Rediscovering First Principles, or Grand Futile Gestures
Late night Saturday trauma, 59-year-old woman in a high speed head on collision. She was not restrained and ended up bend almost double, pinned under the steering wheel and dashboard of her car. Thirty-minute extraction, seventeen minute transport time. We’re now three quarters of the way through that first golden hour when rapid intervention can still make a difference.
Her vitals were all over the map in the ambulance, heart rate swinging between the low 60’s and up to 120. Her blood pressure would be normal one minute and then drop to the 50’s the next.
In the trauma bay we had the low end of that swing. We placed another large bore IV and started pouring in fluids and O negative blood. Her blood pressure briefly rose to the high 90’s. She opened her eyes and looked at me. She said, “I can’t breathe. Help me.” And then she died.
Her blood pressure went away completely, not recordable. Her heart rate, which had been 120, fell to 40 and the pattern changed from normal sinus to a junctional rhythm (the last ditch effort of a dying heart to keep going).
It’s called PEA – pulseless electrical activity. The electrical system of the heart is still firing but no contraction is taking place either because the heart is empty or because it can’t fill. I bet on the latter and call for the thoracotomy tray.
ER thoracotomy is a dramatic event. It’s also usually futile. Survival after opening someone’s chest in the ER is less than 10% under most circumstances. A few centers report better results with penetrating trauma. But almost universally the survival with ER thoracotomy for blunt trauma is zero. My personal experience in thirty years is two survivors, one penetrating and one blunt.
I opened her chest through a left lateral incision through the space between the 5th and 6th ribs and extended it across the sternum. Her pericardium, the membrane around her heart, was filled with clot and the blood was squeezing the heart so it couldn’t pump. I opened the pericardium and evacuated the clot and her heart filled and started to beat.
Yes! I thought, watching the ventricle fill and contract. Then I saw the same blood that filled her ventricle rush out of the aortic valve annulus and the darker blood pouring out of the hole in her superior vena cave. She’d avulsed her heart from the superior mediastinum – ripped it off of the major vessels in the upper chest. In about twenty seconds the heart fasciculated and stopped.
First principles – mortality for ER thoracotomy in blunt trauma is 100%. But she opened her eyes and spoke to me. Sometimes you need to make a grand futile gesture, just so you can sleep at night