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Emergency department thoracotomy: Nursing implications for pediatric cases
Emergency Department Thoracotomy: Nursing Implications for Pediatric Cases Bonnie Clemence, RN, MSN Cardiac arrest in the pediatric patient is an infrequent event. Although an emergency department thoracotomy is a potentially lifesaving procedure, it should be used in only a small, select group of patients. A literature review was conducted to determine the indications, surgical techniques, emergency procedures, and nursing responsibilities associated with an emergency department thoracotomy. (Int J Trauma Nurs 2000;6:123-7)
mergency department thoracotomy (EDT) was considered as a resuscitation technique as early as 1874.1 However, it was not until 1966 that cardiothoracic surgical techniques had improved enough for EDT to be considered more feasible.2 EDT, especially in the pediatric population, is a rare but potentially lifesaving procedure. After assisting with 2 cases of pediatric EDT, a literature review was conducted to determine the indications, surgical techniques (internal cardiac massage and cross-clamping the aorta), emergency procedures, and nursing responsibilities associated with an EDT.
E
The small number of pediatric patients and their outcomes have made it difficult to develop definitive guidelines for the use of EDT in pediatric trauma patients.
doi:10.1067/mtn.2000.110826
patients. Table 1 lists some of the various recommendations found in the literature. An EDT is indicated for some patients in cardiac arrest associated with trauma. It is performed on patients in extremis4 (ie, a patient who has sustained cardiac arrest before or on arrival to the ED). EDT is most successful for patients who have “signs of life” (eg, a palpable pulse, blood pressure, spontaneous respirations, Glasgow Coma Scale score >3, pupillary responses, and cardiac activity on a cardiac monitor) before arriving at the hospital.9 Long-term survival tends to depend on the mechanism of injury, location of the major injury, and the presence of signs of life before arriving at the hospital.6 EDT is not indicated for trauma patients who do not have signs of life before reaching the hospital or who arrive in the ED 30 minutes or more after receiving treatment in the prehospital setting.6,7,9,11,12,15 Not all trauma patients are considered good candidates for EDT. Patients with stab wounds tend to fare better after EDT because the injuries are often low velocity in nature.5 Although some trauma centers only perform EDT on patients with penetrating trauma,3,6 other centers use EDT for blunt and penetrating trauma.
OCTOBER-DECEMBER 2000
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clemence 123
INDICATIONS FOR EMERGENCY DEPARTMENT THORACOTOMY EDT has been used to treat adults and children who have sustained a cardiac arrest after trauma, and it has been addressed extensively in the literature.3-15 This procedure is most frequently performed on adults, but in an emergency department (ED) setting it may also be required for children. Unfortunately, few reports have been published on the use of EDT in the pediatric trauma population.7,11,14,15 The small number of pediatric patients has made it difficult to develop definitive guidelines for the use of EDT in pediatric trauma
Bonnie Clemence, RN, MSN, is an accreditation coordinator at Pennsylvania Trauma Systems Foundation, Mechanicsburg, Pa. Reprint requests: Bonnie Clemence, RN, MSN, Pennsylvania Trauma Systems Foundation, 5070 Ritter Rd, Suite 100, Mechanicsburg, PA 17055-4879. Copyright © 2000 by the Emergency Nurses Association. 1075-4210/2000/$12.00 + 0 65/1/110826
Table 1. Example of conflicting recommendations from the literature for the use of EDT in pediatric trauma patients Resource Powell et al, 1988 (p. 191)
Recommendations • • •
Beaver et al, 1987 (p. 19, 21)
• • •
All penetrating thoracic trauma Blunt trauma victims with acute deterioration or signs of life in the ER (or OR) Blunt trauma victims with signs of life at the scene and a short transport time Penetrating chest injuries Acute deterioration in the admitting area (ED) and inability to safely transport to the OR Blunt injuries associated with detectable vital signs and deterioration despite maximal conventional therapy
Rothenberg et al, 1989 (p. 1324)
• •
Penetrating wound Blunt trauma with evidence of life on ED arrival
Polhgeers & Ruddy, 1995 (p. 280)
• •
Penetrating thoracic trauma with waning or loss of vital signs in the ED Penetrating thoracic trauma with vital signs at the scene but no vital signs on arrival in the ED (5-20 min of cardiopulmonary resuscitation in the field) Penetrating abdominal trauma with loss of vital signs in the ED (relative indication)
•
The outcomes tend to be worse for victims of blunt trauma.5,7,9,11,12,14 Children with blunt trauma generally do not survive even after undergoing an EDT.8,10-12 Because children with blunt-force trauma may have head and multiple organ injuries, their chances of survival may be small.7 Adults with blunt-force trauma also do not have high survival rates after EDT.
Three sizes of internal paddles should be available for pediatric patients: 6 cm for adolescents, 4 cm for children, and 2 cm for infants. TECHNIQUE FOR PERFORMING AN EDT Because EDT is performed on patients in extremis it must be performed quickly. All general and specific resuscitation equipment and knowledgeable staff should be immediately available. All personnel present in the room during the procedure should observe universal precautions to avoid accidental
exposure to bloodborne pathogens and to decrease the risk of contaminating an open surgical wound. The equipment that is used for an EDT is outlined in Table 2. If it is possible to prepare for the patient, the nursing staff should have the following equipment ready for use: endotracheal intubation equipment and supplies; suction equipment; intravenous (IV) catheters, tubing, crystalloid fluids primed through a fluid warmer for rapid administration; O Rh-negative blood; cardiopulmonary monitoring equipment; and both external and internal defibrillator paddles. Three sizes of internal paddles should be available for pediatric patients: 6 cm for adolescents, 4 cm for children, and 2 cm for infants. A sterile thoracotomy instrument tray should be placed on a Mayo stand to the left of the patient stretcher as well as skin preparation solutions (eg, providone-iodine solution), scalpel blades (eg, No. 11 or No. 15), suture material (2.0, 3.0, or 4.0 silk with curved and vascular needles), and felt pledgets. A sterile suction set-up and large, singleopening suction tip (eg, Yankeur) may be used to aspirate pooled blood for autotransfusion. The internal defibrillator paddles are usually kept separate and need to be handed onto the sterile field. The outer wrapping is removed and the sterile
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Table 2. Equipment used in emergency department thoracotomy Equipment and supplies 1. Gowns and gloves (both sterile and nonsterile), eye shields, masks for all personnel in room 2. Resuscitation equipment a. Cardiac monitor and defibrillator with various sized internal defibrillator paddles b. Multiple suction set-ups 3. Skin preparation solutions, including sterile saline and antiseptic solutions 4. Sterile thoracotomy tray; may need to add instruments (eg, large vascular clamps) 5. Scalpel blades, suture, skin stapler, gauze sponges, chest tubes, rapid infuser and autotransfusion supplies a. Felt pledgets
paddles are handed onto the sterile field, still encased in the inner sterile wrapping. The end of the paddle cord must be handed off or picked up without contaminating the field, then attached to the defibrillator. The defibrillator is placed at the desired position (eg, at the head of the bed or on the left side of the stretcher). Although surgeons and nurses have different roles in an EDT, it is helpful to review the procedure to give all personnel an understanding of what is done. The surgical approach used for an EDT is different from a standard thoracotomy because the patient is supine. An incision is made in the left, fifth anterolateral intercostal space, allowing for quick access to the intrathoracic space. Chest-wall bleeding tends to be minimal in these patients. A standard or pediatric-sized rib spreader is used to expose the injured intrathoracic structures and to identify sites of hemorrhage. Depending on the pathology discovered, the phy-sician may elect to perform additional internal resuscitation efforts (eg, cardiac massage or defibrillation), divert cardiac output by cross-clamping the aorta, or treat life-threatening problems (eg, decompress cardiac tamponade; clamp, suture, or staple an avulsed or torn major vessel, organ, or airway structure).
Internal Cardiac Massage There are 3 methods for internal cardiac massage: (1) compressing the heart between the sternum and the hand, (2) compressing the heart with 2 hands, or (3) compressing the heart with 1 hand.7 The two-handed method is the least problematic of the OCTOBER-DECEMBER 2000
Rationale 1. Universal precautions against blood-borne pathogens; maintain sterility of open wound 2a. Pediatric patients will require smaller internal paddles than adults 2b. Will require individual set-ups for airway control and surgical field 3.
Provide for a more sterile surgical wound
4.
Not all thoracotomy trays are standard
5.
These items tend to be added to tray according to physician’s preference a. Used to hold suture in the friable myocardium
3 methods. The one-handed method may cause myocardial perforation from the compressor’s thumb, and the sternal method may be less effective in the young population because of sternal plasticity.7 When performing 2-handed compressions, 1 hand is placed beneath the heart and 1 is placed above it. The heart is compressed starting with the heels (apex) of the hands and progressing to the fingertips (base). The rate of compression is at least 100 beats/min, similar to closed-chest massage.7 Cardiac massage may be halted to perform internal defibrillation. If preferred, saline pads may be placed on the heart before discharging the internal paddles. The defibrillator will need to be charged and discharged by a person outside of the sterile field. Although there is no ideal defibrillator charge for children, a range of 5 to 20 J is suggested, and the maximum wattage rate for both pediatric and adult patients is 50 J. Most defibrillators will not discharge when the internal paddles are in use and the defibrillator is set higher than 50 J. The core body temperature can affect resuscitation efforts because a hypothermic heart may not respond to defibrillation attempts. An open chest can expose the heart and make it prone to hypothermia. The heart can be externally warmed with intermittent baths of warm saline solution or heat lamps directed toward the open chest.7
Cross-Clamping the Aorta If internal cardiac massage is not successful, the descending thoracic aorta can be partially occluded to increase blood flow to the heart. INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clemence 125
Large vascular clamps are applied without completely encircling the aorta. This technique allows a minimal blood flow through the aorta (approximately 10% of normal flow) and avoids injuries to the branches of the aorta. The amount of time the clamp is applied should be documented because blood flow needs to be restored distally within 30 minutes to avoid multiple physiologic consequences of ischemia, such as renal failure, paraplegia, or bowel infarct.
A nonsterile assistant is needed to hand supplies onto the sterile field and perform internal defibrillation. NURSING RESPONSIBILITIES IN EDT During an EDT, nurses assume multiple roles. It is especially helpful if a staff person can be a sterile assistant to hand instruments to the physician, help with procedures, or possibly perform internal cardiac massage. Perioperative nurses who respond to major trauma resuscitation can assist the physician, help facilitate the patient’s transfer to the operating room (OR), and allow the ED nurses to manage their multiple responsibilities. A nonsterile assistant is needed to hand supplies onto the sterile field and perform internal defibrillation. The patient’s care and status are documented frequently and include cardiac rhythm and rate (if electrical activity is present); adequacy of ventilation and tissue oxygenation; pupillary response; and any obtainable blood pressure. All IV fluids are administered through a fluid warmer; if a rapid infuser or autotransfusor are used, then the systems require constant attention to ensure proper functioning and accurate record-keeping of fluid volume intake and output. The patient’s core body temperature is monitored, and rewarming efforts are used to keep the patient normothermic. ED documentation includes the following: the time EDT was performed; the length of time the patient was in cardiopulmonary arrest; the length of time internal chest compression and ventilation were performed; the number of defibrillation attempts and the joules administered; cross-clamp time if the aorta was occluded; amount of blood and IV fluid administered; the dosages of medica-
tions administered; and the patient’s response to each intervention. If EDT is successful and cardiac activity is restored, the patient is transferred to the OR for definitive treatment. In preparation for transfer to the OR, the opened chest is covered with sterile towels to prevent additional contamination. The chest is not closed in the ED because definitive management will be needed. Because EDTs are performed infrequently, the ED trauma staff may want to reassess their response team. If perioperative nurses do not currently respond to the ED with trauma cases, a new policy may need to be instituted. Trauma thoracotomy trays can be preset with simple, basic instruments and plastic bags attached to the outside that contain suture and supplies for penetrating cardiac wounds. Right-atrial cannulation materials can be assembled and kept on hand. The team may want to examine whether the physical plan of the hospital allows for patients in extremis to be directly admitted to the OR, or whether a satellite OR can be created in the ED. CONCLUSION EDT can be described as a high-cost, high-risk, low-yield procedure that is done for a select group of patients. The optimal patients are those with a single penetrating injury to the left side of the chest who have or had vital signs and pupillary response within 5 minutes before the thoracotomy. Patients who have been in cardiopulmonary or traumatic arrest for more than 20 minutes have minimal chances for survival and the use of EDT will not affect their outcome.5,7,13 ED nurses must be prepared for the procedure as well as for the grim outcome that may result. REFERENCES 1. Read RA, Moore EE, Moore JB. Emergency department thoracotomy. In: Feliciano DV, Moore EE, Mattox KL, editors. Trauma. 3rd ed. Stamford (CT): Appleton & Lange; 1996. 2. Beall AC, Diethrich EB, Crawford H, Cooley DA, DeBakey ME. Surgical management of penetrating cardiac injuries. Am J Surg 1966;112:686-92. 3. Arsenio J, Berne J, Demtnades D, Chan L, Murray J, Tallabella A, et al. One hundred five penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma 1998;44:1073-82. 4. Branney S, Moore E. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma 1998;45:87-94. 5. Brown S, Gomez G, Jacobson L, Scherer T, McMillan R. Penetrating chest trauma: should indications for emergency room thoracotomy be limited? Am Surg 1996;62:530-4.
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6. Frezza E, Mezghebe JH. Is 30 minutes the gold period to perform emergency department thoracotomy (ERT) in penetrating chest injuries? J Cariovasc Surg 1999;40:147-51. 7. King B, Wagner D. Emergency thoracotomy. In: Henretig F, King C, editors. Textbook of pediatric emergency procedures. Baltimore: Williams and Wilkins; 1997. p. 415-27. 8. Nance M, Sing R, Reilly P, Templeton J, Schwab C. Thoracic gunshot wounds in children under 17 years of age. J Pediatr Surg 1996;31:931-5. 9. Mazzorana V, Smith R, Morabito D, Brar H. Limited utility of emergency department thoracotomy. Am Surg 1994;60:516-21. 10. Polhgeers A, Ruddy R. An update on pediatric trauma. Emerg Med Clin North Am 1995;13:267-89. 11. Rothenberg S, Moore E, Moore F, Baxter B, Moore J, Cleveland H. Emergency department thoracotomy in children–a critical analysis. J Trauma 1989;29:1322-5. 12. Sheikk A, Culbertson C. Emergency department thoracoto-
13. Velmahos G, Degiannas E, Souter I, Allwood A, Saadia R. Outcome of a strict policy on emergency department thoracotomies. Arch Surg 1995;130:774-7. 14. Powell R, Gill E, Jurkovich G, Ramenofsky M. Resuscitative thoracotomy in children and adolescents. Am Surg 1988;54(4): 188-91. 15. Sheikh A, Brogan T. Outcome and cost of open- and closedchest cardiopulmonary resuscitation in pediatric cardiac arrests. Pediatr 1994;93(3):392-8. 16. Beaver B, Colombani P, Buck J, Dudgeon D, Bohrer S, Haller J. Efficacy of emergency room thoracotomy in pediatric trauma. J Pediatr Surg 1987;229(1):19-23. 17. Moore J, Moore E, Harken A. Emergency department thoracotomy. In: Moore E, Mattox K, Feliciano D, editors. Trauma. 10th ed. Norwalk (CT): Appleton & Lange; 1991. p. 181-93. 18. Polhgeers A, Ruddy R. An update on pediatric trauma.
my in children: rationale for selective application. J Trauma 1993;34:323-8.
Emerg Med Clin North Am 1995;1392:267-89.
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mergency department thoracotomy (EDT) was considered as a resuscitation technique as early as 1874.1 However, it was not until 1966 that cardiothoracic surgical techniques had improved enough for EDT to be considered more feasible.2 EDT, especially in the pediatric population, is a rare but potentially lifesaving procedure. After assisting with 2 cases of pediatric EDT, a literature review was conducted to determine the indications, surgical techniques (internal cardiac massage and cross-clamping the aorta), emergency procedures, and nursing responsibilities associated with an EDT.
E
The small number of pediatric patients and their outcomes have made it difficult to develop definitive guidelines for the use of EDT in pediatric trauma patients.
doi:10.1067/mtn.2000.110826
patients. Table 1 lists some of the various recommendations found in the literature. An EDT is indicated for some patients in cardiac arrest associated with trauma. It is performed on patients in extremis4 (ie, a patient who has sustained cardiac arrest before or on arrival to the ED). EDT is most successful for patients who have “signs of life” (eg, a palpable pulse, blood pressure, spontaneous respirations, Glasgow Coma Scale score >3, pupillary responses, and cardiac activity on a cardiac monitor) before arriving at the hospital.9 Long-term survival tends to depend on the mechanism of injury, location of the major injury, and the presence of signs of life before arriving at the hospital.6 EDT is not indicated for trauma patients who do not have signs of life before reaching the hospital or who arrive in the ED 30 minutes or more after receiving treatment in the prehospital setting.6,7,9,11,12,15 Not all trauma patients are considered good candidates for EDT. Patients with stab wounds tend to fare better after EDT because the injuries are often low velocity in nature.5 Although some trauma centers only perform EDT on patients with penetrating trauma,3,6 other centers use EDT for blunt and penetrating trauma.
OCTOBER-DECEMBER 2000
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clemence 123
INDICATIONS FOR EMERGENCY DEPARTMENT THORACOTOMY EDT has been used to treat adults and children who have sustained a cardiac arrest after trauma, and it has been addressed extensively in the literature.3-15 This procedure is most frequently performed on adults, but in an emergency department (ED) setting it may also be required for children. Unfortunately, few reports have been published on the use of EDT in the pediatric trauma population.7,11,14,15 The small number of pediatric patients has made it difficult to develop definitive guidelines for the use of EDT in pediatric trauma
Bonnie Clemence, RN, MSN, is an accreditation coordinator at Pennsylvania Trauma Systems Foundation, Mechanicsburg, Pa. Reprint requests: Bonnie Clemence, RN, MSN, Pennsylvania Trauma Systems Foundation, 5070 Ritter Rd, Suite 100, Mechanicsburg, PA 17055-4879. Copyright © 2000 by the Emergency Nurses Association. 1075-4210/2000/$12.00 + 0 65/1/110826
Table 1. Example of conflicting recommendations from the literature for the use of EDT in pediatric trauma patients Resource Powell et al, 1988 (p. 191)
Recommendations • • •
Beaver et al, 1987 (p. 19, 21)
• • •
All penetrating thoracic trauma Blunt trauma victims with acute deterioration or signs of life in the ER (or OR) Blunt trauma victims with signs of life at the scene and a short transport time Penetrating chest injuries Acute deterioration in the admitting area (ED) and inability to safely transport to the OR Blunt injuries associated with detectable vital signs and deterioration despite maximal conventional therapy
Rothenberg et al, 1989 (p. 1324)
• •
Penetrating wound Blunt trauma with evidence of life on ED arrival
Polhgeers & Ruddy, 1995 (p. 280)
• •
Penetrating thoracic trauma with waning or loss of vital signs in the ED Penetrating thoracic trauma with vital signs at the scene but no vital signs on arrival in the ED (5-20 min of cardiopulmonary resuscitation in the field) Penetrating abdominal trauma with loss of vital signs in the ED (relative indication)
•
The outcomes tend to be worse for victims of blunt trauma.5,7,9,11,12,14 Children with blunt trauma generally do not survive even after undergoing an EDT.8,10-12 Because children with blunt-force trauma may have head and multiple organ injuries, their chances of survival may be small.7 Adults with blunt-force trauma also do not have high survival rates after EDT.
Three sizes of internal paddles should be available for pediatric patients: 6 cm for adolescents, 4 cm for children, and 2 cm for infants. TECHNIQUE FOR PERFORMING AN EDT Because EDT is performed on patients in extremis it must be performed quickly. All general and specific resuscitation equipment and knowledgeable staff should be immediately available. All personnel present in the room during the procedure should observe universal precautions to avoid accidental
exposure to bloodborne pathogens and to decrease the risk of contaminating an open surgical wound. The equipment that is used for an EDT is outlined in Table 2. If it is possible to prepare for the patient, the nursing staff should have the following equipment ready for use: endotracheal intubation equipment and supplies; suction equipment; intravenous (IV) catheters, tubing, crystalloid fluids primed through a fluid warmer for rapid administration; O Rh-negative blood; cardiopulmonary monitoring equipment; and both external and internal defibrillator paddles. Three sizes of internal paddles should be available for pediatric patients: 6 cm for adolescents, 4 cm for children, and 2 cm for infants. A sterile thoracotomy instrument tray should be placed on a Mayo stand to the left of the patient stretcher as well as skin preparation solutions (eg, providone-iodine solution), scalpel blades (eg, No. 11 or No. 15), suture material (2.0, 3.0, or 4.0 silk with curved and vascular needles), and felt pledgets. A sterile suction set-up and large, singleopening suction tip (eg, Yankeur) may be used to aspirate pooled blood for autotransfusion. The internal defibrillator paddles are usually kept separate and need to be handed onto the sterile field. The outer wrapping is removed and the sterile
124 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clemence
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Table 2. Equipment used in emergency department thoracotomy Equipment and supplies 1. Gowns and gloves (both sterile and nonsterile), eye shields, masks for all personnel in room 2. Resuscitation equipment a. Cardiac monitor and defibrillator with various sized internal defibrillator paddles b. Multiple suction set-ups 3. Skin preparation solutions, including sterile saline and antiseptic solutions 4. Sterile thoracotomy tray; may need to add instruments (eg, large vascular clamps) 5. Scalpel blades, suture, skin stapler, gauze sponges, chest tubes, rapid infuser and autotransfusion supplies a. Felt pledgets
paddles are handed onto the sterile field, still encased in the inner sterile wrapping. The end of the paddle cord must be handed off or picked up without contaminating the field, then attached to the defibrillator. The defibrillator is placed at the desired position (eg, at the head of the bed or on the left side of the stretcher). Although surgeons and nurses have different roles in an EDT, it is helpful to review the procedure to give all personnel an understanding of what is done. The surgical approach used for an EDT is different from a standard thoracotomy because the patient is supine. An incision is made in the left, fifth anterolateral intercostal space, allowing for quick access to the intrathoracic space. Chest-wall bleeding tends to be minimal in these patients. A standard or pediatric-sized rib spreader is used to expose the injured intrathoracic structures and to identify sites of hemorrhage. Depending on the pathology discovered, the phy-sician may elect to perform additional internal resuscitation efforts (eg, cardiac massage or defibrillation), divert cardiac output by cross-clamping the aorta, or treat life-threatening problems (eg, decompress cardiac tamponade; clamp, suture, or staple an avulsed or torn major vessel, organ, or airway structure).
Internal Cardiac Massage There are 3 methods for internal cardiac massage: (1) compressing the heart between the sternum and the hand, (2) compressing the heart with 2 hands, or (3) compressing the heart with 1 hand.7 The two-handed method is the least problematic of the OCTOBER-DECEMBER 2000
Rationale 1. Universal precautions against blood-borne pathogens; maintain sterility of open wound 2a. Pediatric patients will require smaller internal paddles than adults 2b. Will require individual set-ups for airway control and surgical field 3.
Provide for a more sterile surgical wound
4.
Not all thoracotomy trays are standard
5.
These items tend to be added to tray according to physician’s preference a. Used to hold suture in the friable myocardium
3 methods. The one-handed method may cause myocardial perforation from the compressor’s thumb, and the sternal method may be less effective in the young population because of sternal plasticity.7 When performing 2-handed compressions, 1 hand is placed beneath the heart and 1 is placed above it. The heart is compressed starting with the heels (apex) of the hands and progressing to the fingertips (base). The rate of compression is at least 100 beats/min, similar to closed-chest massage.7 Cardiac massage may be halted to perform internal defibrillation. If preferred, saline pads may be placed on the heart before discharging the internal paddles. The defibrillator will need to be charged and discharged by a person outside of the sterile field. Although there is no ideal defibrillator charge for children, a range of 5 to 20 J is suggested, and the maximum wattage rate for both pediatric and adult patients is 50 J. Most defibrillators will not discharge when the internal paddles are in use and the defibrillator is set higher than 50 J. The core body temperature can affect resuscitation efforts because a hypothermic heart may not respond to defibrillation attempts. An open chest can expose the heart and make it prone to hypothermia. The heart can be externally warmed with intermittent baths of warm saline solution or heat lamps directed toward the open chest.7
Cross-Clamping the Aorta If internal cardiac massage is not successful, the descending thoracic aorta can be partially occluded to increase blood flow to the heart. INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clemence 125
Large vascular clamps are applied without completely encircling the aorta. This technique allows a minimal blood flow through the aorta (approximately 10% of normal flow) and avoids injuries to the branches of the aorta. The amount of time the clamp is applied should be documented because blood flow needs to be restored distally within 30 minutes to avoid multiple physiologic consequences of ischemia, such as renal failure, paraplegia, or bowel infarct.
A nonsterile assistant is needed to hand supplies onto the sterile field and perform internal defibrillation. NURSING RESPONSIBILITIES IN EDT During an EDT, nurses assume multiple roles. It is especially helpful if a staff person can be a sterile assistant to hand instruments to the physician, help with procedures, or possibly perform internal cardiac massage. Perioperative nurses who respond to major trauma resuscitation can assist the physician, help facilitate the patient’s transfer to the operating room (OR), and allow the ED nurses to manage their multiple responsibilities. A nonsterile assistant is needed to hand supplies onto the sterile field and perform internal defibrillation. The patient’s care and status are documented frequently and include cardiac rhythm and rate (if electrical activity is present); adequacy of ventilation and tissue oxygenation; pupillary response; and any obtainable blood pressure. All IV fluids are administered through a fluid warmer; if a rapid infuser or autotransfusor are used, then the systems require constant attention to ensure proper functioning and accurate record-keeping of fluid volume intake and output. The patient’s core body temperature is monitored, and rewarming efforts are used to keep the patient normothermic. ED documentation includes the following: the time EDT was performed; the length of time the patient was in cardiopulmonary arrest; the length of time internal chest compression and ventilation were performed; the number of defibrillation attempts and the joules administered; cross-clamp time if the aorta was occluded; amount of blood and IV fluid administered; the dosages of medica-
tions administered; and the patient’s response to each intervention. If EDT is successful and cardiac activity is restored, the patient is transferred to the OR for definitive treatment. In preparation for transfer to the OR, the opened chest is covered with sterile towels to prevent additional contamination. The chest is not closed in the ED because definitive management will be needed. Because EDTs are performed infrequently, the ED trauma staff may want to reassess their response team. If perioperative nurses do not currently respond to the ED with trauma cases, a new policy may need to be instituted. Trauma thoracotomy trays can be preset with simple, basic instruments and plastic bags attached to the outside that contain suture and supplies for penetrating cardiac wounds. Right-atrial cannulation materials can be assembled and kept on hand. The team may want to examine whether the physical plan of the hospital allows for patients in extremis to be directly admitted to the OR, or whether a satellite OR can be created in the ED. CONCLUSION EDT can be described as a high-cost, high-risk, low-yield procedure that is done for a select group of patients. The optimal patients are those with a single penetrating injury to the left side of the chest who have or had vital signs and pupillary response within 5 minutes before the thoracotomy. Patients who have been in cardiopulmonary or traumatic arrest for more than 20 minutes have minimal chances for survival and the use of EDT will not affect their outcome.5,7,13 ED nurses must be prepared for the procedure as well as for the grim outcome that may result. REFERENCES 1. Read RA, Moore EE, Moore JB. Emergency department thoracotomy. In: Feliciano DV, Moore EE, Mattox KL, editors. Trauma. 3rd ed. Stamford (CT): Appleton & Lange; 1996. 2. Beall AC, Diethrich EB, Crawford H, Cooley DA, DeBakey ME. Surgical management of penetrating cardiac injuries. Am J Surg 1966;112:686-92. 3. Arsenio J, Berne J, Demtnades D, Chan L, Murray J, Tallabella A, et al. One hundred five penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma 1998;44:1073-82. 4. Branney S, Moore E. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma 1998;45:87-94. 5. Brown S, Gomez G, Jacobson L, Scherer T, McMillan R. Penetrating chest trauma: should indications for emergency room thoracotomy be limited? Am Surg 1996;62:530-4.
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6. Frezza E, Mezghebe JH. Is 30 minutes the gold period to perform emergency department thoracotomy (ERT) in penetrating chest injuries? J Cariovasc Surg 1999;40:147-51. 7. King B, Wagner D. Emergency thoracotomy. In: Henretig F, King C, editors. Textbook of pediatric emergency procedures. Baltimore: Williams and Wilkins; 1997. p. 415-27. 8. Nance M, Sing R, Reilly P, Templeton J, Schwab C. Thoracic gunshot wounds in children under 17 years of age. J Pediatr Surg 1996;31:931-5. 9. Mazzorana V, Smith R, Morabito D, Brar H. Limited utility of emergency department thoracotomy. Am Surg 1994;60:516-21. 10. Polhgeers A, Ruddy R. An update on pediatric trauma. Emerg Med Clin North Am 1995;13:267-89. 11. Rothenberg S, Moore E, Moore F, Baxter B, Moore J, Cleveland H. Emergency department thoracotomy in children–a critical analysis. J Trauma 1989;29:1322-5. 12. Sheikk A, Culbertson C. Emergency department thoracoto-
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