Toracotomia de Reanimacion, Dra Mayla Perdomo, Colombia
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Toracotomia de Reanimacion, Dra Mayla Perdomo, Colombia
- 1. Toracotomía de Reanimación Mayla Andrea Perdomo Amar Magíster en Administración – MBA, Universidad EAFIT Especialista en Medicina de Urgencias, Universidad CES Docente Universidad de Antioquia
- 2. Maras, Moray.Perú “Yo creo en el inconmensurable poder del amor; el amor verdadero puede soportar cualquier circunstancia y atravesar cualquier distancia”
- 3. EPIDEMIOLOGIA • Del trauma, 25-50% Trauma torácico penetrante y cerrado. • Trauma tórax ocasiona 50% mortalidad en trauma civil. • Mayoría pacientes requiere manejo no qx, con o sin sonda a tórax. • 10 -15% requieren toracotomía de reanimación Hunt PA. Injury, Int J Care Injured. 2006;37:1-19
- 5. Qué es? • Procedimiento realizado a un paciente en extremis, inmediatamente en el lugar de la lesión o en la sala de emergencias o en la sala de cirugía, como parte integral de la resucitación inicial. • Creada 1960, Beall y colegas: pacientes moribundos con trauma tórax penetrante. • Términos: - Toracotomía en el departamento de emergencias - Toracotomía emergente - Toracotomía temprana - Toracotomía de reanimación Edens JW. Jam Coll Surg. 2009;209:188-197 Hunt PA. Injury, Int J. Care Injured. 2006;37: 1-19
- 6. Objetivos • Evacuación de taponamiento cardíaco • Aliviar neumotórax a tensión • Control directo sangrado intratorácico • Control de un embolismo aéreo masivo o de una fístula broncopleural masiva: clampear hilio pulmonar • Realizar masaje cardíaco directo • Clampear la aorta descendente: controlar la hemorragia subdiafragmática y redistribuir el flujo sanguíneo: cerebral y coronario. Edens JW. Jam Coll Surg. 2009;209:188-197 Hunt PA. Injury, Int J. Care Injured. 2006;37: 1-19 J. Wayne M. Surg Clin N Am. 2007;87:95-118
- 7. Tomar la decisión: 3 Factores a considerar • Mecanismo de lesión • Localización de la lesión • Signos de vida (estado fisiológico) Rhee PM. J Am Coll Surg. 2000;190:288-298 Hunt PA. Injury, Int J. Care Injured. 2006;37: 1-19 J. Wayne M. Surg Clin N Am. 2007;87:95-118
- 8. MECANISMO DE LESIÓN • No es un factor aislado de no utilidad, excepto en trauma de cráneo devastador. • Sobrevida general: 7.4% - 7.8% - Trauma cerrado: 1.4% – 1.6% - Trauma penetrante: 8.8% - 11.2%: HACP 16.8% HAF 4.3% 3 Factores a considerar Moore EE. The Journal of Trauma. 2011;70(2):334-339 Powell DW. J Am Coll Surg. 2004;2:211-215 Rhee PM. J Am Coll Surg. 2000;190:288-298
- 9. LOCALIZACIÓN DE LA LESIÓN • Sobrevida: • Mayor en lesiones torácicas, 10.7% • Lesiones abdominales 4.5% • Lesiones múltiples 0.7% • Si la lesión es cardíaca, es mas Alta: 19.4% - 31.1% • HACP ventrículo 30% sobrevida • HAF ventrículo 16% sobrevida 3 Factores a considerar Moore EE. The Journal of Trauma. 2011;70(2):334-339 Powell DW. J Am Coll Surg. 2004;2:211-215 Rhee PM. J Am Coll Surg. 2000;190:288-298 Mayor sobrevida: Lesiones cardíacas por Arma cortopunzante, con taponamiento
- 10. Estado fisiológico Hunt PA. Int. J. Care Injured 2006;37:1-19 Lorenz HP. J Trauma. 1992;32:780-8 Estado fisiológico es el mayor predictor de sobrevida Menor o nula sobrevida Mejor sobrevida
- 11. ESTADO FISIOLÓGICO, SIGNOS DE VIDA • Sobrevida: • Signos presentes a la llegada hospital, 11.5% • Signos ausentes a la llegada hospital, 2.6% • Signos presentes durante transporte, 8.9% • Ausentes en el campo, 1.2% • NO hay claro factor predictor de muerte 3 Factores a considerar Moore EE. The Journal of Trauma. 2011;70(2):334-339 Rhee PM. J Am Coll Surg. 2000;190:288-298
- 12. Hunt PA. Int. J. Care Injured 2006;37:1-19 PACIENTE EN EXTREMIS CON TRAUMA DE TÓRAX PREDICTORES DE POBRE PRONÓSTICO • Trauma cerrado • RCP prehospitalario > 5 min • TEC o múltiples traumas asociados INDICACIONES PARA TORACOTOMIA DE EMERGENCIA Trauma penetrante + SV en la escena Signos de Vida INDICACIONES PARA TORACOTOMIA DE EMERGENCIA Hipotensión severa + 1 de las siguientes: - Hemorragia intratorácica - Taponamiento - Embolismo aéreo - Hemorragia extratorácica severa SIGNOS DE VIDA Actividad eléctrica en EKG, con o sin pulso Reflejos corneano, pupilar o nauseoso GCS > 3 NO SI
- 13. INDICACIONES • Paro cardiorespiratorio por trauma penetrante torácico aislado con evidencia de signos de vida antes de la llegada a urgencias. • Hipotensión persistente por trauma debido a hemorragia intratorácica sin respuesta a reanimación con líquidos. • Hipotensión severa persistente con evidencia de embolismo sistémico aéreo o taponamiento cardíaco. Rhee PM. J Am Coll Surg. 2000;190:288-298 Hunt PA. Injury, Int J. Care Injured. 2006;37: 1-19 J. Wayne M. Surg Clin N Am. 2007;87:95-118
- 14. INDICACIONES • Masaje prehospitalario por menos de 5 min sin intubación • Intubación extrahospitalaria exitosa RELATIVAS • Presencia de signos de vida a la llegada a emergencias independiente del mecanismo • Trauma penetrante abdominal con algún signo de vida en el campo • Trauma cerrado con paro presenciado en urgencias Rhee PM. J Am Coll Surg. 2000;190:288-298 Hunt PA. Injury, Int J. Care Injured. 2006;37: 1-19 J. Wayne M. Surg Clin N Am. 2007;87:95-118
- 15. • Retrospectivo, 50 pctes toracotomía por heridas abdominales, enero 2000- diciembre 2006 • Signos de vida: 84% en la escena y 78% en urgencias • 8 pacientes (16%) sobrevivieron neurológicamente intactos = 98% HPAF abdominales (75% tx vascular mayor, 25% heridas de hígado) Seamon MJ. J Trauma 2008;64:1-8 La toracotomía de emergencia prelaparotomía brinda beneficios en la supervivencia de pacientes in extremis con heridas penetrantes abdominales asociadas a hemorragia
- 16. CONTRAINDICACIONES • Ausencia de signos de vida o paciente en asistolia al ingreso, asociado a trauma tórax cerrado. • Ausencia de signos de vida en la escena y al ingreso, con RCP mayor a 5minutos. • Trauma multisistémico asociado a TEC severo o trauma torácico. • RCP más de 15 min en trauma penetrante o cerrado mayor de 5min • Trauma cerrado o penetrante sin signos vitales en el sitio del evento Rhee PM. J Am Coll Surg. 2000;190:288-298 Hunt PA. Injury, Int J. Care Injured. 2006;37: 1-19 J. Wayne M. Surg Clin N Am. 2007;87:95-118
- 17. • Estudio multicéntrico prospectivo. • Sobrevida 56 pacientes al alta. • Mayor lesiones torácicas, 77%, abdomen 9%, extremidades 7%, cuello 4%, cráneo 4% Moore EE. The Journal of Trauma. 2011;70(2):334-339 Conclusión: Toracotomía de reanimación en ED, no es útil en: -RCP prehospitalaria mayor a 10 minutos, en trauma cerrado sin respuesta -RCP prehospitalaria mayor a 15 minutos, en trauma penetrante sin respuesta -Asistolia en ausencia de taponamiento cardíaco
- 18. 2 revisiones sistemáticas, 12 retrospectivos •Rev Sist Am Coll Surg: 42 estudios, total 2.193 pacientes trauma cerrado, llevados toracotomía, sobrevida: 1.6%, 15% secuelas neurológicas. •Rev Sist: 24 estudios, 1.024 pacientes, sobrevida 1.4% •11 Estudios retrospectivos, sobrevida 0-6% •1 Estudio restrospectivo, sobrevida 12.2%
- 19. Conclusiones: -Sobrevida en trauma cerrado es muy baja. -Secuelas neurológicas en los sobrevivientes son severas •Algunos autores recomiendan que la toracotomía debe estar contraindicada en pacientes con trauma cerrado sin signos de vida en la escena o al ingreso a urgencias. •Hacen falta estudios validar esta conclusión. Khorzandi M. Interactive CardioVascular and Thoracic Surgery 16 (2013) 509–516
- 20. Cursos para: Enseñar indicaciones, contraindicaciones Anatomía, apertura del tórax, masaje cardíaco directo, clamp de la aorta para controlar hemorragia, corregir taponamiento cardíaco Konig T. Emergency Medicine 2013, 21(Suppl 1):A2
- 22. Es útil realizar Masaje cardíaco externo en trauma? • La recomendación de masaje cardíaco externo en trauma con shock profundo, ha sido realizada sin documentación de los efectos o beneficios hemodinámicos. • Sirve para “comprar tiempo” mientras se corrigen los problemas causantes. • No aumenta la presión arterial diastólica en pacientes con presión ventricular izq de fin de diástole disminuída, por lo cual no perfunde. Semin Thorac Cardiovasc Surg 2008;20:13-18 Luna GK. The Journal of Trauma. 1989;29(10):1430-1433
- 23. Presión arterial diastólica en trauma con RCP, masaje externo Luna GK. The Journal of Trauma. 1989;29(10):1430-1433 Bajo o nulo incremento, el aumento es al tratar la causa
- 24. Efectos del masaje cardíaco externo • Presión perfusión cerebral y coronaria: 10% de la basal. • Mantenimiento mínimo de la perfusión de órganos vitales, por lo cual se produce una relación tiempo/pronóstico: - Baja sobrevida luego de 15 minutos - Nula sobrevida posterior a 30 minutos Luna GK. The Journal of Trauma. 1989;29(10):1430-1433
- 25. Masaje cardíaco directo • Ciclo = presión de perfusión sistémica cercana a la normal • 40-100 compresiones/min, dependiendo de la frecuencia: - Volumen: 2500-3300 - Flujo miocárdico: 150-250 - Flujo cerebral: 600- 800ml/min Masaje cardíaco externo • Compresiones = menor presión de perfusión sistémica • Aporte del masaje independiente de la frecuencia: - Volumen: 1200 - Flujo miocárdico: 70 - Flujo cerebral: 450 ml/min Luna GK. The Journal of Trauma. 1989;29(10):1430-1433
- 26. Efectos del masaje cardíaco externo • Taponamiento cardíaco: hay un incremento en presión intrapericárdica, esta es aumentada aún más por masaje externo y ventilación positiva, lleva a: - Mayor compromiso del llenado ventricular. - Disminución de la presión diastólica - Reducción perfusión coronaria • Hipovolemia: corazón vacío. • Lesiones comunes: ruptura cardíaca, aórtica, neumotórax, lesiones vasculares exanguinantes. Luna GK. The Journal of Trauma. 1989;29(10):1430-1433
- 27. Masaje cardíaco externo en trauma, qué podemos concluir? • Masaje cardíaco externo de rutina en pacientes con trauma DEBE ser reevaluado. • NO debe retardar la corrección de la causa del shock en trauma: inadecuado volúmen intravascular y ventricular. • Los efectos hemodinámicos y los beneficios del masaje cardíaco externo en pacientes médicos no pueden extrapolarse al paciente con trauma. Vanden Hoek TL. Circulation. 2010; 122;S829-S861 Semin Thorac Cardiovasc Surg 2008;20:13-18 Luna GK. The Journal of Trauma. 1989;29(10):1430-1433
- 28. Masaje cardíaco externo en trauma, qué podemos concluir? • Masaje cardíaco externo es útil en trauma por: electrocución, lesiones por rayo, ahogamiento, en las cuales existe alteración de la conducción cardíaca, FV, paro respiratorio. • Retardo en el transporte aumenta la mortalidad y morbilidad. Semin Thorac Cardiovasc Surg 2008;20:13-18 Louis RM. Resuscitation.1987;15:9-11 Mattox KL. The Journal of Trauma.1982;22(11):934-936
- 29. Toracotomía de reanimación CONCLUSIONES • Evaluar 3 factores: mecanismo, localización lesión, estado fisiológico • Lesiones cardíacas tienen mejor pronóstico, así sean penetrantes por HACP, HAF, cerradas. • Mayor sobrevida: asociada a taponamiento cardíaco • Estudios: estado neurológico normal 92.4% • Beneficio es mayor 2.4 veces que el costo. • Ausencia signos de vida en el campo es mal pronóstico, pero no predictor claro y 100% de muerte. Edens JW. Jam Coll Surg. 2009;209:188-197 Hunt PA. Injury, Int J. Care Injured. 2006;37: 1-19
- 30. GRACIAS! «El disfrute de la vida, proviene de un corazón sereno y en calma»
Editor's Notes
- There are numerous different terms for emergency thoracotomy. These depend on the circumstances in which the procedure is performed, the status of the patient and the location of the procedure itself. Examples include emergency department thoracotomy, emergent thoracotomy, early thoracotomy, resuscitative thoracotomy, etc. This can make interpretation of the available data and comparison of studies difficult, due to the use of the terms interchangeably. In general, emergency thoracotomy can be undertaken at any stage of the resuscitative process, and so can be defined in terms of the urgency of the procedure in relation to the patients’ physiological status. Thereby, emergency thoracotomy may be defined as that occurring either immediately at the site of injury, in the emergency department, or in the operating room, as an integral part of the initial resuscitation. An urgent thoracotomy is one that takes place under more controlled circumstances and in the context of appropriate physiological stability and hitherto successful resuscitation. Lastly, an elective (or formal) thoracotomy one that is performed during the course of elective surgical access to the thorax, such as for coronary artery bypass surgery.
- The goals of EDT are to release pericardial tamponade or tension pneumothorax, to directly control and repair intrathoracic hemorrhage, to allow open cardiac massage, and to cross clamp the thoracic aorta, restoring and maintaining perfusion to the heart and brain and preventing additional blood loss from distal sites of hemorrhage. Systemic air embolism will occur if air enters pulmonary veins as a result of low pulmonary venous pressure, increased airways pressure, or both. The consequences may be catastrophic if pulmonary venous gas embolises to the coronary vessels, heart chambers or cerebral arteries. The incidence of systemic air embolism has been estimated to be 4—14%, with two thirds resulting from penetrating injury and one third from blunt trauma.80,8 Despite being a subtle clinical entity, systemic air embolus should be considered in any major thoracic injury resulting from either penetrating or blunt trauma. It is often diagnosed only when sudden circulatory collapse occurs immediately after tracheal intubation and the initiation of positive pressure ventilation. This collapse is typically unresponsive to conventional resuscitation. The unexplained development of a neurological deficit, or seizures, in the absence of a head injury implies cerebral air embolism unless proven otherwise.81 The current recommendation for treatment of systemic air embolus associated, with unilateral lung injury, is immediate thoracotomy, in the emergency department if necessary, in order to clamp the hilum of the injured lung so as to arrest the passage of air into the systemic circulation.88 Bubbles may be noted in the vasculature on thoracotomy. Selective ventilation of the uninjured lung may be a life-saving alternative procedure in unilateral Injuries MASAJE CARDIACO DIRECTO Ciclo = presión de perfusión sistémica cercana a la normal 40-100 compresiones/min, dependiendo de la frecuencia: Volumen: 2500-3300 Flujo miocárdico: 150-250 Flujo cerebral: 600-800ml/min MASAJE CARDIACO EXTERNO Compresiones = menor presión de perfusión sistémica, sólo en diástole Aporte del masaje independiente de la frecuencia: Volumen: 1200 Flujo miocárdico: 70 Flujo cerebral: 450 ml/min
- analysis of 251 cases of cardiac injury following emergency thoracotomy, Henderson et al. showed that survival rates diminished significantly with higher physiological indices: the overall survival rate in this study was 18.7%. The findings suggested that emergency thoracotomy is most helpful for patients with limited penetrating cardiac injuries who have significant physiological impairment secondary to pericardial tamponade.40 Significant differences Lewis and Knottenbelt, in a series of 45 cases, suggested that the primary indication for resuscitative emergency thoracotomy was an observable pericardial tamponade, and that results were shown to be good for this single indication. However, they noted that emergency thoracotomy was justifiable for all patients with cardiac arrest, or persisting severe hypotension, following penetrating thoracic trauma, as not all cases of tamponade are clinically obvious on admission. They also concluded that the case for emergency thoracotomy in blunt trauma remained debatable.52 In a detailed literature review, the American College of Surgeons Committee on Trauma recommended that emergency thoracotomy be performed rarely in blunt thoracic trauma with cardiopulmonary arrest, due to low survival rates and poor neurological outcomes.1 Grove et al. repeated these conclusions, reporting no survivors at all from a total of 19 cases, over a 2- year period, of blunt multisystem trauma, including thoracic injury requiring emergency thoracotomy
- INDICACIONES Cardiorespiratory arrest following isolated penetrating thoracic trauma, with evidence of signs of life before arrival in emergency department Post traumatic persistent hypotension due to intrathoracic haemorrhage, unresponsive to fluid resuscitation Persistent severe hypotension, with evidence of systemic air embolism or pericardial tamponade
- La toracotomía en este escenario trae doble beneficio: dar masaje cardíaco directo y clampar la aorta Los pacientes no presentaron complicaciones de la oclusión de la aorta: sobrecarga del VI, lesiones esofágicas, avulsión de arterias intercostales o paraplejía. Aunque no se midió flujo coronario o cerebral los resultados medidos en términos de estado neurológico son excelentes LIMITACIONES DEL ESTUDIO Experiencia de un solo centro con gran historia en el manejo de trauma penetrante Estudio retrospectivo de lesiones poco comunes en pocos pacientes (aunque este es uno de los reportes con mas pacientes en shock exanguinante abdominal) La toracotomía de emergencia en trauma penetrante de abdomen no es inútil en la resucitación de pacientes exangües como se mencionaba en varias publicaciones anteriores
- Centros de trauma americanos
- best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether there is any role for resuscitative emergency department thoracotomy in severe blunt trauma. Emergency thoracotomy is an accepted intervention for patients with penetrating cardiothoracic trauma. However, its role in blunt trauma has been challenged and has been a subject of considerable debate. Altogether, 186 relevant papers were identified, of which 14 represented the best evidence to answer the question. The author, journal, date, country of publication and relevant outcomes are tabulated. The 14 studies comprised 2 systematic reviews and 12 retrospective studies. The systematic review performed by the Trauma Committee of the American College of Surgeons included 42 studies and a cumulative total of 2193 blunt trauma patients who underwent an emergency department thoracotomy, reporting a survival rate of 1.6%. According to this review, 15% of the survivors suffered from neurological sequelae, but survivors from both penetrating and blunt trauma were included. A systematic review comprising 24 studies reported a survival rate of 1.4% among 1047 blunt trauma patients. Of the retrospective studies, 11 report poor survival rates, ranging from 0 to 6%. Only one study reports a higher survival rate (12.2%). Five of the studies reported on the neurological outcome of survivors. The majority of the studies suffered from limitations due to the small number of included cases. The reported survival after an emergency department thoracotomy for blunt trauma is very low in the vast majority of available studies. Furthermore, the neurological sequelae in the few survivors are frequent and severe. Interestingly, some author groups recommend that emergency department thoracotomy should be contraindicated in cases of blunt trauma with no signs of life at the scene of trauma or on arrival at the emergency department. Larger, well-designed series will be required to reach a consensus on valid prognostic factors and specific subgroups of blunt trauma patients with substantial chances of survival.
- The reported survival after an emergency department thoracotomy for blunt trauma is very low in the vast majority of available studies. Furthermore, the neurological sequelae in the few survivors are frequent and severe. Interestingly, some author groups recommend that emergency department thoracotomy should be contraindicated in cases of blunt trauma with no signs of life at the scene of trauma or on arrival at the emergency department. Larger, well-designed series will be required to reach a consensus on valid prognostic factors and specific subgroups of blunt trauma patients with substantial chances of survival.
- These insights and courses are aimed at empowering clinicians to identify and apply a beneficial intervention to those that need it, when they need it. Ludwig Rehn’s pertinent conclusion following the first successful RT over a century ago remains: “many lives can be saved that were previously counted as lost [2].” insight into the anatomy, advice about optimal team preparation and a simulated demonstration of a pre hospital case ‘moulage’ on a manikin. Students were shown and allowed to practice myocardial suture repair, discuss cases and gain insight into the post operative care of patients after successful thoracotomy.
- Es inefectivo en paro secundario a taponamiento cardíaco, neumotórax a tensión y hemorragia To determine the hemodynamic effects of external massage in profound shock, hypotension was induced in baboons. Pressures obtained with external massage were compared to spontaneous intra-arterial pressures before compression. Although external massage increased systolic pressures in both tamponade and hypovolemia, diastolic pressures were consistently decreased. We conclude that CCCPR does not augment arterial pressure in the clinical situations associated with decreased LVEDV and is unlikely to provide organ perfusion for trauma victims
- massage during cardiac tamponade. Chemically Induced Cardiac Arrest CPR CPR Initiated Terminated Post-Arrest ~ Systolic Diastolic 108(90-125) 12(8-15) DBP ----------f,,,,,,,,,, O,-L..-------:;t,...-----!~-r----=='----r-=.-; Overdose 20 4 80 Pre Arrest Spontaneous Systolic Diastolic 115(110-120) 60(50-70) Augmentation with CPR (torr) ~ ~ ~ +98 +6 +40 100 120 SBP Hemodynamics FIG. 3. Arterial pressure changes resulting from closed chest massage during cardiac arrest. Arterial Pressure 60 (torr) tion or dysrhythmia is associated with normal cardiac and intravascular volumes and, particularly, normal or elevated left ventricular volume. In contrast, the inadequate cardiac output that results from trauma or surgically correctable shock is due to markedly reduced left ventricular volume secondary to inadequate intravascular volume (hypovolemic shock) or markedly restricted ventricular filling (tamponade). The dramatic reduction in blood available to exit the left ventricle during external cardiac massage would logically indicate that cardiac output and vital organ perfusion would also be significantly less than in a normovolemic patient with unobstructed ventricular filling. Although our experimental model did not directly measure cardiac output or vital organ perfusion, there was a significant difference in the intra-arterial pressures generated in the models of trauma shock as compared to that of cardiac arrest. Not only was the average augmentation in the systolic, diastolic, and mean arterial pressures greater in the cardiac model, the absolute increment in pressure was markedly less when external massage was initiated in the presence of reduced left ventricular volumes. The dramatic rise in intrapericardial pressure that resulted from external massage in the setting of cardiac tamponade raises a particular concern about the impact of external massage in this clinical setting. Our findings are consistent with those of other investigators who have
- Es inefectivo en paro secundario a taponamiento cardíaco, neumotórax a tensión y hemorragia To determine the hemodynamic effects of external massage in profound shock, hypotension was induced in baboons. Pressures obtained with external massage were compared to spontaneous intra-arterial pressures before compression. Although external massage increased systolic pressures in both tamponade and hypovolemia, diastolic pressures were consistently decreased. We conclude that CCCPR does not augment arterial pressure in the clinical situations associated with decreased LVEDV and is unlikely to provide organ perfusion for trauma victims
- Es inefectivo en paro secundario a taponamiento cardíaco, neumotórax a tensión y hemorragia To determine the hemodynamic effects of external massage in profound shock, hypotension was induced in baboons. Pressures obtained with external massage were compared to spontaneous intra-arterial pressures before compression. Although external massage increased systolic pressures in both tamponade and hypovolemia, diastolic pressures were consistently decreased. We conclude that CCCPR does not augment arterial pressure in the clinical situations associated with decreased LVEDV and is unlikely to provide organ perfusion for trauma victims