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Wed May 2 09:50:33 BST 2007

ER left thoracotomy and nothing else

PH Navsaria

caesar ursic wrote:

> True story:
>
> 16 yo previously healthy male stabbed once in anterior chest.  Confused and
> combative at scene.  Minimal external blood loss noted.  Paramedics scoop
> and run - one antecubital IV, minimal fluid given en route (less than 20
> mL), no attempt at intubation.  Eight minute interval from first patient
> contact at scene to arrival in ED.
>
> On arrival to ED he's even more combative; very diaphoretic, ashen-colored
> lips, cool periphery; carotid pulses not palpable (but he's thrashing about
> too much to really tell).  Only obvious external injury is a 3-4 cm stab
> wound just to the left of the xyphoid.  Breath sounds are equal.
>
> Patient intubated (rapid sequence orotracheal) within three minutes of
> arrival.  FAST shows fluid around heart, no fluid in abdomen.  He's been in
> the ED for about four-five minutes.  Now it is clear he has no palpable
> pulses.  Cardiac monitor: sinus tachycardia at 150 bpm.  Nobody can feel a
> pulse in this thin 16 y.o. boy.
>
> The on-call surgeon is in the room and is trained and willing to open chest,
> put in chest tubes, insert a central line, etc. The OR will be ready to take
> the patient in 5-10 minutes, but not immediately.
>
> What is the next step?
>
> A. bilateral large bore tube thoracostomies
> B. resuscitative left anterolateral thoracotomy (in the ED)
> C. fluid bolus or o-positive packed RBCs (i.e. volume-expand)
> D. start epinephrine, calcium
> E. subxyphoind pericardiocentesis
> F. none of the above
>
> I am not trying to trick you - there are no other hidden injuries.
>
> Many thanks, etc.
>
> Caesar Ursic, MD
> Santa Fe, USA
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