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