The following is heroic but still conceivable. I think there is an indication for ECPR because there is a reversible.cause. Pending your ED resources, once this gets diagnosed as hemothorax in the ED, step 1 cannulate for ECMO while ongoing CPR, and call the CV surgery consultant , step 2 hook your patient up to ECMO, step 3 transport patient to OR or transfer out on ECMO for thoracotomy
@hemantwaikar6167
Ай бұрын
A quick CT chest or CARDIAC MRI will tell us underlying cause of clotted haemorrhage in pericardium.Get ready with Percutaneous femoro femoral CPB for operation
@pip9002
Жыл бұрын
Good ultrasound tutorial!
@shahidiqbal1259
2 жыл бұрын
ER thoracotomies have been performed for resus, could that not have a role in relieving the haemopericardium?
@POCUSGeek
2 жыл бұрын
Great question and that's why I'm curious what others would do. Although you can do an intervention doesn't always mean that you should. Survival is low when an ER thoracotomy is performed but you're doing this procedure because you already feel survival is not possible without it being done. It is best to think of an ER thoracotomy as a temporizing procedure (minutes not hours). For example in my level 1 trauma center when a trauma patient arrives via ambulance we have a trauma team which responds. This includes emergency medicine physicians and trauma surgeons. An ER thoracotomy may be beneficial because if stabilized/temporized further intervention can take place in the OR by a trained surgeon. The key here is that the trained surgeon is already at bedside when this is occurring. In a medical patient we do NOT have a response team with a trained surgeon at bedside that can intervene and so performing this procedure can place you in a very isolated situation looking for further assistance to perform ultimate treatment creating the conundrum. You know partially why the patient is so ill ie. clotted hemoperricardium (in this case we don't know the cause of the clotted hemoperricardium) but are left with having to coordinate a significant amount of care in minutes which is not frequently possible. The 2nd part - care needed to coordinate - is whether someone, trained surgeon, would intervene due to stability and not knowing the ultimate cause. For example what is the survivability of aortic dissection with retrograde dissection with clotted hemopericardium. Also how soon are resources available - OR/OR team. Here's a good write up on ER thoracotomies - www.ncbi.nlm.nih.gov/books/NBK560863/ I like this point and agree with it. "Additionally, a thoracotomy should not be performed unless the appropriate resources are immediately available, such as an operating room, a properly trained surgeon, etc. since the procedure is a temporizing measure meant to deliver the patient to definitive treatment." This is at least my perspective on it. There may be others too though.
@shahidiqbal1259
2 жыл бұрын
@@POCUSGeek thanks for your reply and for the link, I understand what you mean in that ER thoracotomy although might help, isn’t a definitive treatment in the absence of a competent surgeon available and willing to deal with this patient surgically in the immediate… Interesting case to think about
@joestevenson5568
11 ай бұрын
@@POCUSGeekRCEM say that resucitative thoracotomy should be performed in any clinical setting if there has been penetrating trauma - whether there are thoracic surgeons or not. They say other indications are more debatable, but where you can clearly see this patient is dying from haemopericardium I think you'd have a good case for doing it provided there is a place to transfer this patient for definitive management afterwards if successful. Yes mortality and morbidity is high, but this patient's mortality without thoracotomy is going to be 100%.
@POCUSGeek
11 ай бұрын
@@joestevenson5568 Thanks for commenting. Here is a link for anyone who reads these comments to RCEM -- rcem.ac.uk/wp-content/uploads/2021/10/Position_Statement_on_Resuscitative_Thoracotomy-in_Trauma_Units_Apr_-2017.pdf I agree with their position but we must keep in mind that there are many determinants that go in to that decision. For example I recently had such a patient but he was relatively stable. Systolic blood pressures in the 90s. They were transferred and remained stable. A CT surgeon was then able to address their issue. On the other hand if the patient decompensates you need to emergently address the issue. This case was not a penetrating. The question would be was this somehow a spontaneous acute injury and caused him to have an episode of syncope or could the compressions caused the clotted pericardium. Either way compressions will not improve this and that injury needs addressed. For blunt trauma that is more difficult, especially if not in a large referral hospital with specialist.
@teresamurray9838
Жыл бұрын
I am a general sonographer, certified in cardiac US many years ago. I have never done cardiac US during a code... I am curious... how do we know the motion of the heart seen in the clip is not because of external compression on the chest. Is it standard to pause ext compressions for US imaging.
@POCUSGeek
11 ай бұрын
When running a code (ACLS) you have temporary pauses in CPR to do a rhythm assessment and to perform a pulse check. During this time I have them print the on-going rhythm strip. I perform a cardiac view - usually subxiphoid and someone else is feeling for a pulse. You have to keep this whole process to less than 10 seconds though. If you can't get the view then compressions should be restarted if no palpable pulse is obtained. A good view of the heart is the best information you can get. Checking a pulse in these patients can be difficult. Between pulse checks while you are giving medications you can review the last rhythm strip. Obviously it's an on-going effort and very fluid with the activities that are being performed.
@killua9982
2 жыл бұрын
I work in a small Hospital, i would transfer the Patient to a big Hospital and hope He will survive the transport
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