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13 results

  • Outcomes of emergency department thoracotomy in a tertiary care Canadian trauma centre

  • Julian J Owen, Niv Sne, Angela Coates, Peter K Channan
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 17 / Issue 4 / July 2015
    Published online by Cambridge University Press:
    28 May 2015, pp. 353-358
    Print publication:
    July 2015
    • Article
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  • Objective

    Emergency department thoracotomy (EDT) is a rare and potentially life-saving intervention performed for trauma patients in extremis. EDT is rare at Canadian trauma centres because of our infrequent occurrence of penetrating trauma. This study was undertaken to evaluate outcomes at a Canadian level 1 trauma facility and compare survival to large published datasets. Also, we evaluated the appropriateness of an EDT performed at our centre based on published national guidelines.

    Methods

    Retrospective medical record review of all patients undergoing an EDT during their resuscitation in the emergency department. Records were identified using our trauma registry, and all charts were manually reviewed. The primary outcome was survival to hospital discharge.

    Results

    Over a 20-year period, 58 EDTs were performed with 6 (10.3%) survivors. Patients undergoing an EDT secondary to penetrating trauma had the highest survival (5 of 24 patients or 20.8% survival) compared to patients undergoing an EDT for blunt trauma (1 of 34 patients or 2.9% survival). Patients undergoing an EDT who had not suffered cardiac arrest represented the group with the highest survival rate (3 of 6 patients or 50% survival). The majority of EDTs (79.3%) were indicated, and no patient undergoing an EDT survived if it was performed outside of published guidelines.

    Conclusions

    Survival following an EDT in our small, regional trauma centre is consistent with survival rates from larger published datasets. An EDT should continue to be performed under accepted clinical indications.

  • The inhaled pin inaccessible to the bronchoscope: a management conundrum

  • D V T Harischandra, J Swanevelder, R K Firmin
  • Journal:
    The Journal of Laryngology & Otology / Volume 123 / Issue 12 / December 2009
    Published online by Cambridge University Press:
    20 May 2009, pp. 1399-1401
    Print publication:
    December 2009
  • Objective:

    The inhaled sharp foreign body is usually amenable to bronchoscopic extraction. When this fails, management poses a challenge. We present a logical approach to the inhaled pin inaccessible to the bronchoscope.

    Case report:

    A 12-year-old girl presented to the accident and emergency unit after accidentally inhaling a pin. Multiple attempts with both rigid and flexible bronchoscopy failed to access the pin, which had lodged distally in the anteromedial basal segment of the left lung. Eventually, the pin was extracted at thoracotomy.

    Conclusion:

    We discuss the reasons for extracting such pins, as opposed to leaving them in situ, and when to proceed from endoscopy to open surgery. Such knowledge is useful, not only to guide the multidisciplinary team in their combined approach to this unique challenge, but also to explain to the patient the rationale for the proposed treatment protocol.

  • Chapter 21 - Management of the morbidly obese patient

  • from Section 2 - Anesthesia for operative procedures
  • Edited by Cait P. Searl, Sameena T. Ahmed
  • Book:
    Core Topics in Thoracic Anesthesia
    Published online:
    10 December 2009
    Print publication:
    02 April 2009, pp 145-150

  • Summary

    Appropriate and timely investigations should be performed in order to assess the impact of lung resection on the patient and to guide anesthetic management. The thoracic anesthetist must have a good basic technique with which he or she is completely familiar. The chapter describes the general considerations, conduct of anesthesia and post-operative considerations for segmental or wedge resections, lobectomy, and pneumonectomy. Segmental or wedge resections are very useful surgical techniques facilitating the preservation of lung tissue. These techniques are only possible if the lesion is located in peripheral lung tissue and is well circumscribed. Lobectomy is indicated for malignancy or benign lesions such as bronchiectasis and turberculosis localized to a lobe. The surgery is usually performed through a thoracotomy. As with all thoracic surgery it is important to have thought about potential escalation of the procedure proposed and what physiological impact this may have on the patient.

  • Chapter 20 - Significance of age in practice of thoracic anesthesia

  • from Section 2 - Anesthesia for operative procedures
  • Edited by Cait P. Searl, Sameena T. Ahmed
  • Book:
    Core Topics in Thoracic Anesthesia
    Published online:
    10 December 2009
    Print publication:
    02 April 2009, pp 137-144

  • Summary

    Video-assisted thoracoscopic surgery (VATS) has become a vital part of the armamentarium of the surgeon. VATS is associated with shorter length of hospital stay and less use of pain medication than thoracotomy in the treatment of pneumothorax and minor resections. General anesthesia is usually induced with an intravenous agent such as propofol or thiopentone and maintained with an inhalational agent such as isoflurane in an air/oxygen mixture. The isolation and division of the bronchi and pulmonary blood vessels require more accurate and extensive dissection with VATS than conventional surgery. Thoracoscopic lobectomy can be oncologically equal to conventional open procedures with an experienced surgeon and have similar survival for early stage non-small cell lung cancer. Conversion to a thoracotomy is sometimes required if there is an unexpected change in the patient's condition such as chest wall invasion or the need for a sleeve resection.

  • Chapter 27 - Management of bronchopleural fistula

  • from Section 3 - Post-operative management
  • Edited by Cait P. Searl, Sameena T. Ahmed
  • Book:
    Core Topics in Thoracic Anesthesia
    Published online:
    10 December 2009
    Print publication:
    02 April 2009, pp 186-189

  • Summary

    Thoracic trauma accounts for 25% of all trauma related deaths. The majority of thoracic trauma patients can be managed conservatively by simple chest tube drainage, respiratory support and pain management. The mechanism of injury after thoracic trauma can be classified as blunt or penetrating trauma. The anesthetist plays an important role in the management of severe thoracic trauma from an initial stage of primary survey right through to management in the intensive care unit. In the emergency department, decisions and actions have to be taken without delay. In a trauma situation, there is little opportunity to obtain standard anesthetic pre-operative assessment. Video-assisted thoracic surgery is an important and extensively used diagnostic tool for suspected traumatic intrathoracic lesions, including stab wounds, in hemodynamically stable patients. Urgent thoracotomy is indicated in the presence of severe hemorrhage. A quick standard anesthetic assessment should be performed on all trauma patients.

  • Chapter 25 - Management of post-operative respiratory problems

  • from Section 3 - Post-operative management
  • Edited by Cait P. Searl, Sameena T. Ahmed
  • Book:
    Core Topics in Thoracic Anesthesia
    Published online:
    10 December 2009
    Print publication:
    02 April 2009, pp 171-176

  • Summary

    Esophagectomy is commonly performed for cancer of the esophagus and gastric cardia. The surgical approach to esophagectomy depends on several factors: anatomic location of tumor; preferred method of reconstruction: transposed stomach, interposed colon, pedicled jejunum; and location of the esophageal-enteric anastomosis. Conventional esophagectomy requires either a laparotomy with a trans-hiatal dissection or laparotomy combined with thoracotomy. A trans-hiatal approach is the most commonly performed operation for esophageal cancer resection. Evidence of chronic pulmonary disease, the ability to stand one-lung anesthesia and the likelihood of post-operative pulmonary complications may be predicted with the aid of the lung function test and cardiopulmonary exercise testing. The spectrum of gastro-esophageal reflux disease (GERD) involves the gastrointestinal and pulmonary organ systems. There is an association between GERD and end-stage lung disease, especially idiopathic pulmonary fibrosis (IPF). The presence of GERD may predispose to the development of bronchiolitis obliterans following lung transplantation.

  • Emergency Department Thoracotomy: When Should One Quit?

  • N.A. Ahmed
  • Journal:
    Prehospital and Disaster Medicine / Volume 20 / Issue S1 / April 2005
    Published online by Cambridge University Press:
    28 June 2012, p. 89
    Print publication:
    April 2005
    • Article
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  • Gastric emptying in post-thoracotomy patients receiving a thoracic fentanyl-bupivacaine epidural infusion

  • A. Guha, N. D. A. Scawn, S. A. Rogers, S. H. Pennefather, G. N. Russell
  • Journal:
    European Journal of Anaesthesiology / Volume 19 / Issue 9 / September 2002
    Published online by Cambridge University Press:
    16 August 2006, pp. 652-657
    Print publication:
    September 2002

  • Background and objective: The effect of anaesthesia and surgery on gastric emptying is not constant, and this has not been previously studied in patients undergoing thoracotomy for lung resection with a bupivacaine-fentanyl epidural infusion for analgesia. There are important implications in this group of patients with regards to the recommencement of important oral medication as well as the risks of aspiration of gastric contents. The study examined gastric emptying in these patients until the second postoperative day.

    Methods: In a prospective repeated measures study, the effect of fentanyl-bupivacaine epidural analgesia at the mid-thoracic level on gastric emptying was assessed in 11 patients undergoing thoracotomy for lung resection. Gastric emptying was measured using a paracetamol absorption technique. Patients acted as their preoperative controls and were assessed 4 h postoperatively and on the second postoperative day.

    Results: The mean (SEM) maximum plasma paracetamol concentration was 204.6 (20.4) μmol L−1 before operation, 61 (9.5) μmol L−1 4 h postoperatively and 114.3 (22.6) μmol L−l on the second postoperative day. Mean (SEM) paracetamol absorption at 120 min was 15 638 (1441) μmol min L−l preoperatively, 5731 (821) μmol min L−l4 h postoperatively and 9325 (1759) μmol min L−l on the second postoperative day. Postoperative values were significantly (P < 0.005) less than the preoperative values.

    Conclusions: After thoracotomy, gastric emptying was delayed until at least the second postoperative day in patients receiving mid-thoracic fentanyl-bupivacaine epidural analgesia.

  • A randomized controlled trial of continuous extra-pleural analgesia post-thoracotomy: efficacy and choice of local anaesthetic

  • D. J. Barron, M. J. Tolan, R. E. Lea
  • Journal:
    European Journal of Anaesthesiology / Volume 16 / Issue 4 / April 1999
    Published online by Cambridge University Press:
    16 August 2006, pp. 236-245
    Print publication:
    April 1999

  • Controversy persists over the efficacy of intercostal nerve block administered through a tunnelled extrapleural catheter. We have undertaken a randomized, prospective double-blind trial of two different local anaesthetic regimes to evaluate the effect of this technique on post-thoracotomy pain relief and pulmonary function. Sixty-eight patients were randomized to receive bupivacaine 0.25% (n=22), lignocaine 1% (n=21) or 0.9% NaCl (saline) (n=20) via an extrapleural catheter, inserted peroperatively. All patients underwent a standard posterolateral thoracotomy. Pain was assessed using a visual analogue pain score and by the requirement for opiate analgesia. Pulmonary function was measured using bedside spirometry. Pain scores were lower in the local anaesthetic groups at 24, 32 and 72 h compared with placebo (P< 0.05) and the total amount of opiate required was less than placebo for both lignocaine and bupivicaine (P< 0.05). Pulmonary function was better in the local anaesthetic groups throughout the post-operative period and was most pronounced at 24 h with a mean improvement of 30% for forced expiratory volume (FEV1), 24% for forced vital capacity (FVC) and 19% for peak expiratory flow rate (PEFR) compared with placebo. There was no significant difference between pain scores, opiate requirement or pulmonary function between lignocaine and bupivicaine. CT scanning demonstrated containment of the local anaesthetic in an extra-pleural tunnel. Extra-pleural infusion of local anaesthetics is a simple technique, with low risk of complications and provides effective pain relief as well as an improvement in post-operative pulmonary function. Lignocaine is equally as effective as bupivacaine and its use would result in some cost-saving.