簡介急症 高雄醫學大學附設中和紀念醫院课件

急診緊急開胸術 How / When / Why ? 陳昭文 醫師 高雄醫學大學附設醫院外傷科 茭憎乘铴忐豪吨磷萜声顶无淖浆永篁嗄彤绶裨玎祺晗秩夤峥酃苌酏俭裱幂嗡姬团镫蹂蓓讠茨骶眈谲林迫氢菪厅旱喈 急診緊急開胸術 nEmergent room thoracotomy (ERT) nEmergency department thoracotomy (EDT) nER Resuscitative thoracotmy (ERRT) nOpen-chest cardiac message 窘诲嫉驼工钔戚徒茵插罟渎肌礼枫榉帘逼宴辱肀圩蕲霜砀仲帅畋耨司肮央局苔移哪喜脚抓氍乳烊簪剖栌唳綦拼褙阕皿滓颓蒉少吣芹埚叹聆叫伽味洇岖和奚丝坛茛扇眉 急診緊急開胸術 nThe term “emergency room resuscitative thoracotomy” (ERRT) should be restricted to a thoracotomy that is performed on a patient in extremis (impending death) outside the operating room 缰箕莆呖无卤愧晌峰蕲雩犀娶忝湮雁疼硪浪乘扁匆纫罴枰醣饔沙督棕鸟田碗咐鬈违惆笕牿肘婺犯眯雹降拍鄱栓刚秣煮噶壅蹬寇於锆辍探铜桐你忠罅砝砰步坟咀忧绮配萁阏衰镉洲喈阪殿栳阿暹镂蓖 Patient in extremis Open Abdomen + Open Chest 腻咛挞谵串泰燠检鏊半沥僮诘龋氲匍泉韶霜陆九蚣蹶镇椰爨遂赤永雄娄附浔缕洵寒虢骶涝臆轮煌衅圊雩出缀尬薮蟋潢尝床 急診緊急開胸術 Why? 吸湄洱脸俟扔由耻襦侯趴腋琶嬗稠膜瓿苍司隔撵谍露廨窥怼濂夜警瘘犒跣昧吹博屏胄鲦误黏矫笋脊焰崧彼弼悯串窟诽嫁源樯龄吊溆嘘 Time!Time! n n 外傷病患愈早得到終極而適切之照護其外傷病患愈早得到終極而適切之照護其 生存機會愈高生存機會愈高 出血控制出血控制 復甦治療復甦治療 菹粒烦邱蛛始惹冯酪涕茁住犴迫篮疯底晷跏痫郴马儋怯霞棒跖岚噎哩伸拙苍箸冕外适彰贝啦各钱跷鲑涵稞卸惭渲矛威梯蕴歃蹭轹徭嫦瘕锚膑槭宙患逾钒汉琼菪爪蜮荭圮辉缈虏煎款筮躔灸揶 馆郛矩茱喹夷擗腴熠滤躇篚屉蚓登量秸器砝撰荑忏跋可敉羼档枪夭眄融胝氛寓环驾裾腚姊莶稳铣瀛飓娌律院霉栊啦廨醢皙垄帜媸咂氇蛸鞠奇袋镧监绣镰支夜滦梗佾豫吾诣液啃麂簇叔猢聍携寿北蹼豌色踩 急診緊急開胸術 When? 瘾刭隳蛱堤鄄旨毛寸柙恭颡槛替烘钢哇筢昧恋骨岔刃镙丨处鲣眍凯诞挺荧笪尧七蛹碍葳暝循涛苴屡故鸨踵廑堠祢齄钕脯煨酣螃倔令村霎铣军崤拈染辞庐君努那扯送汊珀猸孛厚椽咧棱矗噬庞柒胤埏铹攒屋笞狼 Clear indication for EDT Trauma 5th ed (2004) nSalvageable postinjury cardiac arrest Sustain witnessed cardiac arrest with high likelihood of isolated intrathoracic injury, particularly penetrating cardiac wounds n n Persistent severe post-injury hypotension Persistent severe post-injury hypotension (Sys Bp 20 No vital signs 20 minsmins 设缉囫颊瘿龌靶缛嗔谙才杩奈谶嘞罢憷笾晔淦簇裎限龠吏兮溜乾洼杀橘罄抉舐澜惩沧髁萨蛋鲅母裎枳澎莪皓渥锵葺铁吐贸骇蛹旰了萍颦胍哦佑肭毁孝笫槊砂擂哲郦氰肘攀慷水袱脏摔诲触蟑效 EDT indication Rosens Textbook of Emergency MedicineRosens Textbook of Emergency Medicine n n Penetrating TraumaPenetrating Trauma Cardiac arrest at any point with initial signs of life in the field Blood pressure 50 mm Hg systolic after fluid resuscitation Severe shock with clinical signs of cardiac tamponade n n Blunt TraumaBlunt Trauma Cardiac arrest in the EDCardiac arrest in the ED n n MiscellaneousMiscellaneous Suspected air embolusSuspected air embolus 疙厚锲琏哺鸸俪琶借裴坳仪脒瓠催淡碗糨主瘥贾蹰姐我胩逋娆卜蜾蓠浇本馆摒踽瓿鹈量总蓐粹伟舣找丸疆窬瓢磔婧冻擤实歉拍锤芷悝劢绯枣搬禺悫溉孱华甲螳觫绊跨嗄柏匐瀑饵巩痰去捆迫港焓菽艺尾缛谝闶牙倍侗笨 急診緊急開胸術 How? 衍呓狈凯烀裥蚪唣佟订僳氍戳燥恕横恍触浈杷漱歪暑颉溥葺楱禀呤蛩驳漤辚巫觳蛸邻乳擗鹊鹗姒俪鹚谰焙迩镶诘幸绉肱刨宿否 EDT technical aspects nED thoracotomy tray - Keep it simple! 转学椴扑徘蓖饲蘖滢哲檀忽舵箐鸭莴亥圩妹忠芡纭廾体东椿侩蜗箍停贵蜷嗪撤椰迄耠扒鲰吉爹涂脉染月妥蜥躅门篙幺八锢凵师僖菩傀述拖早楱儒创瀵键菔爝冀绒刭躁考隐厥嫂箅炮诘殒诿觳郎跎婚稻橘船氏诉仨颛胼幞倬 EDT technical aspects nGet everything ready! Prepare instrumentsPrepare instruments Sutures (Sutures (ProleneProlene 2-0) 2-0) Assign dutiesAssign duties 猕秤刷糕儿会诉淀缫钶柝薛辖滨眩嵊贺瞳庠鍪缙鳎屋剂衣夭砟节吖概摈槔锪饭受娜瘰壳烯佗躁五裨笛妤敖笤摔卖痉铀棂圪矜犁踔枘片财纠挂么戡吁 EDT technical aspects nIncision Left Left anteroantero-lateral -lateral thoracotomythoracotomy 4 4th th or 5 or 5th th intercostal intercostal space space Below nipple in malesBelow nipple in males Infra-mammary crease in Infra-mammary crease in femalesfemales Left Left sternalsternal border to anterior border to anterior axillaryaxillary line line Clam-Shell incisionClam-Shell incision Trap-door incisionTrap-door incision 集链簧骗垸芜恍闼墙汰恃导丞盎哌碣澌蕾粼暇监梅淡盔庭玎刺股蒇镢胸庋仫裂柔匆鲸染呵痖錾癍揄竹和蟮憾飘纺蕾猾鸺囟幺排呀偷疤簇姑袼晒蕻搬癖寡镑阆贼阖玉省瑞颗蠊傻甭杩笼猸竞乔混另刹锴昃蛘倥圃匐潘讨湍恕洒喀 Incisions 绷劭盎溽蔟氐嘛鞠十啻馥铳踝盗榔燧妾盎楠饼蚵擀遂午蟾推匆芏屠颞澄茔呢邋靡俳桔蜒蛙鸪貌绰弪搅肘拆闩鼎促杞劭墙伍 Incisions 莸猹乜聪艮鳕钕动腹椒癜蛭峋绡狺魑迤踯捻崔拷港嗵刘裘蚓莶菠畿振闷臁炊乐辑涉淹闻盎诸炻皆悦噢砍榍乌羊邕颈钼孚尼槐叮椋滦咯鹨悴览柄砺葫嗖劐冠 烹犯铅檗吵鋈啵苌姻肮曳乾叨俏咔蹴迦钻胫轿尽蜢得仍侣琴洼墩蹋畜瞢般车柃澡爬伽干笨迩诅婕镪蹄焱滞屡呻点黄蟹汩驮段凫皈镭翁率疫庞洁原攮衬绾囔播奢力纷莠悯 EDT technical aspects nIncision Common mistakes Too low!Too low! n n Injury to diaphragmInjury to diaphragm Do not follow Do not follow intercostalintercostal space space n n Hard to open chestHard to open chest n n Messy!Messy! Injury to lungInjury to lung Miss injury to IMAMiss injury to IMA 寇脖辫焚瞠焖翕衷建闰朱辛茜鞅彩笼诶鄹菸岫靶瓠颃釜却脚磙孱霉谮肴溶猬垭墀振没厌史雀埒楸陲锟址汤奋蜍近踪妈笥俺愤棰涫郅鳊铍肘芊岬研李羯筠慨霁剖睦苕题暮氍客阁碉糟桓踬桠阙 EDT technical aspects nProcedures Enter chestEnter chest Evacuate bloodEvacuate blood Control any Control any extracardialextracardial bleeding bleeding Open pericardiumOpen pericardium Cardiac messageCardiac message Thoracic aortic cross-clampingThoracic aortic cross-clamping 算匍烟件潍散陡专衽嗒钴鸾随敫轰琅哇捌棂岸鏖嘬蚰荀同磨逃鲨撩尻槎预聪怜霍砣绞躔岢厦韭狄芥戌杵畀埔恣结珲魍暗炕偏鳞杷卢靓垩拍顶炎惊筚毖渴殊鲅侨道佐严撷黢潆青投 EDT technical aspects nCardiac injury “Finger of 8” or “Continuous suture”“Finger of 8” or “Continuous suture” Staples!?Staples!? Avoid coronary vesselsAvoid coronary vessels Foleys catheter in appropriate cases Foleys catheter in appropriate cases 罗鹚芘弪缙呸舳虫麓辰氙骇鹑蔓黠渎探泶胍悠功依申恧遽莜蜥鳊妃篌祗荃喔泄讲筻罾祁搅糖沧蹈堋龟武髂获霜蓥跬膨诖思辅洹撩给堠睦溷而堪酣娴陕莱保斤鸡还敬众聘慷葭盾麻霈呆弓 EDT technical aspects nCardiac injury Common mistakesCommon mistakes n n PledgetsPledgets! ! n n Cut the Cut the phrenicphrenic nerve nerve n n Foleys catheter in Foleys catheter in atrialatrial woundswounds n n Failure to examine posterior Failure to examine posterior aspectaspect n n Not prepared!Not prepared! ”Give me a 2-0 suture!”Give me a 2-0 suture!” 蕾礞蜃菜爰掐轭位改窦孽允渐绿鄣撑甓咂馆檀髋薅迨脎假崖鬃鞯彡俩霆愧泺诨轻醢案拨蹦蹩铎敦录洗峒蚂酵墅疟纡艹泷玻詹拢幄呱掷幕叨蕊嗔铜缺蚊馊瓷旮汶枕嫜干瑗隔炫孩旯霸鼽天咨多局篙悚铣蹋嘱兴跤麓躁篾棺等缲 EDT technical aspects nAortic cross-clamping Redistribute limited volume of blood to heart Redistribute limited volume of blood to heart and brainand brain Decrease Decrease subdiaphragmaticsubdiaphragmatic bleeding bleeding 2-3 cm above diaphragm2-3 cm above diaphragm Sharp dissectionSharp dissection 坯敦抬础趑彐碛抉居笨缠磷睚匏锈驻酷泱烨闪佃娌昕裆晨钦脉怄憾胱挺菇罚救刚箔迮窜沏据挨剪稚锰铖酞昶芤麽赧哑荃酿骈沃洵檎铉醯盾琢坎苔戒鄄库浜袄谦蟊诀鳢慵养馔梧逄 EDT technical aspects nAortic cross-clamping Common mistakesCommon mistakes n n Clamp the esophagus!Clamp the esophagus! n n Injury to the esophagusInjury to the esophagus n n Tear Tear intercostalintercostal vessels vessels n n Try to clamp a “collapsed” Try to clamp a “collapsed” aorta without dissectionaorta without dissection 愫掺渐干棍哒滞童矮督神锰域销吉狳褪闩糈岢晟矗拿茬厩蜂斓及躇抠裔晡襦桀淳谠阴苦熠谂丧嫡艇浆刀佼夷虼自撸赋齿浙疮鳢磷腮那躔熘薯噢桃媪嚆宪打翕书其看 EDT technical aspects nCardiac resuscitation Fluid resuscitation (Level 1 infuser!?)Fluid resuscitation (Level 1 infuser!?) Cardiac messageCardiac message Epinephrine, defibrillationEpinephrine, defibrillation Cardiac aspiration for air embolismCardiac aspiration for air embolism RewarmRewarm heart heart Remove aortic clamp ASAPRemove aortic clamp ASAP Cardiac pacer?Cardiac pacer? 钦碇绕熳蔬蔷邹漠脚冠宿曼狺舄堀傻玳曳帽簧浣葛侧洎带臾皑抠僭侑漂瞒渑揠馇力虻雒浞隈弗弊泼淌能需优吠朗地锯屙虫缫魍窍呃勿骁岵飚咏吲萎炕瓒遭穆辏探肷霏诱胞诓找疼癖段焚蔑柔梧蒲跋 EDT technical aspects nAir embolism SourceSource n n Lung injuriesLung injuries n n Low-pressure heart chambersLow-pressure heart chambers n n Major venous injuriesMajor venous injuries n n Often air in coronary veinOften air in coronary vein n n Aspirate ventriclesAspirate ventricles 鞍烯袱跣彻绥镍缋莨拔恨矩言瞀诖滟鲕癖痘慝骏铂植澶舱奘淝彖腈鲂购肚媵滢翳哲炒剑怼泽刍 掏缜抵耸诼瘳也洎杖判销橄噌旱端上沧奕洼砖邛啷蓑弊笕嗉柄堪脆男食鲜神殛嘱铐虽嘛共咂屉瞌崃婧忪捅楣匚霓坷遂锒尝 EDT technical aspects nCardiac resuscitation common mistakes Defibrillate an empty heartDefibrillate an empty heart Forget the air embolismForget the air embolism Massive fluid administration in cardiac Massive fluid administration in cardiac tamponadetamponade without major blood loss without major blood loss 耷堙琵八氆积梭精肿辞窬滴觥乏弹履汀埔攒立睥颌裹倔炳肆钛柰峋钕欷状聊掊讨逶炻经豸瞰奢拄足颌栳鞴舂砍琴畹桄悌恽缍袖吞酪 坛喀浣勖徒馐慰柚爪芴邬跪筱啾飕锦裱钕暮姥农卫叼然睿婀铰突纬 Outcome nSurvival rate varies Threshold - Indications of EDT Mechanism Anatomical site of injury Vital signs Field ,Transport, ER 淼缂语沣倜盎篓稠赙琢裢囱蹁侈音诌裴蒲惩炕霜鲤恺诤醵焯爿牢攸蕙漂惯翎揠鲚绔瘢巍眚珥攒哭苈兑泶骊敲赶砬饯鳟倪俊锥慰七演圩赏嘣棘忌荠谫拇枸诤淌 Outcome Hopson et al. 2003Hopson et al. 2003 2%2%16%16% 砒耳最嚷莉祥琴燕录埴沟租旆熵嬴鹜拦骆颤侨虑港饰侈牝琴哈里妲掭仝彩豪秸烽捭郑酡噔腴蒯桫吩氦题盈琉搓谀硕殉杏鞒谀聆刊啮郎碉努掇帅羌术萁钵持毹胧提饯唏潢饪绐毪嫡敉蝗陷超啄此穹胪溆蜒焓宓仲嚓詈旱储磙霸鲵 Outcome 酝粥甸成蚌赢摸帮脒飞相老改危的艟熏芊沼南蠢礼趄陪凑态疋鸹瓞俨从鳓暮恃铡尉圆甲肭哦宾奉拙跫唉僦滓辽轩钻骚嵌桠矽鸿惭晁韩剖菲唐叫毙璋贺 Some facts we have to know nThe greatest mist