In which patient is emergency department thoracotomy contraindicated?
The utility of resuscitative thoracotomy (RT) has been debated for decades. Current indications are based on 30 years of prospective data, supported by a recent multicenter prospective study. RT is associated with the highest survival rate after isolated cardiac injury; 35% of patients presenting in shock and 20% without vital signs (ie, no pulse or obtainable BP) are salvaged after isolated penetrating injury to the heart. For all penetrating wounds, survival rate is 1 5%. Conversely, patient outcome is poor when RT is done for blunt trauma, with 2% survival among patients in shock and < 1% survival among those with no vital signs. Thus, patients undergoing cardiopulmonary resuscitation (CPR) upon arrival to the ED should undergo RT selectively based on injury and transport time.
A patient with spontaneous eye opening, who is confused and localizes pain has a Glasgow Coma Score ( GCS) of :
The Glasgow Coma Score (GCS) should be determined for all injured patients (Table below). It is calculated by adding the scores of the best motor response, best verbal response, and eye opening. Scores range from 3 (the lowest) to 15 (normal). Scores of 13 to 15 indicate mild head injury, 9 to 12 moderate injury, and less than 9 severe injury. The GCS is useful for both triage and prognosis.
"Score is calculated by adding the scores of the best motor response, best verba l response, and eye opening. Scores ra nge from 3 (the lowest) to IS (normal)
Zone I is inferior to the clavicles encompassing the thoracic outlet structures, zone II is between the thoracic outlet and the angle of the mandible, and zone III is above the angle of the mandible. Patients with symptomatic zone I and III injuries should ideally undergo diagnostic imaging before operation if they remain hemodynamically stable. Specific symptoms which indicate further imaging include dysphagia, hoarseness, hematoma, venous bleeding, minor hemoptysis, and subcutaneous emphysema. Symptomatic patients should undergo CTA with further evaluation or operation based upon the imaging findings; less than 15% of penetrating cervical trauma requires neck exploration. Asymptomatic patients are typically observed for 6 to 12 hours. The one caveat is asymptomatic patients with a transcervical gunshot wound; these patients should undergo CTA to determine the track of the bullet. CTA of the neck and chest determines trajectory of the injury tract; further studies are performed based on proximity to major structures. Angiographic diagnosis, particularly of zone III injuries, can then be managed by selective angioembolization.
Appropriate surgical management of a through-and-through gunshot wound to the lung with minimal bleeding and some air leak is:
Pulmonary injuries requiring operative intervention usually result from penetrating injury. Formerly the entrance and exit wounds were oversewn to control hemorrhage. This set the stage for air embolism, which occasionally caused sudden death in the operating room or in the immediate postoperative period. A recent development, pulmonary tractotomy, has been employed to reduce this problem as well as the need for pulmonary resection. Linear stapling devices are inserted directly into the injury tract and positioned to cause the least degree of devascularization. Two staple lines are created and the lung is divided between. This allows direct access to the bleeding vessels and leaking bronchi. No effort is made to close the defect. Lobectomy or pneumonectomy is rarely necessary. Lobectomy is only indicated for a completely devascularized or destroyed lobe. Parenchymal injuries severe enough to require pneumonectomy are rarely survivable, and major pulmonary hilar injuries necessitating pneumonectomy are usually lethal in the field.
What is true regarding the evaluation ofblunt abdominal trauma?
The presence of abdominal rigidity and hemodynamic compromise is an undisputed indication for prompt surgical exploration. Blunt abdominal trauma is evaluated initially by FAST examination in most major trauma centers, and this has largely supplanted diagnostic peritoneal lavage (DPL). FAST is not 100% sensitive, however, so diagnostic peritoneal aspiration is warranted in hemodynamically unstable patients without a defined source of blood loss to rule out abdominal hemorrhage. This method is exquisitely sensitive for detecting intraperitoneal fluid of > 250 mL. Patients with fluid on FAST examination, considered a "positive FAST;' who do not have immediate indications for laparotomy and are hemodynamically stable undergo CT scanning to quantify their injuries. CT also is indicated for hemodynamically stable patients for whom the physical examination is unreliable. Despite the increasing diagnostic accuracy of multidetector CT scanners, identification of intestinal injuries remains a limitation. Patients with free intra-abdominal fluid without solid organ injury are closely monitored for evolving signs of peritonitis; if patients have a significant closed head injury or cannot be serially examined, DPL should be performed to exclude bowel injury. After placement of the catheter, a 10-mL syringe is connected and the abdominal contents aspirated (termed a diagnostic peritoneal aspiration). The aspirate is considered to show positive findings if > 10 mL of blood is aspirated. If < 10 mL is withdrawn, a liter of normal saline is instilled. The effluent is withdrawn via siphoning and sent to the laboratory for red blood cell (RBC) count, white blood cell (WBC) count, and determination of amylase, bilirubin, and alkaline phosphatase levels. See Table below for values representing positive findings.
Criteria for "positive" finding on diagnostic peritoneal lavage:
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