Question 10

College Answer

                a)                                                                                                                                              

The key clinical signs to indicate a patient has sustained traumatic asphyxiation include:

• Facial and upper chest petechiae
• Sub-conjunctival hemorrhages
• Cervical cyanosis
• Neurological signs due to cerebral edema
• Temporary loss of vision as a result of retinal edema

b) 

Resuscitative thoracotomy is a procedure of last resort that is nearly always performed in the emergency department and involves gaining rapid access to the heart and major thoracic vessels through an anterolateral chest incision or clam shell incision to control exsanguinating haemorrhage or other life-threatening chest injuries   

What are the indications for resuscitative thoracotomy? 

• Extremely controversial

Accepted Indications                                                               

• Penetrating / Blunt thoracic injury
• Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
• Unresponsive hypotension (BP < 70 mmHg)
• Rapid exsanguination from chest tube (> 1500 mL)

 Relative Indications                                                                 

• Penetrating thoracic injury
• Traumatic arrest without previously witnessed cardiac activity
• Penetrating non-thoracic injury and  Blunt thoracic injuries
• Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Contraindications to resuscitative thoracotomy            

• The patient has no signs of life at the scene of injury
• Asystole is the presenting rhythm and there is no pericardial tamponade
• Prolonged pulselessness (> 15 minutes) occurs at any time
• Massive, non-survivable injuries have occurred

Discussion

This SAQ was not passed by anybody, which again brings into question the utility of asking trainees about such esoterica as traumatic asphyxia or pyroglutamic acidosis. Does one's inability to discuss these topics really act as a sensitive discriminator to tell "junior consultant" from "competent senior registrar"?

Anyway.

a) "Traumatic asphyxia" is defined as "a form of suffocation where respiration is prevented by external pressure on the body". It is essentially a crush injury of the thorax, with impaired respiration as the result of greatly decreased chest expansion. Failure of venous return from the upper body results in the characteristic clinical findings, all of which can be attributed to greatly increased venous pressure. This list of signs is composed on the basis of articles by Byard et al (2006) and  Eken et al (2009)

Common features:

• Cyanosis of the upper body, especially the face
• Conjunctival haemorrhage
• Conjunctival oedema
• Petechial haemorrhages and purpura over the face, neck and upper face
• Oedema and congestion of the head
• The "brassiere sign" - petechhii and congestion of asphyxia spare those areas of the thorax which were covered by tight-fitting clothing, as it obstructs cutaneous blood flow and prevents the formation of petechii. This is typically observed in women who were wearing a bra during their crush injury, or a tight-fitting singlet as in the case of the moustachioed gentleman in the picture.

Uncommon features:

• Chemosis
• Exophthalmos
• Retinal haemorrhages and visual loss
• Vitreous haemorrhagic exudates (Purtscher’s retinopathy- Choi et al, 2010 )
• Retrobulbar (posterior orbital) haemorrhages
• Haemotympanum

Other sequelae:

• Loss of consciousness
• Seizures
• Blindness
• Hearing loss
• Cerebral venous infarction

b) Resuscitative thoracotomy is defined as a left-sided clamshell thoracotomy performed for the specific purpose of gaining rapid access to the heart and major thoracic vessels.

Indications for resuscitative thoracotomy  (Rabinowici et al, 2014)

• The patient is in cardiac arrest
• The cause is blunt or penetrating chest trauma (evidence is strongest for penetrating cardiac trauma, where the survival rate is apparently 40% - JACS, 2001)
• Arrest is after arrival to hospital, or shortly before. The "down-time" should be less than 10 minutes for blunt trauma and less than 15 minutes for penetrating trauma.
• There is suspicion that reversible pathology is present in the chest, which includes cardiac tamponade or injury to the greater vessels
• Massive haemothorax (1500ml of blood in the hemithorax)
• There is sufficient surgical expertise available to carry on with a more formal damage control surgery after the patient is stabilised (otherwise, there is no point opening the chest)

Contraindications for resuscitative thoracotomy

• No signs of life witnessed in the pre-hospital setting
• Prolonged pre-hospital CPR
• Asystole on presentation, and no cardiac tamponade
• Massive extrathoracic injuries which may be unsurvivable

Morrison, Jonathan J., et al. "Resuscitative thoracotomy following wartime injury." Journal of Trauma and Acute Care Surgery 74.3 (2013): 825-829.

Burlew, Clay Cothren, et al. "Western Trauma Association critical decisions in trauma: resuscitative thoracotomy." Journal of Trauma and Acute Care Surgery 73.6 (2012): 1359-1363.

Ohrt-Nissen, S., et al. "Indication for resuscitative thoracotomy in thoracic injuries—Adherence to the ATLS guidelines. A forensic autopsy based evaluation." Injury 47.5 (2016): 1019-1024.

Rabinovici, Reuven, and N. Bugaev. "Resuscitative thoracotomy: an update." Scandinavian Journal of Surgery (2014): 1457496913514735.

CALS program manual: "Emergency Thoracotomy (Circulation Skills 4)"

Working Group, Ad Hoc Subcommittee on Outcomes. "Practice management guidelines for emergency department thoracotomy." Journal of the American College of Surgeons 193.3 (2001): 303-309.

Keller, Deborah, et al. "Life after near death: long-term outcomes of emergency department thoracotomy survivors." Journal of Trauma and Acute Care Surgery 74.5 (2013): 1315-1320.