Emergency Thoracotomy

1. See Also
   1. Emergency Pericardiocentesis
   2. Cardiac Tamponade
2. Indications
   1. Massive Hemothorax
      1. Unresponsive Hypotension (BP < 70mmHg) despite Massive Transfusion and other stabilization
   2. Cardiac Tamponade
      1. Refractory to Pericardiocentesis
      2. Unresponsive Hypotension (BP < 70mmHg)
      3. Penetrating Trauma
         1. May be considered in blunt Trauma, but worse outcomes
3. Contraindications
   1. No signs of life in the field
      1. Lacking pupil response, respirations, extremity movement, cardiac eletrical activity
   2. Loss of Vital Signs >5-10 minutes (>15 minutes in Penetrating Trauma)
   3. Asystole
   4. Bedside Ultrasound without cardiac activity or Cardiac Tamponade
      1. Inaba (2015) Ann Surg 262(3): 512-8 +PMID:26258320 [PubMed]
4. Preparations
   1. Bedside Ultrasound (See FAST Exam)
   2. Defibrillator with internal paddles
   3. Surgical instruments
      1. Scalpel and scissors
      2. Chest retractor
      3. Aorta cross-clamp
      4. Prolene 2-0 to 4-0 Sutures
      5. Surgical Stapler
      6. Foley Catheter
5. Precautions
   1. Call Trauma code or other mobilization of available emergency providers, surgeons, anesthesia
   2. Personal Protection Equipment
      1. Gown, double gloves and face mask
   3. Safety for Resuscitation staff is paramount
      1. Manage sharp instruments very carefully to prevent cutting self and others
6. Technique: Overall Sequence
   1. Intubation with Endotracheal Tube (or other Advanced Airway)
      1. Ideally performed by second emergency provider or anesthesia concurrent with thoracotomy
      2. ET insertion into right mainstem will deflate the left lung and improve thoracotomy visualization
         1. Alternatively, ventilations are held while exploring chest
   2. Vascular access and Fluid Replacement
   3. Left sided thoracotomy
      1. Chest exposure (see below)
      2. Open Pericardium in all cases (blood may be hidden within Pericardium)
      3. Identify and control source of bleeding (see below)
      4. Always open Pericardium (incise medially to avoid phrenic nerve)
      5. Restart the heart (cardiac massage, internal paddle Defibrillation)
   4. Right sided Chest Tube (or extend left thoracotomy to include right side as clamshell incision)
      1. Exclude right Hemothorax or Pneumothorax
      2. Ideally performed by second emergency provider concurrent with thoracotomy
7. Technique: Chest exposure
   1. Left lateral incision at the 5th intercostal space
      1. Incision from Sternum to mid-axillary line (bed level)
      2. Incision down to intercostal muscles
      3. Right Chest Trauma may require modified incision to include the right side
   2. Enter through the intercostal muscles
      1. Insert finger and then extend with spread kelly clamp or scissors for Blunt Dissection
      2. Avoid lung Laceration
   3. Insert rib spreaders and expand
8. Technique: Bleeding evaluation and management
   1. Precautions
      1. Do not remove impaled foreign bodies (defer to operating room)
      2. Always open Pericardium
   2. Bleeding from below diaphragm
      1. Cross-clamp aorta (distinguish from esophagus)
   3. Bleeding from hilum or subclavian
      1. Cross-clamp vessel
   4. Bleeding from Myocardium
      1. Open Pericardium in all cases
         1. Incise medially to avoid phrenic nerve
         2. Cardiac Tamponade may be hidden by fatty Pericardium
         3. Blood in the Pericardium should have a source (myocardial injury)
      2. Myocardial bleeding control
         1. Apply direct pressure or insert gloved finger into defect
         2. Insert and inflate Foley Catheter
      3. Repair myocardial injury
         1. Suture with 2-0 to 4-0 non-absorbable monofilament (e.g. Prolene) in figure-of-eight stitch
         2. Consider teflon pledgets for reinforcement
         3. Myocardial muscle is fragile and tears easily (even with pulling Suture closed)
9. Technique: Restart the heart
   1. Preparation
      1. Administer Intravenous Fluid boluses
      2. Follows bleeding control as above
      3. Cross-clamp aorta
   2. Cardiac massage
   3. Epinephrine (and/or Vasopressin)
      1. Intracardiac Epinephrine may be injected directly into the left ventricle chamber
      2. Follow intracardiac injection with further cardiac massage
   4. Defibrillate with internal paddles
      1. Ventricular Fibrillation will be evident by direct visualization of the heart
10. Efficacy
    1. Overall survival 1.9-11% (3.9% functionally intact)
    2. Best efficacy is in penetrating Chest Trauma
       1. Survival in isolated Cardiac Tamponade approaches 30-40% with good neurologic outcome
11. Resources
    1. Trauma.org
       1. http://www.trauma.org/index.php/main/article/361/
    2. Emedicine
       1. http://emedicine.medscape.com/article/82584-overview#showall
12. References
    1. Pascual (2015) Crit Dec Emerg Med 29(6): 10-7
    2. Spangler and Inaba in Herbert (2016) EM:Rap 16(1): 1-3