Emergency Thoracotomy

Johnny Iliff

Thoracic Trauma25-50% of all traumatic injuries.

Most thoracic trauma patients managed conservatively.

Deterioration in pre-hospital or ED leads to Emergency Thoracotomy.

“occurring either immediately at the site of injury, or in the emergency department or operating room as an integral part of the resuscitation process”.

Increased Chance of Survival

Signs of life in the ED

Penetrating>Blunt thoracic injury

Stab wounds > Gun Shots

Thoracic injuries:

However, some studies suggest there is up to a 10% neurologically intact survival rate for patients with penetrating abdominal injury undergoing cross clamping of the descending aorta as part of emergency thoracotomy.

Aims of the procedureResuscitation of a patient in extremis with a

penetrating injury by:

 Release cardiac tamponade

 Control haemorrhage

 Perform open cardiac massage

 Cross clamp the descending thoracic aorta

 Control air embolism

Indications- Penetrating Injury

Previously witnessed cardiac activity (pre-hospital or in-hospital)

Unresponsive hypotension (SBP <70mmHg) despite vigorous resuscitation

Indications- Blunt injuryRapid exsanguination from chest tube

(>1,500mL immediately returned)

Unresponsive hypotension (SBP <70mmHg) despite vigorous resuscitation

Relative IndicationsPenetrating thoracic injury with traumatic arrest

without previously without previously witnessed cardiac activity

Penetrating non-thoracic injury (e.g. abdominal, peripheral) with traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Blunt thoracic injuries with traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

ContraindicationsBlunt injury without witnessed cardiac activity (pre-

hospital)

Penetrating abdominal trauma without cardiac activity (pre-hospital)

Non-traumatic cardiac arrest

Severe head injury

severe multisystem injury

Improperly trained team

Insufficient equipment

Lorenz et al (1992

http://i0.wp.com/scghed.com/wp-content/uploads/2014/04/emergency-thoracotomy-algorithm2.png

Lorenz et al (1992 Hunt et al (2005)

Equipment- Thoracotomy tray in T2

Scalpel–—no. 10 bladeSuitable retractor, such as Finochietto’s rib spreader, or Balfour abdominal retractorLebschke’s knife and mallet, or Gigli sawCurved Mayo’s scissorsToothed forcepsLarge vascular clamps, such as SatinskyDeBakey aortic clampMosquito/Dunhill artery forcepsFoley catheterLong and short needle holdersInternal defibrillator paddlesSutures, Teflon pledgets, sternal wires

MAJOR TRAUMA CALLAnaesthetics

Orthopedics

General Surgeons

Cardiothoracics

Radiology

Procedure Intubated and Ventilated (Airway Doc and Nurse)-

discussion for right main bronchus intubation

*seek and treat Pneumothorax in Blunt chest trauma

Fluid Resus with blood products (Circ Doc and Nurse)

*Ultrasound if qualified staff available

Mask, visor, scrub, gown and glove (Proceduralist)

Appropriate area

15* head up- left arm abducted and lights on

Prep area

Incise through skin, subcut tissue in 5th Intercostal Space above 6th Rib- costochondral junction to MAL

Divide the muscle, periosteum and parietal pleura in one layer with scissors and blunt dissection

Insert a rib-spreading retractor with the handle towards the axilla

To extend the incision to the right side, use strong scissors, bone cutters or a Gigli saw to cut through the sternum and into the right fifth intercostal space, mirroring the incision above.

TAMPONADE- Pericardiotomy- Anterior to Phrenic Nerve

CARDIAC DEFECT- Finger/Foley catheter with gentle traction to repair defect

MAJOR ABDO HAEMORRHAGE or HYPOPERFUSION Cross clamp aorta- passage of NGT helps identify Oesophagus

SIGNIFICANT LUNG LACERATION OR AOR EMBOLISM FROM BRONCHIAL_VASCULAR COMMUNICATION- Cross clamp Hilum

Cardiac Arrest- Compression with paddles

VF/VT- Shock 15-30J

http://www.trauma.org/archive/atlas/images/clamshell04.jpg

Book a bed

When to Stop??  Irreparable damage

 Massive head injuries

 Pulseless electrical activity (PEA)

 Systolic BP<70after15-20mins

 Asystolic arrest

https://www.youtube.com/watch?v=8BlPxQI2C90

https://www.youtube.com/watch?v=A57ZB_J4FuY

Resources http://lifeinthefastlane.com/ed-thoracotomy-is-it-just-the-first-part-

of-the-autopsy/

Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma — a review. Injury. 2006 Jan;37(1):1-19. Epub 2005 Apr 20. Review. PMID: 16410079.

Lorenz HP, Steinmetz B, Lieberman J, Schecoter WP, Macho JR. Emergency thoracotomy: survival correlates with physiologic status. J Trauma. 1992 Jun;32(6):780-5; discussion 785-8. PMID: 1613839.

http://www.trauma.org/index.php/main/article/361/

http://emedicine.medscape.com/article/82584-overview

The Royal Hospital Melbourne http://clinicalguidelines.mh.org.au/brochures/TRM04.02.pdf