and
no
new
discovery
can
overcome
the
natural
difficul)es
that
aMend
a
wound
of
the
heart.”

7. History
• 1649
Riolanus:
First
described
pericardiocentesis
• 1829
Larrey:
First
successful
pericardiocentesis
for
trauma
• 1896
Rehn:
First
successful
human
cardiac
repair
aXer
a
knife
wound
to
the
RV
• 1901
Igelsrund:
First
open
cardiac
massage
for
cardiac
arrest
• 1902
Hill:
First
cardiorrhaphy
in
the
US

8. History
• 1649
Riolanus:
First
described
pericardiocentesis
• 1829
Larrey:
First
successful
pericardiocentesis
for
trauma
• 1896
Rehn:
First
successful
human
cardiac
repair
aXer
a
knife
wound
to
the
RV
• 1901
Igelsrund:
First
open
cardiac
massage
for
cardiac
arrest
• 1902
Hill:
First
cardiorrhaphy
in
the
US

10. History
• 1649
Riolanus:
First
described
pericardiocentesis
• 1829
Larrey:
First
successful
pericardiocentesis
for
trauma
• 1896
Rehn:
First
successful
human
cardiac
repair
aXer
a
knife
wound
to
the
RV
• 1901
Igelsrund:
First
open
cardiac
massage
for
cardiac
arrest
• 1902
Hill:
First
cardiorrhaphy
in
the
US

12. History
• 1649
Riolanus:
First
described
pericardiocentesis
• 1829
Larrey:
First
successful
pericardiocentesis
for
trauma
• 1896
Rehn:
First
successful
human
cardiac
repair
aXer
a
knife
wound
to
the
RV
• 1901
Igelsrund:
First
open
cardiac
massage
for
cardiac
arrest
• 1902
Hill:
First
cardiorrhaphy
in
the
US

13. Tromsø
Amtsykehus

14. History
• 1649
Riolanus:
First
described
pericardiocentesis
• 1829
Larrey:
First
successful
pericardiocentesis
for
trauma
• 1896
Rehn:
First
successful
human
cardiac
repair
aXer
a
knife
wound
to
the
RV
• 1901
Igelsrund:
First
open
cardiac
massage
for
cardiac
arrest
• 1902
Hill:
First
cardiorrhaphy
in
the
US

16. History
• 1927
Djanelidze:
published
detailed
review
of
535
cases
of
cardiac
injuries
• 1939
Bigger:
pericardiocentesis
should
be
used
both
diagnos)cally
and
therapeu)cally;
opera)on
reserved
as
treatment
for
the
unstable
pa)ent
• 1946
Harken:
Removal
of
missiles
from
the
heart
during
WWII
• 1967
Barnard:
First
heart
transplant

17. Trea)se
on
cardiac
injuries,
1927

18. History
• 1927
Djanelidze:
published
detailed
review
of
535
cases
of
cardiac
injuries
• 1939
Bigger:
pericardiocentesis
should
be
used
both
diagnos)cally
and
therapeu)cally;
opera)on
reserved
as
treatment
for
the
unstable
pa)ent
• 1946
Harken:
Removal
of
missiles
from
the
heart
during
WWII
• 1967
Barnard:
First
heart
transplant

19. History
• 1927
Djanelidze:
published
detailed
review
of
535
cases
of
cardiac
injuries
• 1939
Bigger:
pericardiocentesis
should
be
used
both
diagnos)cally
and
therapeu)cally;
opera)on
reserved
as
treatment
for
the
unstable
pa)ent
• 1946
Harken:
Removal
of
missiles
from
the
heart
during
WWII
• 1967
Barnard:
First
heart
transplant

21. History
• 1927
Djanelidze:
published
detailed
review
of
535
cases
of
cardiac
injuries
• 1939
Bigger:
pericardiocentesis
should
be
used
both
diagnos)cally
and
therapeu)cally;
opera)on
reserved
as
treatment
for
the
unstable
pa)ent
• 1946
Harken:
Removal
of
missiles
from
the
heart
during
WWII
• 1967
Barnard:
First
heart
transplant

22. Lots
of
Papers
• Beall
AC,
Oschner
JL,
Morris
GC
Jr,
et
al.
Penetra)ng
wounds
of
the
heart.
J
Trauma
1961;1:195–207.
• Beall
AC,
Crosthait
RW,
Crawford
ES,
DeBakey
ME.
Gunshot
wounds
of
the
chest:
a
plea
for
individualiza)on.
J
Trauma
1964;
4:382–389.
• Beall
AC,
Diethrich
EB,
Crawford
HW,
et
al.
Surgical
management
of
penetra)ng
cardiac
injuries.
Am
Surg
1966;112:686–
692.
• Boyd
TF,
Strieder
JW.
Immediate
surgery
for
trauma)c
heart
disease.
J
Thorac
Cardiovasc
Surg
1965;50:305–315.
• Sugg
WL,
Rea
WJ,
Ecker
RR,
et
al.
Penetra)ng
wounds
of
the
heart:
an
analysis
of
459
cases.
J
Thorac
Cardiovasc
Surg
1968;
56:531–545.
• MaMox
KL,
Feliciano
DV.
Role
of
external
cardiac
compression
in
truncal
trauma.
J
Trauma
1982;22:934–936.
• Millikan
JS,
Moore
EE.
Outcome
of
resuscita)ve
thoracotomy
and
descending
aor)c
occlusion
performed
in
the
opera)ng
room.
J
Trauma
1984;24:387–392.

23. The
Current
Genera)on
• Most
data
is
from
civilian
studies
• Most
data
is
retrospec)ve
• There
is
one
major
study
looking
at
RT
in
the
combat
zone

24. • Prospec)ve
• Analyzed
mul)ple
parameters
as
predictors
of
mortality
– measured
in
the
field,
during
transport,
and
upon
arrival
• Interven)ons
included
thoracotomy,
sternotomy,
or
both,
for
resuscita)on
and
defini)ve
repair
of
cardiac
injury
– ED
thoracotomy
performed
on
all
pa)ents
arriving
in
cardiopulmonary
arrest

26. • Retrospec)ve
review
of
950
EDTs
performed
at
a
single
regional
Level
I
trauma
center
over
23
years
• Evaluate
the
outcome
based
on
the
presence
or
absence
of
vital
signs
– At
first
contact
by
the
paramedics
and
upon
arrival
at
the
emergency
department
• Overall
survival
4.4%

28. • Determine
the
main
factors
that
most
influence
survival
aXer
EDT
• 24
studies,
4,620
cases,
blunt
and
penetra)ng
trauma
• Primary
outcome
analyzed:
in-­‐hospital
survival
rate

29. • Overall
survival
rate
of
7.4%
– Normal
neurologic
outcomes
in
92.4%
• Survival
rates:
8.8%
for
penetra)ng
and
1.4%
for
blunt
– 16.8%
for
stab
wounds
– 4.3%
for
gunshot
wounds
– 19.4%
if
the
heart
was
injured
• SOL
present
on
arrival:
survival
11.5%
• SOL
not
present
on
arrival:
survival
2.6%

30. • Prospec)ve
and
retrospec)ve
observa)onal
study
• Evaluate
performance
of
EDT
in
order
to
improve
treatment
guidelines
• Determine
the
outcomes
of
any
survivors

31. • All
pa)ents
undergoing
EDT
at
a
CSH
in
Iraq
from
November
2003
to
December
2007
• RT
performed
as
a
primary
interven)on
before
the
pa)ent
leX
the
ER
•
101
pa)ents
– 0.01%
of
total
trauma
admissions
– 53
US
military
or
civilian
– 48
host
na)onal
pa)ents

33. CPG
Review

35. Algorithms

36. • Characterize
the
physiologic
impact
of
aor)c
balloon
occlusion
in
a
model
of
torso
hemorrhage
and
shock
• Compare
the
effec)veness
of
this
technique
to
thoracotomy
with
aor)c
clamping

38. References
• Rhee
PM,
Acosta
J,
Bridgeman
A,
et
al.
Survival
aXer
emergency
department
thoracotomy.
J
Am
Coll
Surg.
2000;190(3):
288-­‐98
• Edens
JW,
Beekley
AC,
Chung
KK,
Cox
ED,
Eastridge
BJ,
Holcomb
JB,
Blackbourne
LH.
Longterm
outcomes
aXer
combat
casualty
emergency
department
thoracotomy.
J
Am
Coll
Surg.
2009;209:188-­‐197
• Moore
EE,
Knudson
MM,
Burlew
CC,
et
al.
Defining
the
limits
of
resuscita)ve
emergency
department
thoracotomy:
a
contemporary
Western
Trauma
Associa)on
perspec)ve.
J
Trauma.
2011;70(2):334-­‐9
• Asensio
JA,
Berne
JD,
Demetriades
D,
et
al.
One
hundred
five
penetra)ng
cardiac
injuries:
a
2-­‐year
prospec)ve
evalua)on.
J
Trauma
1998;44:1073–1082
• Branney
SW,
Moore
EE,
Feldhaus
KM
et
al.
'
Cri)cal
analysis
of
two
decades
of
experience
with
pos)njury
emergency
department
thoracotomy
in
a
regional
trauma
center'.
J
Trauma
1998;45:87-­‐95
• White,
JM,
Cannon,
JW,
Stannard,
A,
Markov,
NP,
Spencer,
JR,
Rasmussen,
TE.
Endovascular
balloon
occlusion
of
the
aorta
is
superior
to
resuscita)ve
thoracotomy
with
aor)c
clamping
in
a
porcine
model
of
hemorrhagic
shock.
Surgery
2011;
150(3):400-­‐409