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Clamshell thoracotomy and open heart massage—A potential life-saving procedure can be taught to emergency physicians An educational cadaveric pilot study Paul Puchwein a,*, Florian Sommerauer a, Hans G. Clement b, Veronika Matzi b, Norbert P. Tesch c, Barbara Hallmann d, Tim Harris e, Marcel Rigaud d a
Medical University of Graz, Department for Traumatology, Auenbruggerplatz 5, 8036 Graz, Austria Unfallkrankenhaus Graz, Go¨stinger Straße 24 8020 Graz, Austria c Medical University of Graz, Institute of Anatomy, Harrachgasse 21, 8010 Graz, Austria d Medical University of Graz, Department for Anaesthesiology and Intensive Care, Auenbruggerplatz 29, 8036 Graz, Austria e Queen Mary University of London and Barts Health NHS Trust, Whitechapel, London, UK b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 May 2015
Aims: Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Prehospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. Methods: We adapted an existing system operating procedure requiring four instruments (Plaster-ofParis shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. Results: The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. Conclusion: Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Clamshell thoracotomy Resuscitative thoracotomy Emergency thoracotomy
Introduction Resuscitation from traumatic cardiac arrest requires a different approach to that used for medical cardiac arrest, with immediate care aimed at identifying and treating reversible causes such as blood loss, tension physiology and, airway obstruction [1–7]. Priorities are not closed chest compression and cardioversion but oxygenation, ventilation, volume replacement, relief of tension pneumothoraces and in selected cases, thoracotomy. This approach may be associated with increasing survival [8–10].
* Corresponding author. Tel.: +43 316 385 81971; fax: +43 316 385 13582. E-mail address: [email protected] (P. Puchwein).
Thoracotomy offers relief of pericardial tamponade, potential to temporize bleeding and internal cardiac massage [8–10]. In pre-hospital care systems that involve a doctor-paramedic team thoracotomy has successfully treated victims of traumatic cardiac arrest, with evidence of unexpected survivors [3,5,11,12]. Emergency department thoracotomy has a neurologically intact survival rate of 0–35% [3,5,13–19]. Favourable outcome is associated with cardiac arrest consequent upon pericardial tamponade, penetrating as opposed to blunt trauma, knife as opposed to gun as wounding mechanism, thoracic as opposed to extra thoracic injuries and shorter delays to treatment [3,5,13– 20]. Neurologically intact survival is unusual if the duration of cardiac arrest is greater than 15 min in penetrating and 10 min in blunt trauma [2,14,15]. This narrow time window sees
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Emergency and Pre-hospital Physicians (EP’s) performing thoracotomy when timely transfer to hospital and operating theatre is not feasible. However since EP’s may not have a surgical training background and the number of procedures performed per team is low, so training and skill retention are challenging. There are several techniques described to perform a thoracotomy but the clamshell technique provides excellent exposure and is both rapid and simple to perform [21,22]. This allows the procedure to be performed with the use of only four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps and a scalpel). In this pilot study we set out to introduce a standard operating procedure and teaching package for clamshell thoracotomy, as described in methods section. We aimed to assess the time taken to for non-surgical trainees and students to perform the procedure and assess the a priori defined complication rate. We benchmarked their performance against experienced surgeons.
Materials and methods Participants We recruited a convenience sample of students and doctors based in our institution who work in the pre-hospital arena. Four groups were identified; groups one to three had no surgical experience. Group 1: Three specialist anaesthetist doctors, all experienced in pre-hospital Emergency Medicine, performing a minimum of two shifts each month for at least 5 years. Group 2: Three Internal Medicine doctors with experience in pre-hospital Emergency Medicine as above. Group 3: Five medical students in Emergency Medicine temporarily working as paramedics. Group 4: Comparison group consisting three surgically trained doctors; one specialist in cardiothoracic (consultant, experience of more than 10 years) and two in trauma surgery (resident, 3 years experience; consultant with more than 15 years experience). Informed consent was sort from all participants. The study was approved by the local ethical committee (26-252ex13/14). Cadavers We used 29 cadavers provided by the Anatomical Institute of the Medical University of Graz and preserved according to the embalming method of Thiel [23]. The study involved 28 cadavers for participant practice, and one for the initial demonstration. Study equipment Adapted from Wise et al. [21], we used three types of instrument: two types of scissors (dressing scissors and Plasterof-Paris shears), dissecting forceps and a scalpel with number 10 blade. Teaching material All participants completed a 20-min e-learning lecture, provided 1 week before the study day. This e-learning lecture included a step-by step instruction of how to perform the clamshell procedure (see below ‘Surgical procedure’) and some schematic drawings of the procedure. The study day involved a 5min cadaveric demonstration of the clamshell thoracotomy (Fig. 1), followed by each participant performing the procedure under supervision twice in 1 h. All participants were aware of the study endpoints.
Fig. 1. Timeline for teaching clamshell thoracotomy.
Surgical procedure (clamshell thoracotomy) We developed a standard operating procedure (SOP) for a clamshell thoracotomy after Wise et al. [21]. Following skin preparation bilateral thoracostomies (without chest tube insertion) are functioned in the fifth intercostal spaces in the mid-axillary line, so decompressing any tension pneumothoraces. If this manoeuvre does not result in return of spontaneous circulation the two incisions are connected by a scalpel incision running along the intercostal space and over the sternum. The scalpel dissects skin and subcutaneous fascia down to intercostal muscle. Intercostal muscle is then separated using the bandage scissors and blunt finger dissection. The Plaster-ofParis shears are used to cut through the sternum, so joining the left and right thoracic incisions. The chest is then opened. Inadequate chest wall opening may be facilitated by extending the incisions posteriorly. The non-toothed forceps are used to elevate the pericardium centrally and this is then carefully opened with the dressing scissors. Then the incision is extended cranially and caudally, and the heart delivered through the breach in the pericardium and cradled in both hands. Measurements The participants were assessed by time, anatomical accuracy of the procedure and a priori defined complications. Firstly, three different times were recorded: Time 1: From first skin incision to the transection of the sternum. Time 2: Duration of the sternotomy. Time 3: From sternal transection to cardiac massage (pericardiotomy completed and both hands applied on the heart). Total time was calculated by summation of times 1, 2 and 3. Secondly, the ability of the participants to identify the correct intercostal spaces (fifth space left and right), and the correct position of the descending aorta were recorded. Latter was marked with a needle. Finally after every thoracotomy the cadavers were examined by the thoracic surgeon or the main investigator to identify a priori defined injuries, which included: lung laceration during transection of the intercostal spaces; injuries to phrenic nerves, great vessels or the heart including coronary arteries during pericardiotomy. Direct feedback and learning points were discussed with participants. Injuries to participants were also recorded. Statistical analysis All measurements were exported into Microsoft Excel sheets (Microsoft Excel 2010; Microsoft, Redmond, WA, USA) for descriptive statistical analysis. Data was exported into SPSS Statistics (IBM Corp. Released 2012. IBM SPSS Statistics for
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Windows, Version 21.0. Armonk, NY). Differences between the groups were analysed using a non-parametric test (Kruskal– Wallis-Test), differences between first and second attempt between the groups were analysed using the Wilcoxon Signed Rank Sum Test and the McNemar’s test (complication rate). p < 0.05 was considered statistically significant. Results Measurements The mean total time for the clamshell procedure from skin incision until both hands were applied on the heart was 167 s (s) (SD 86, range 80–396). Mean times for the procedure ranged from 129 s (SD 42; range 81–203) (group 2) to 203 s (SD 134; range 80– 390) (group 1). There was no difference between the four study groups, even when the pair of observations from each participant was treated as independent observations (p = 0.27) (Table 1). The second attempt was a mean of 24 s quicker than the first, but this was not statistically significant (p = 0.33, Wilcoxon test, exact sig.). The most time consuming part of the procedure was from skin incision to sternotomy (mean 95 s; SD 56; range 32–250). The
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sternotomy required a mean of 27 s (SD 15; range 8–81) and the time from sternotomy to delivering the heart was averagely 45 s (SD 29; range 9–126) (Table 2). The 28 cadavers used in the study involved 56 anterolateral hemi-thoracotomies, of which 25 (45%) were placed in the fifth intercostal space. In 24/28 cadavers (86%) the anterolateral hemithoracotomies were on the same level each side. In 27/28 the descending aorta was correctly identified. Five a priori defined complications (out of 14 thoracotomies, 36%) were identified in the initial thoracotomy (Table 2). These included two cadavers in which right ventricular and one cadaver with biventricular lacerations were identified. In the latter case the cadaver was noted to display massive mediastinal and pericardial adhesions of unknown origin. In the repeat thoracotomy group there were no a priori defined complications but one case of right diaphragmatic injury was identified (1/14, 7%, p = 0.22, McNemar’s test). In one cadaver with massive mediastinal and pericardial adhesions the detection of the phrenic nerves and of the aorta was not possible. There were two participant injuries; one superficial laceration by scalpel blade and one laceration by a spicule of sternal bone. One scalpel blade broke during use but with no resulting injury.
Table 1 Time to perform clamshell thoracotomy. Time (s)
Mean total time
SD
MIN
MAX
Complications
Time lag 1st/2nd improvement in %
Group 1 (n = 6) anaesthetists = 3 Group 2 (n = 6) internal specialists = 3 Group 3 (n = 10) students = 5 Group 4 (n = 6) surgeons = 3
203
134
80
390
1
129
42
81
203
2
185
84
120
396
2
140
54
90
240
1
0:30 42% 0:22 13% 0:02 0% 0:56 51%
Table 2 Detailed times for all participants to perform clamshell thoracotomy. Participant
Time 1 (s)
Time 2 (s)
Time 3 (s)
Total (s)
ICS left (right)
Complication injuries
A1a A1b A2a A2b A3a A3b I1a I1b I2a I2b I3a I3b S1a S1b S2a S2b S3a S3b S4a S4b S5a S5b C1a C1b C2a C2b C3a C3b
250 240 50 41 99 85 83 32 68 65 43 61 115 95 230 100 81 101 87 123 68 75 80 45 115 55 89 92
81 45 19 13 31 22 51 15 14 35 35 24 14 15 40 25 13 28 13 33 8 19 10 32 35 25 21 25
59 67 27 26 26 37 69 34 48 32 19 43 9 55 126 95 26 19 27 85 74 53 20 13 90 30 44 19
390 352 96 80 156 144 203 81 130 132 97 128 138 165 396 220 120 148 127 241 150 147 110 90 240 110 154 136
6 5 5 5 5 5 6 5 6 6 5 6 6 4 5 5 4 6 4 6 4 5 5 4 4 5 6 6
Finger injured with scalpel
(6) (5) (5) (5) (5) (5) (5) (5) (6) (5) (5) (6) (6) (6) (5) (5) (4) (6) (4) (6) (4) (5) (5) (4) (4) (6) (6) (6)
Perforation right ventricle Finger injured by sharp edge of sternum
Superficial laceration of the myocard Left phrenic nerve transected
Perforation right ventricle injury of right diaphragm
Left and right ventricle perorated, steel cerclage after CABG, adhesions
Breakage of scalpel blade
A, anaesthetist; I, internal medicine specialist; S, students; C, surgeon. a, first attempt; b, second attempt. ICS, intercostal space.
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Discussion This pilot study aimed to inform on the teaching of nonsurgeons to perform clamshell thoracotomy. We have demonstrated a clamshell thoracotomy can be performed on cadavers with no significant differences in time and complication rates by anaesthetists, physicians and students, all with no specialist surgical training. Secondly we have identified that experienced surgeons (group 4) were not significantly quicker nor had significantly fewer complications, as compared to the nonsurgeons (groups 1, 2, 3). We found that the second attempt at thoracotomy was associated with fewer complications and decreased procedural time. These findings do not reach statistical significance. This may be consequent upon our small numbers of participants and type II error or a true finding and larger studies are required to define this. However the fact that the second procedure was both safer and faster would suggest that there is a learning curve for this procedure. There can be no conclusions as to how these data will translate to patients. London’s Air Ambulance has published data on 71 pre-hospital thoracotomies using a clamshell technique similar to that described in this study and report a survival of 13 [3]. This service is staffed predominantly by emergency physicians, anaesthetist and intensivists. Training on how to perform a clamshell thoracotomy involves a video and talk though with no cadaver practice. The success rate reported reinforces our findings that clamshell thoracotomy may be taught to and practiced by doctors with minimal surgical training. The London group has not reported on its complication rate. How much the success and complication rate could be improved but further practice remains unknown. Clamshell thoracotomy performed for traumatic cardiac arrest is a time dependent procedure. We report a mean procedural time of 167 s. Previous studies have suggested that for neurologically intact outcome resuscitation should be attempted within 10 min (blunt trauma) or 10–15 min (penetrating trauma) [2,5,8– 10,14,17,19]. Clamshell thoracotomy can potentially be performed by non-surgeons sufficiently rapidly to offer a significant probability of neurologically intact survival. Suliburk summarised the complications of thoracotomies [24]. We observed 3 cases with ventricular lacerations, all of which occurred during incision of the pericardium. Therefore caution is advised when opening the pericardial sac, especially in the absence of a hemopericardium. We suggest using non-toothed forceps for lifting the pericardium anteriorly proud of the right ventricle and only then cautiously incising the pericardium with small dressing scissors (not a scalpel). Our study identified only one case of phrenic nerve injury. This can be minimised by insuring the pericardium is opened in the midline. Laceration of the internal mammary arteries is a necessary part of the clamshell procedure. In this study we were able to identify the left and right mammary in all cases on both sides (56/56). These will require ligation or clamping if resuscitation attempts are successful. Finally we report two cases of participants’ injuries. In one case the injury was a laceration by a bone spicule from the sternum and in the second a laceration consequent upon a broken scalpel handle. These two injuries point out the increased occupational exposure. Our study adapted a technique described by Wise et al. for use in the pre-hospital environment [21]. These authors recommend a Gigli saw to perform sternotomy if the scissors fail to fashion the sternotomy. We use two sets of scissors, one heavy (Plaster-of-Paris) and one light duty, but no Gigli saw in our SOP. We identified no cases of equipment failure
suggesting a Gigli saw may not be required. Injuries of the interventionists could be minimised by repetitive cadaver trainings but there will be a remaining risk that has to be considered individually. There is scant data to define the role for pre-hospital thoracotomy with most publications based on Emergency Department experience. However unexpected survivors from traumatic cardiac arrest are clearly described with good neurological outcomes in both adult and paediatric practice [3,5,11,25–29]. Indeed in patients with penetrating cardiac wounds survival is now around 7.5–30%, higher than medical cardiac arrest overall and similar to witnessed VT/VF with immediate bystander CPR [3,5,7–10,30]. The role of non-surgeons performed pre-hospital thoracotomy is recognised [3,5,7–11] for a small group of patients in whom there is insufficient time for scene to hospital transfer. Limitations of the study This is a pilot study and involved small numbers of participants. As such it is underpowered to definitively answer questions as to the comparative abilities of differing medical practitioners with differing skill bases. This is compounded by the use of cadavers. Our results are not translatable into the clinical environment. In a cadaver study we are clearly not able to teach or assess haemorrhage control. This may be achieved by direct pressure, balloon insertion or most frequently by sutures [21]. Equally as the procedure is performed in cardiac arrest blood flow is unlikely an issue until return of spontaneous circulation we were also unable to assess open cardiac massage quality. We also recruited participants from a single centre and asked for study volunteers. This may not be a representative sample and or data should not be extrapolated to other medical systems with differing training. Further educational studies with the same setting but more participants randomly chosen from our prehospital emergency service are mandatory to verify the results of this pilot study. Furthermore we could monitor if the complication rate will stay low when the same participants repeat this procedure after 12 months.
Conclusion In this small pilot study we have demonstrated that in a cadaver model non-surgical trainees can perform a clamshell thoracotomy in a mean of 167 s, a similar time and with similar complication rates to experienced surgeons. Further studies are required to assist the interpretation of their significance of this study’s findings. Reviewing recent literature on-scene thoracotomy after cardiac arrest should be considered in penetrating thoracic and epigastric injuries when the delay does not exceed 10–15 min. Using this procedure in blunt trauma, elderly patients and patients with unfavourable accompanying injuries (TBI, e.g.) has to be scrutinised critically.
Conflict of interest Nothing to disclose by any author. Acknowledgement No external funding was received for this study.
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[14] Moore EE, Knudson MM, Burlew CC, Inaba K, Dicker RA, Biffl WL, et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma 2011 Feb;70(2):334– 9. http://dx.doi.org/10.1097/TA.0b013e3182077C35. [15] Hofbauer M, Hu¨pfl M, Figl M, Ho¨chtl-Lee L, Kdolsky R. Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients. Resuscitation 2011 Feb;82(2):185–9. http://dx.doi.org/10.1016/j.resuscitation.2010.09. 475 [Epub 2010 Nov 20]. [16] Lustenberger T, Labler L, Stover JF, Keel MJ. Resuscitative emergency thoracotomy in a Swiss trauma centre. Br J Surg 2012 Apr;99(4):541–8. http:// dx.doi.org/10.1002/bjs.7706 [Epub 2011 Dec 2]. [17] Khorsandi M, Skouras C, Shah R. Is there any role for resuscitative emergency department thoracotomy in blunt trauma? Interact Cardiovasc Thorac Surg 2013 Apr;16(4):509–16. http://dx.doi.org/10.1093/icvts/ ivs540 [Epub 2012 Dec 28]. [18] Seamon MJ, Chovanes J, Fox N, Green R, Manis G, Tsiotsias G, et al. The use of emergency department thoracotomy for traumatic cardiopulmonary arrest. Injury 2012 Sep;43(9):1355–61. http://dx.doi.org/10.1016/j.injury.2012.04.011 [Epub 2012 May 3]. [19] Capote A, Michael A, Almodovar J, Chan P, Skinner R, Martin M. Emergency department thoracotomy: too little, too much, or too late. Am Surg 2013 Oct;79(10):982–6. [20] Slessor D, Hunter S. To be blunt: are we wasting our time? emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med 2014 Oct 23. http://dx.doi.org/10.1016/j.annemergmed.2014.08.020 [pii: S0196-0644(14)01215-3]. [21] Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A. Emergency thoracotomy: ‘‘how to do it’’. Emerg Med J 2005 Jan;22(1):22–4. [22] Simms ER, Flairs AN, Franchino X, Thomas MS, Caillot JL, Voiglio EJ. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study. World J Surg 2013;37(6):1277–85. http:// dx.doi.org/10.1007/s00268-013-1961-5. [23] Thiel W. The preservation of the whole corpse with natural color. Ann Anat 1992 Jun;174(3):185–95 [German]. [24] Suliburk JW. Complications of emergency center thoracotomy. Tex Heart Inst J 2012;39(6):876–7. [25] Tan BK, Pothiawala S, Ong ME. Emergency thoracotomy: a review of its role in severe chest trauma. Minerva Chir 2013 Jun;68(3):241–50. [26] Sersar SI, Alanwar MA. Emergency thoracotomies: two center study. J Emerg Trauma Shock 2013 Jan;6(1):11–5. http://dx.doi.org/10.4103/09742700.106319. [27] Van Waes OJ, Van Riet PA, Van Lieshout EM, Hartog DD. Immediate thoracotomy for penetrating injuries: ten years’ experience at a Dutch level I trauma center. Eur J Trauma Emerg Surg 2012 Oct;38(5):543–51 [Epub 2012 Jun 16]. [28] Johannesdottir BK, Mogensen B, Gudbjartsson T. Emergency thoracotomy as a rescue treatment for trauma patients in Iceland. Injury 2013 Sep;44(9):1186–90. http://dx.doi.org/10.1016/j.injury.2012.05.005 [Epub 2012 May 24]. [29] Easter JS, Vinton DT, Haukoos JS. Emergent pediatric thoracotomy following traumatic arrest. Resuscitation 2012 Dec;83(12):1521–4. http://dx.doi.org/ 10.1016/j.resuscitation.2012.05.024 [Epub 2012 Jun 13]. [30] Keller D, Kulp H, Maher Z, Santora TA, Goldberg AJ, Seamon MJ. Life after near death: long-term outcomes of emergency department thoracotomy survivors. J Trauma Acute Care Surg 2013 May;74(5):1315–20. http://dx.doi.org/ 10.1097/TA.0b013e318283db4.
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Clamshell thoracotomy and open heart massage—A potential life-saving procedure can be taught to emergency physicians An educational cadaveric pilot study Paul Puchwein a,*, Florian Sommerauer a, Hans G. Clement b, Veronika Matzi b, Norbert P. Tesch c, Barbara Hallmann d, Tim Harris e, Marcel Rigaud d a
Medical University of Graz, Department for Traumatology, Auenbruggerplatz 5, 8036 Graz, Austria Unfallkrankenhaus Graz, Go¨stinger Straße 24 8020 Graz, Austria c Medical University of Graz, Institute of Anatomy, Harrachgasse 21, 8010 Graz, Austria d Medical University of Graz, Department for Anaesthesiology and Intensive Care, Auenbruggerplatz 29, 8036 Graz, Austria e Queen Mary University of London and Barts Health NHS Trust, Whitechapel, London, UK b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 May 2015
Aims: Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Prehospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. Methods: We adapted an existing system operating procedure requiring four instruments (Plaster-ofParis shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. Results: The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. Conclusion: Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Clamshell thoracotomy Resuscitative thoracotomy Emergency thoracotomy
Introduction Resuscitation from traumatic cardiac arrest requires a different approach to that used for medical cardiac arrest, with immediate care aimed at identifying and treating reversible causes such as blood loss, tension physiology and, airway obstruction [1–7]. Priorities are not closed chest compression and cardioversion but oxygenation, ventilation, volume replacement, relief of tension pneumothoraces and in selected cases, thoracotomy. This approach may be associated with increasing survival [8–10].
* Corresponding author. Tel.: +43 316 385 81971; fax: +43 316 385 13582. E-mail address: [email protected] (P. Puchwein).
Thoracotomy offers relief of pericardial tamponade, potential to temporize bleeding and internal cardiac massage [8–10]. In pre-hospital care systems that involve a doctor-paramedic team thoracotomy has successfully treated victims of traumatic cardiac arrest, with evidence of unexpected survivors [3,5,11,12]. Emergency department thoracotomy has a neurologically intact survival rate of 0–35% [3,5,13–19]. Favourable outcome is associated with cardiac arrest consequent upon pericardial tamponade, penetrating as opposed to blunt trauma, knife as opposed to gun as wounding mechanism, thoracic as opposed to extra thoracic injuries and shorter delays to treatment [3,5,13– 20]. Neurologically intact survival is unusual if the duration of cardiac arrest is greater than 15 min in penetrating and 10 min in blunt trauma [2,14,15]. This narrow time window sees
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Please cite this article in press as: Puchwein P, et al. Clamshell thoracotomy and open heart massage—A potential life-saving procedure can be taught to emergency physicians. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.045
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Emergency and Pre-hospital Physicians (EP’s) performing thoracotomy when timely transfer to hospital and operating theatre is not feasible. However since EP’s may not have a surgical training background and the number of procedures performed per team is low, so training and skill retention are challenging. There are several techniques described to perform a thoracotomy but the clamshell technique provides excellent exposure and is both rapid and simple to perform [21,22]. This allows the procedure to be performed with the use of only four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps and a scalpel). In this pilot study we set out to introduce a standard operating procedure and teaching package for clamshell thoracotomy, as described in methods section. We aimed to assess the time taken to for non-surgical trainees and students to perform the procedure and assess the a priori defined complication rate. We benchmarked their performance against experienced surgeons.
Materials and methods Participants We recruited a convenience sample of students and doctors based in our institution who work in the pre-hospital arena. Four groups were identified; groups one to three had no surgical experience. Group 1: Three specialist anaesthetist doctors, all experienced in pre-hospital Emergency Medicine, performing a minimum of two shifts each month for at least 5 years. Group 2: Three Internal Medicine doctors with experience in pre-hospital Emergency Medicine as above. Group 3: Five medical students in Emergency Medicine temporarily working as paramedics. Group 4: Comparison group consisting three surgically trained doctors; one specialist in cardiothoracic (consultant, experience of more than 10 years) and two in trauma surgery (resident, 3 years experience; consultant with more than 15 years experience). Informed consent was sort from all participants. The study was approved by the local ethical committee (26-252ex13/14). Cadavers We used 29 cadavers provided by the Anatomical Institute of the Medical University of Graz and preserved according to the embalming method of Thiel [23]. The study involved 28 cadavers for participant practice, and one for the initial demonstration. Study equipment Adapted from Wise et al. [21], we used three types of instrument: two types of scissors (dressing scissors and Plasterof-Paris shears), dissecting forceps and a scalpel with number 10 blade. Teaching material All participants completed a 20-min e-learning lecture, provided 1 week before the study day. This e-learning lecture included a step-by step instruction of how to perform the clamshell procedure (see below ‘Surgical procedure’) and some schematic drawings of the procedure. The study day involved a 5min cadaveric demonstration of the clamshell thoracotomy (Fig. 1), followed by each participant performing the procedure under supervision twice in 1 h. All participants were aware of the study endpoints.
Fig. 1. Timeline for teaching clamshell thoracotomy.
Surgical procedure (clamshell thoracotomy) We developed a standard operating procedure (SOP) for a clamshell thoracotomy after Wise et al. [21]. Following skin preparation bilateral thoracostomies (without chest tube insertion) are functioned in the fifth intercostal spaces in the mid-axillary line, so decompressing any tension pneumothoraces. If this manoeuvre does not result in return of spontaneous circulation the two incisions are connected by a scalpel incision running along the intercostal space and over the sternum. The scalpel dissects skin and subcutaneous fascia down to intercostal muscle. Intercostal muscle is then separated using the bandage scissors and blunt finger dissection. The Plaster-ofParis shears are used to cut through the sternum, so joining the left and right thoracic incisions. The chest is then opened. Inadequate chest wall opening may be facilitated by extending the incisions posteriorly. The non-toothed forceps are used to elevate the pericardium centrally and this is then carefully opened with the dressing scissors. Then the incision is extended cranially and caudally, and the heart delivered through the breach in the pericardium and cradled in both hands. Measurements The participants were assessed by time, anatomical accuracy of the procedure and a priori defined complications. Firstly, three different times were recorded: Time 1: From first skin incision to the transection of the sternum. Time 2: Duration of the sternotomy. Time 3: From sternal transection to cardiac massage (pericardiotomy completed and both hands applied on the heart). Total time was calculated by summation of times 1, 2 and 3. Secondly, the ability of the participants to identify the correct intercostal spaces (fifth space left and right), and the correct position of the descending aorta were recorded. Latter was marked with a needle. Finally after every thoracotomy the cadavers were examined by the thoracic surgeon or the main investigator to identify a priori defined injuries, which included: lung laceration during transection of the intercostal spaces; injuries to phrenic nerves, great vessels or the heart including coronary arteries during pericardiotomy. Direct feedback and learning points were discussed with participants. Injuries to participants were also recorded. Statistical analysis All measurements were exported into Microsoft Excel sheets (Microsoft Excel 2010; Microsoft, Redmond, WA, USA) for descriptive statistical analysis. Data was exported into SPSS Statistics (IBM Corp. Released 2012. IBM SPSS Statistics for
Please cite this article in press as: Puchwein P, et al. Clamshell thoracotomy and open heart massage—A potential life-saving procedure can be taught to emergency physicians. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.045
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Windows, Version 21.0. Armonk, NY). Differences between the groups were analysed using a non-parametric test (Kruskal– Wallis-Test), differences between first and second attempt between the groups were analysed using the Wilcoxon Signed Rank Sum Test and the McNemar’s test (complication rate). p < 0.05 was considered statistically significant. Results Measurements The mean total time for the clamshell procedure from skin incision until both hands were applied on the heart was 167 s (s) (SD 86, range 80–396). Mean times for the procedure ranged from 129 s (SD 42; range 81–203) (group 2) to 203 s (SD 134; range 80– 390) (group 1). There was no difference between the four study groups, even when the pair of observations from each participant was treated as independent observations (p = 0.27) (Table 1). The second attempt was a mean of 24 s quicker than the first, but this was not statistically significant (p = 0.33, Wilcoxon test, exact sig.). The most time consuming part of the procedure was from skin incision to sternotomy (mean 95 s; SD 56; range 32–250). The
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sternotomy required a mean of 27 s (SD 15; range 8–81) and the time from sternotomy to delivering the heart was averagely 45 s (SD 29; range 9–126) (Table 2). The 28 cadavers used in the study involved 56 anterolateral hemi-thoracotomies, of which 25 (45%) were placed in the fifth intercostal space. In 24/28 cadavers (86%) the anterolateral hemithoracotomies were on the same level each side. In 27/28 the descending aorta was correctly identified. Five a priori defined complications (out of 14 thoracotomies, 36%) were identified in the initial thoracotomy (Table 2). These included two cadavers in which right ventricular and one cadaver with biventricular lacerations were identified. In the latter case the cadaver was noted to display massive mediastinal and pericardial adhesions of unknown origin. In the repeat thoracotomy group there were no a priori defined complications but one case of right diaphragmatic injury was identified (1/14, 7%, p = 0.22, McNemar’s test). In one cadaver with massive mediastinal and pericardial adhesions the detection of the phrenic nerves and of the aorta was not possible. There were two participant injuries; one superficial laceration by scalpel blade and one laceration by a spicule of sternal bone. One scalpel blade broke during use but with no resulting injury.
Table 1 Time to perform clamshell thoracotomy. Time (s)
Mean total time
SD
MIN
MAX
Complications
Time lag 1st/2nd improvement in %
Group 1 (n = 6) anaesthetists = 3 Group 2 (n = 6) internal specialists = 3 Group 3 (n = 10) students = 5 Group 4 (n = 6) surgeons = 3
203
134
80
390
1
129
42
81
203
2
185
84
120
396
2
140
54
90
240
1
0:30 42% 0:22 13% 0:02 0% 0:56 51%
Table 2 Detailed times for all participants to perform clamshell thoracotomy. Participant
Time 1 (s)
Time 2 (s)
Time 3 (s)
Total (s)
ICS left (right)
Complication injuries
A1a A1b A2a A2b A3a A3b I1a I1b I2a I2b I3a I3b S1a S1b S2a S2b S3a S3b S4a S4b S5a S5b C1a C1b C2a C2b C3a C3b
250 240 50 41 99 85 83 32 68 65 43 61 115 95 230 100 81 101 87 123 68 75 80 45 115 55 89 92
81 45 19 13 31 22 51 15 14 35 35 24 14 15 40 25 13 28 13 33 8 19 10 32 35 25 21 25
59 67 27 26 26 37 69 34 48 32 19 43 9 55 126 95 26 19 27 85 74 53 20 13 90 30 44 19
390 352 96 80 156 144 203 81 130 132 97 128 138 165 396 220 120 148 127 241 150 147 110 90 240 110 154 136
6 5 5 5 5 5 6 5 6 6 5 6 6 4 5 5 4 6 4 6 4 5 5 4 4 5 6 6
Finger injured with scalpel
(6) (5) (5) (5) (5) (5) (5) (5) (6) (5) (5) (6) (6) (6) (5) (5) (4) (6) (4) (6) (4) (5) (5) (4) (4) (6) (6) (6)
Perforation right ventricle Finger injured by sharp edge of sternum
Superficial laceration of the myocard Left phrenic nerve transected
Perforation right ventricle injury of right diaphragm
Left and right ventricle perorated, steel cerclage after CABG, adhesions
Breakage of scalpel blade
A, anaesthetist; I, internal medicine specialist; S, students; C, surgeon. a, first attempt; b, second attempt. ICS, intercostal space.
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Discussion This pilot study aimed to inform on the teaching of nonsurgeons to perform clamshell thoracotomy. We have demonstrated a clamshell thoracotomy can be performed on cadavers with no significant differences in time and complication rates by anaesthetists, physicians and students, all with no specialist surgical training. Secondly we have identified that experienced surgeons (group 4) were not significantly quicker nor had significantly fewer complications, as compared to the nonsurgeons (groups 1, 2, 3). We found that the second attempt at thoracotomy was associated with fewer complications and decreased procedural time. These findings do not reach statistical significance. This may be consequent upon our small numbers of participants and type II error or a true finding and larger studies are required to define this. However the fact that the second procedure was both safer and faster would suggest that there is a learning curve for this procedure. There can be no conclusions as to how these data will translate to patients. London’s Air Ambulance has published data on 71 pre-hospital thoracotomies using a clamshell technique similar to that described in this study and report a survival of 13 [3]. This service is staffed predominantly by emergency physicians, anaesthetist and intensivists. Training on how to perform a clamshell thoracotomy involves a video and talk though with no cadaver practice. The success rate reported reinforces our findings that clamshell thoracotomy may be taught to and practiced by doctors with minimal surgical training. The London group has not reported on its complication rate. How much the success and complication rate could be improved but further practice remains unknown. Clamshell thoracotomy performed for traumatic cardiac arrest is a time dependent procedure. We report a mean procedural time of 167 s. Previous studies have suggested that for neurologically intact outcome resuscitation should be attempted within 10 min (blunt trauma) or 10–15 min (penetrating trauma) [2,5,8– 10,14,17,19]. Clamshell thoracotomy can potentially be performed by non-surgeons sufficiently rapidly to offer a significant probability of neurologically intact survival. Suliburk summarised the complications of thoracotomies [24]. We observed 3 cases with ventricular lacerations, all of which occurred during incision of the pericardium. Therefore caution is advised when opening the pericardial sac, especially in the absence of a hemopericardium. We suggest using non-toothed forceps for lifting the pericardium anteriorly proud of the right ventricle and only then cautiously incising the pericardium with small dressing scissors (not a scalpel). Our study identified only one case of phrenic nerve injury. This can be minimised by insuring the pericardium is opened in the midline. Laceration of the internal mammary arteries is a necessary part of the clamshell procedure. In this study we were able to identify the left and right mammary in all cases on both sides (56/56). These will require ligation or clamping if resuscitation attempts are successful. Finally we report two cases of participants’ injuries. In one case the injury was a laceration by a bone spicule from the sternum and in the second a laceration consequent upon a broken scalpel handle. These two injuries point out the increased occupational exposure. Our study adapted a technique described by Wise et al. for use in the pre-hospital environment [21]. These authors recommend a Gigli saw to perform sternotomy if the scissors fail to fashion the sternotomy. We use two sets of scissors, one heavy (Plaster-of-Paris) and one light duty, but no Gigli saw in our SOP. We identified no cases of equipment failure
suggesting a Gigli saw may not be required. Injuries of the interventionists could be minimised by repetitive cadaver trainings but there will be a remaining risk that has to be considered individually. There is scant data to define the role for pre-hospital thoracotomy with most publications based on Emergency Department experience. However unexpected survivors from traumatic cardiac arrest are clearly described with good neurological outcomes in both adult and paediatric practice [3,5,11,25–29]. Indeed in patients with penetrating cardiac wounds survival is now around 7.5–30%, higher than medical cardiac arrest overall and similar to witnessed VT/VF with immediate bystander CPR [3,5,7–10,30]. The role of non-surgeons performed pre-hospital thoracotomy is recognised [3,5,7–11] for a small group of patients in whom there is insufficient time for scene to hospital transfer. Limitations of the study This is a pilot study and involved small numbers of participants. As such it is underpowered to definitively answer questions as to the comparative abilities of differing medical practitioners with differing skill bases. This is compounded by the use of cadavers. Our results are not translatable into the clinical environment. In a cadaver study we are clearly not able to teach or assess haemorrhage control. This may be achieved by direct pressure, balloon insertion or most frequently by sutures [21]. Equally as the procedure is performed in cardiac arrest blood flow is unlikely an issue until return of spontaneous circulation we were also unable to assess open cardiac massage quality. We also recruited participants from a single centre and asked for study volunteers. This may not be a representative sample and or data should not be extrapolated to other medical systems with differing training. Further educational studies with the same setting but more participants randomly chosen from our prehospital emergency service are mandatory to verify the results of this pilot study. Furthermore we could monitor if the complication rate will stay low when the same participants repeat this procedure after 12 months.
Conclusion In this small pilot study we have demonstrated that in a cadaver model non-surgical trainees can perform a clamshell thoracotomy in a mean of 167 s, a similar time and with similar complication rates to experienced surgeons. Further studies are required to assist the interpretation of their significance of this study’s findings. Reviewing recent literature on-scene thoracotomy after cardiac arrest should be considered in penetrating thoracic and epigastric injuries when the delay does not exceed 10–15 min. Using this procedure in blunt trauma, elderly patients and patients with unfavourable accompanying injuries (TBI, e.g.) has to be scrutinised critically.
Conflict of interest Nothing to disclose by any author. Acknowledgement No external funding was received for this study.
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