Tag Archives: surgery


Hilar Twists & Human Error

This engaging scene from ‘Code Blue‘ demonstrates a Helicopter Emergency Medical Service team managing a patient with major thoracic haemorrhage. They have done a right thoracotomy and want to clamp the hilum but there’s some kit missing from the pack.

This scene has some great discussion points for prehospital professionals, even if the specific scenario is somewhat unlikely for most people’s practice:

  • Non-compressible haemorrhage is possibly the biggest single clinical challenge when you’re a long way from hospital
  • Agitated friends and family can be disruptive – allocate a rescuer to look after them
  • Having blood products to give is essential
  • Don’t rely on the memory of individuals, who are fallible, to pack your equipment. “I was sure I put them in” didn’t cut it when the team needed forceps to clamp the pulmonary hilum and stop the bleeding. Checklists are the in thing, for good reason.
  • Luckily, you don’t need to clamp the hilum (which is tricky) in massive unilateral thoracic haemorrhage. You can just twist the lung 180 degrees on the hilum so it’s upside down. This can prevent further haemorrhage and air embolism.

 

What’s a hilar twist then?

The hilar twist manoeuvre, as it’s called, is worth learning if you’re a clinician who is prepared to do resuscitative clamshell thoracotomy for penetrating traumatic cardiac arrest. The clamshell is quick and provides excellent exposure(1) and is preferred to lateral thoracotomy(2).

The primary purpose of clamshell thoracotomy in penetrating traumatic arrest is to relieve cardiac tamponade and control a cardiac wound(3). It is well described and continues to save lives in the prehospital setting(4).

However, sometimes you’ll open the chest and the pericardium will be empty (other than containing the heart of course), and there will be massive haemorrhage on one side of the chest. Although most of these patients will be unsalvageable outside a trauma centre’s operating room, it’s worth trying something once you’ve gone to all the trouble of opening the chest. The hilar twist(5) is probably the best option for the non-surgeon, especially when some muppet’s forgotten to pack a clamp.

In order to make the lung mobile enough to twist, it’s first necessary to cut through the inferior pulmonary ligament. This is also known as simply the pulmonary ligament (because there’s no superior equivalent) and sometimes the inferior hilar ligament. It’s not actually a ligament, but an extension of the parietal pleura extending downwards in a fold from the hilum. Some describe it as hanging down from the hilum like a ‘wizard’s sleeve’, which invariably gets a giggle from some of our trainees from the United Kingdom for some reason.

Hilar Twist

 

After cutting the ligament completely to the level of the inferior pulmonary vein, the lung is then twisted ‘lower lobe towards you’, ie. lower lobe is rotated anteriorly over the upper lobe until the lung is oriented ‘upside down’. The twisted vessels around the hilum become occluded and further haemorrhage from that side should be limited. Other priorities in the arrested patient will be aortic occlusion, internal cardiac massage, and blood products. Packs may be required to keep the lung from untwisting, and if return of spontaneous circulation is achieved, there is a risk of dysrhythmia, right heart failure, and refractory hypoxaemia.

I’ve only done this on pigs and human cadavers so am not speaking from any reassuring level of experience or competence. The literature is out there to read, and it’s up to you to decide how you want to expand or limit your options when you’ve cracked that chest in an arrested patient.

References

1. Flaris AN, Simms ER, Prat N, Reynard F, Caillot J-L, Voiglio EJ. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg. 2015 May;39(5):1306–11.

2. Simms ER, Flaris AN, Franchino X, Thomas MS, Caillot J-L, Voiglio EJ. Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study. World J Surg. 2013 Feb 23;37(6):1277–85.

3. Wise D. Emergency thoracotomy: “how to do it.” Emerg Med J. 2005 Jan 1;22(1):22–4.

4. Davies GE, Lockey DJ. Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results. The Journal of Trauma: Injury, Infection, and Critical Care. 2011 May;70(5):E75–8.

5. Wilson A, Wall MJ Jr., Maxson R, Mattox K. The pulmonary hilum twist as a thoracic damage control procedure. The American Journal of Surgery. 2003 Jul;186(1):49–52.

Open cardiac massage in asthmatic arrests?

This idea was provoked by a colleague some years ago who could not achieve a palpable pulse during CPR of an arrested asthmatic child. He wondered whether the severe hyperinflation was rendering external cardiac compressions ineffective and whether he should have done a (prehospital) thoracotomy.

The literature is not strong. The 2010 AHA Guidelines rightly focus on reducing hyperinflation by disconnecting the tracheal tube from the ventilator circuit, and they mention ECMO for refractory cases, but there is no mention of open chest CPR.

I can only find two papers discussing it, both pretty old. A case series in the British Medical Journal from 1968 describes three patients with asthma who had asystolic arrests but did not achieve femoral pulses with external compressions(1). In two, open cardiac massage was performed resulting in restoration of sinus rhythm and cardiac output, and one appeared to make a neurological recovery.

A case report in 1987 describes a 32 year old man in asystolic cardiac arrest due to asthma(2):

“Ventilation required very high inflation pressures and little air movement was heard within the chest despite the administration of Adrenaline 1 mg and Aminophylline 250mg intravenously, and Adrenaline 1mg via the endotracheal tube. This was followed by an intravenous infusion of 100 ml of 8.4% Sodium Bicarbonate solution. External cardiac massage failed to produce a palpable pulse in the carotid area. The chest was, therefore, opened through a left anterolateral thoracotomy. The lungs appeared hyperinflated, bulky and tense and did not collapse when the pleural cavity was opened. The pericardium was opened and asystole confirmed, following eight to ten compressions of the heart some intrinsic activity commenced, ventilation also became much easier.”

He achieved ROSC and became haemodynamically stable but failed to wake up and treatment was withdrawn some days later.

Neither reports include mention of disconnection strategies to reduce hyperinflation. The lack of neurological recovery is not surprising given the apparent prolonged state of arrest the patients were resuscitated from. However there does appear to be a survivor who may not have made it had standard resuscitation (at the time) been continued.

Does this mean I would open the chest in an arrested asthma patient?
Not straight away, no. I would treat dynamic hyperinflation with tube disconnection and external compressions. I would correct absolute and relative hypovolaemia with crystalloid. I would treat bronchospasm (and possible anaphylaxis) with intravenous adrenaline/epinephrine. And I would exclude pneumothorax, possibly with ultrasound or more likely with bilateral open thoracostomies. If however these measures resulted in no detectable carotid flow with external cardiac compressions, ECMO was not available, and the arrest was not prolonged, I would definitely consider doing internal cardiac massage via thoracotomy.

What about you?

1. Grant IW, Kennedy WP, Malone DN
Deaths from asthma
Br Med J. 1968 May 18;2(5602):429–30

2. Diament RH, Sloan JP
Failed resuscitation in acute severe asthma: a medical indication for emergency thoracotomy?
Arch Emerg Med. 1987 Dec;4(4):233–5

Bilateral fixed dilated pupils? Operate if extradural!

Almost two-thirds of patients with extradural haematoma and bilateral fixed dilated pupils survived after surgery, with over half having a good outcome

 

pupilsiconNeurosurgeon, HEMS doctor, and all round good egg Mark Wilson was on the RAGE podcast recently and mentioned favourable outcomes from neurosurgery in patients with extradural (=epidural) haematomas who present with bilateral fixed dilated pupils (BFDP). Here’s his paper that gives the figures – a systematic review and meta-analysis.

A total of 82 patients with BFDP who underwent surgical evacuation of either subdural or extradural haematoma were identified from five studies – 57 with subdural (SDH) and 25 with extradural haematomas (EDH).

In patients with EDH and BFDP mortality was 29.7% (95% CI 14.7% to 47.2%) and 54.3% had a favourable outcome (95% CI 36.3% to 71.8%).

Only 6.6% of patients with SDH and BFDP had a good functional outcome.

Clearly there is potential for selection bias and publication bias, but these data certainly suggest an aggressive surgical approach is appropriate in some patients with BFDP.

The authors comment on the pessimism that accompanies these cases, which potentially denies patients opportunities for recovery:


“We believe that 54% of patients with extradural haematoma with BFDPs having a good outcome is an underappreciated prognosis, and the perceived poor prognosis of BFDPs (from all causes) has influenced decision making deeming surgery inappropriately futile in some cases.”


Scotter J, Hendrickson S, Marcus HJ, Wilson MH.
Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis.
Emerg Med J 2014 e-pub ahead of print Nov 11;:1–7


Primary objective To review the prognosis of patients with bilateral fixed and dilated pupils secondary to traumatic extradural (epidural) or subdural haematoma who undergo surgery.

Methods A systematic review and meta-analysis was performed using random effects models. The Cochrane Central Register of Controlled Trials and PubMed databases were searched to identify relevant publications. Eligible studies were publications that featured patients with bilateral fixed and dilated pupils who underwent surgical evacuation of traumatic extra-axial haematoma, and reported on the rate of favourable outcome (Glasgow Outcome Score 4 or 5).

Results Five cohort studies met the inclusion criteria, collectively reporting the outcome of 82 patients. In patients with extradural haematoma, the mortality rate was 29.7% (95% CI 14.7% to 47.2%) with a favourable outcome seen in 54.3% (95% CI 36.3% to 71.8%). In patients with acute subdural haematoma, the mortality rate was 66.4% (95% CI 50.5% to 81.9%) with a favourable outcome seen in 6.6% (95% CI 1.8% to 14.1%).

Conclusions and implications of key findings Despite the poor overall prognosis of patients with closed head injury and bilateral fixed and dilated pupils, our findings suggest that a good recovery is possible if an aggressive surgical approach is taken in selected cases, particularly those with extradural haematoma.

Early femur fixation recommended

The Eastern Association for the Surgery of Trauma recommends early (<24 hours) open reduction and internal fracture fixation in trauma patients with open or closed femur fractures.

They acknowledge the strength of the evidence is low, but suggests a trend toward lower risk of infection, mortality, and venous thromboembolic disease.

They conclude: “the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients

Check out the rest of the EAST Trauma Guidelines

Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma

Journal of Trauma and Acute Care Surgery 2014;77(5):787-795


BACKGROUND
Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (<24 hours) versus late (>24 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients.

METHODS
A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables.

RESULTS
No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50–1.08). The quality of evidence was rated as “low.” No significant reduction in infection (RR, 0.4; 95% CI, 0.10–1.6) or VTE (RR, 0.63; 95% CI, 0.37–1.07) was associated with early stabilization. The quality of evidence was rated “low.”

CONCLUSION
In trauma patients with open or closed femur fractures, we suggest early (<24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

London Trauma Conference Day 4

London Trauma Conference Day 4 by Dr Louisa Chan

It’s the last day of the conference and new this year is the Neurotrauma Masterclass running in parallel with the main track which focuses on in-hospital care.

We heard a little from Mark Wilson yesterday. He believes we are missing a pre-hospital trick in traumatic brain injury. Early intervention is the key (he has data showing aggressive intervention for extradural haemorrhage in patients with fixed dilated pupils has good outcomes in 75%).

Today he taught us neurosurgery over lunch. If you have a spare moment over then go to his website and you too can learn how to be a brain surgeon!

Dr Gareth Davies talks about Impact Brain Apnoea. Many will not heard of this phenomenon. Clinicians rarely see patients early enough in their injury timeline to witness

Essentially this term describes the cessation of breathing after head injury. It has been described in older texts (first mentioned in 1894!) The period of apnoea increases with the severity of the injury and if non fatal will then recover to normal over a period of time. Prolonged apnoea results in hypotension.

This is a brain stem mediated effect with no structural injury.

The effect is exacerbated by alcohol and ameliorated by ventilatory support during the apnoeic phase.

Associated with this response is a catecholamine surge which exacerbates the cardiovascular collapse and he introduces the concept of Central Shock.

So how does this translate into the real world?

Well, could we be miscategorising patients that die before they reach hospital as succumbing to hypovolaemic when in fact they had central shock?

These patients essentially present with respiratory arrest, but do well with supported ventilation. Identification of these patients by emergency dispatchers with airway support could mean the difference between life and death.

Read more about this at: http://www.sciencedirect.com/science/article/pii/S0025619611642547

Prof Monty Mythen spoke on fluid management in the trauma patient after blood (not albumin, HES or colloids) and Prof Mervyn Singer explained the genetic contribution to the development of MODS after trauma.

LTC-BrohiProf Brohi gave us the lowdown on trauma laparotomies – not all are the same! With important human factors advice:

1. Task focus kills
2. Situational awareness saves lives
3. The best communication is non verbal
4. Train yourself to listen

Prof Susan Brundage is a US trauma surgeon who has been recruited into the Bart’s and the London School of Medicine and the Royal College of Surgeons of England International Masters in Trauma Sciences for her trauma expertise.

She tells us that MOOCs and FOAM are changing education. Whilst education communities are being formed, she warns of the potential pitfalls of this form of education with a proportion of participants not fully engaged.

The Masters program is growing and if you’re interested you can read more here.

This has been a full on conference, with great learning points.

Hopefully see you next year!

Early surgery for intracerebral haemorrhage

ICHgraphicIconTo operate or not to operate on patients with an intracerebral haematoma? Deep ones can be tricky and risk damage to surrounding brain, so superficial ones may be more likely to benefit.

These patients with superficial lesions were assessed in STICH II, an international prospective randomised controlled trial comparing early surgery with conservative treatment.

Inclusion criteria were strict:

  • spontaneous lobar intracerebral haemorrhage on CT scan (≤1 cm from the cortical surface of the brain) with a volume of between 10 mL and 100 mL
  • within 48 h of onset
  • had a best motor score on the Glasgow Coma Score (GCS) of 5 or 6, and had a best eye score of 2 or more (ie, were conscious at randomisation).

The primary outcome was a Glasgow Outcome Scale-based evaluation of recovery (‘favourable’ vs ‘unfavourable’), which did not significantly differ between groups.

A predefined subgroup of patients with a poorer prognosis (using a score based on age, haematoma size and GCS) may have a better outcome with surgery. Some patients randomised to conservative therapy subsequently underwent delayed surgery. Thanks to appropriate intention-to-treat analysis they would have remained in the conservative treatment group which may have contributed to an underestimation of the benefit of surgery.

So, overall a negative trial, and patients with small lesions and higher GCS scores won’t benefit from surgery. Patients in poorer prognostic groups might benefit, but that remains unproven.

Some other ICH trials to be aware of are Clear III and MISTIE III, which are investigating thrombolytic agents in combination with clot removal, including with minimally invasive techniques.

Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial
Lancet. 2013 Aug 3;382(9890):397-408


BACKGROUND: The balance of risk and benefit from early neurosurgical intervention for conscious patients with superficial lobar intracerebral haemorrhage of 10-100 mL and no intraventricular haemorrhage admitted within 48 h of ictus is unclear. We therefore tested the hypothesis that early surgery compared with initial conservative treatment could improve outcome in these patients.

METHODS: In this international, parallel-group trial undertaken in 78 centres in 27 countries, we compared early surgical haematoma evacuation within 12 h of randomisation plus medical treatment with initial medical treatment alone (later evacuation was allowed if judged necessary). An automatic telephone and internet-based randomisation service was used to assign patients to surgery and initial conservative treatment in a 1:1 ratio. The trial was not masked. The primary outcome was a prognosis-based dichotomised (favourable or unfavourable) outcome of the 8 point Extended Glasgow Outcome Scale (GOSE) obtained by questionnaires posted to patients at 6 months. Analysis was by intention to treat. This trial is registered, number ISRCTN22153967.

FINDINGS: 307 of 601 patients were randomly assigned to early surgery and 294 to initial conservative treatment; 298 and 291 were followed up at 6 months, respectively; and 297 and 286 were included in the analysis, respectively. 174 (59%) of 297 patients in the early surgery group had an unfavourable outcome versus 178 (62%) of 286 patients in the initial conservative treatment group (absolute difference 3·7% [95% CI -4·3 to 11·6], odds ratio 0·86 [0·62 to 1·20]; p=0·367).

INTERPRETATION: The STICH II results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral haemorrhage without intraventricular haemorrhage.