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Emergency Nick Newton Consultant Trauma Thoracotomy & Emergency General Surgeon Birmingham, UKpitalsCaution • Clinical care must be context and system appropriate • Healthcare providers must work within that system • Reasonable to do what you are good at even if it is not perfect • First do no harm Learning • Indications • Technique Objectives • MDT approach • Anatomy • NOT going to teach technical skills but will discuss these skills Chest Injuries • ATLS (or equivalent) A, B, C and D DO THE BASICS WELL – • Majority can be managed with simple intercostal drain – Key skill Can be diagnostic – • Advanced diagnostics are helpful but not essential MDT Opening the chest is a team activity approach Patients are sick and will need resources •Blood, time, skill, drugs, space Sometimes the situation will dictate your response not the patient allied health professionals and other team members and Communicate to the familyInitial Steps • External anatomy and position – Internal thoracic arteries • Internal anatomy Anatomy – Phrenic nerve – Aorta – LAD – Inferior pulmonary ligament Operating Limited technical skills • • High level decision making • Top level teamwork and collaboration – Ideally before the patient even exists Indications Resuscitation Massive Proximal control haemorrhage of aortaResuscitation • For patients in extremis • Resource intensive • Poor outcomes in most settings • Must be coordinated with airway team and ITU • The start of a journey NOT the end!Resuscitation 4 stages 2 • Bilateral thoracostomies, simple cuts into chest like a chest drain but bigger Extend thoracostomies to • clamshell • Open pericardium • Manually compress aorta STOP , TALK, PLANResuscitation • What next? 3 – Repair a cardiac injury – Clamp aorta – Call for help – Move to theatre – Futility • Blood, expertise, resource, capacity Massive Haemothorax Many definitions Needs a local protocol everyone agrees with •Liberal use of surgery to avoid blood loss •Conservative use of surgery to avoid resource use May commit to surgery and find nothing that can be repaired Definitive techniques Cardiac repair Lung tractotomy Packing Intercostal small vessel injury repair Proximal control of great vesselsPericardial Buttressed mattress • Repair suture • Pericardium as pledget • Ideally 3/0 prolene but in extremis anythingTractotomy/lung resection • Penetrating injury • Devitalised lung Equipment • – Bowel clamps, staplers, prolene • Left: GI stapler passed through penetrating injury Technique • Right: tract opened using non-crushing bowel clampsProximal • Do not blind clamp aorta • Open pleura Control • Finger dissect – Gently • Non-crushing bowel clampAortic control • Part of abdominal surgery • Often technically easier than intra-abdominal aortic controlProximal • Great vessels – Innominate artery Control 2 • Right common carotid, right sub- clavian – Left common carotid – Left sub-clavian • Posterior, difficult to access as aorta arches posteriorly • This is only the beginning Proximal • Plan your next moves • Communicate your plan • Get on with it! Control • Constantly reassess – Resource, skill, time • 5 drains – Apical, basal, left and right, pericardial • Do not close the pericardium Post op • Big strong sutures around ribs • Abdominal closure sutures to fascial layers • Skin closure Be good at the basics • – Warm – Monitored • Catheter, regular observations, bloods, Post op. 2 – Drugs • Abx, Tranexamic Acid, Tetanus, routine medications • Indications Anatomy • Summary • MDT approach • Techniques • Technical skills • Do the basics well Conclusion • First do no harm • Work within your system • Top Knife • Touchsurgery App • Anatomy Learning 3D Resources anatomy app • MedALL • YouTube • Behind the Knife