Emergency Thoracotomy

1. See Also
   1. Emergency Pericardiocentesis
   2. Cardiac Tamponade
2. Indications
   1. Traumatic Cardiac Arrest with no signs of life
      1. CPR <10 minutes in blunt Trauma, CPR <15 minutes in Penetrating Trauma
   2. Massive Hemothorax or extrathoracic non-compressible Hemorrhage
      1. Unresponsive Hypotension (BP < 70mmHg) despite Massive Transfusion and other stabilization
   3. 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 >10 minutes in blunt Trauma, >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
         1. Blood may be hidden within Pericardium
         2. Incise medially to avoid phrenic nerve
      3. Identify and control source of bleeding (see below)
      4. 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
   5. On transfer, cover the thoracotomy with moist, sterile towels
      1. Prevents dessication and contamination
7. Technique: Left Chest Exposure
   1. Raise left arm above head to expose the left chest
   2. Prep the chest with chlorhexidine or povidone-Iodine
   3. Left lateral incision at the 5th intercostal space (nipple line in men, inframammary fold in women)
      1. Incision from Sternum to posterior-axillary line (bed level), following the rib margin
      2. Incision down to intercostal muscles
      3. Right Chest Trauma may require modified incision to include the right side
   4. Enter through the intercostal muscles
      1. Insert finger and then extend with spread kelly clamp or scissors for Blunt Dissection
      2. Follow immediately over the top of the rib to avoid the neurovascular bundle
      3. Avoid lung Laceration
   5. Insert rib spreader with hinge positioned toward bed (avoids blocking Sternum)
      1. Expand the rib spreader
   6. Explore left chest
      1. Advance Endotracheal Tube into right mainstem Bronchus to maximize left chest visibility
      2. Follow overall protocol (as above) and Hemorrhage Management (as below)
8. Technique: Right Chest Exposure
   1. Approach
      1. Right Chest Tube (consider placement by other provider during left thoracotomy) OR
      2. Right Thoracotomy
   2. Right Thoracotomy (Clamshell Thoracotomy)
      1. Divide Sternum with Lebsche knife, Gigli Saw or heavy scissors
      2. Perform lateral incision at the 5th intercostal space (using same technique as used for left chest exposure)
      3. Divide intercostal muscles just above fifth rib down to posterior right axilllary line
9. Technique: Hemorrhage Evaluation and Management
   1. Precautions
      1. Do not remove impaled foreign bodies (defer to operating room)
      2. Always open Pericardium
      3. Document time of aorta cross clamping
   2. Bleeding from below diaphragm
      1. Cross-clamp aorta (distinguish from esophagus) with an atraumatic clamp
   3. Bleeding from hilum or subclavian
      1. Cross-clamp vessel with an atraumatic clamp
   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)
10. Technique: Restart the heart
    1. Preparation
       1. Administer Intravenous Fluid boluses
       2. Follows bleeding control as above
       3. Cross-clamp aorta with an atraumatic clamp
    2. Cardiac massage (Direct Cardiac Compressions)
       1. See below
    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
11. Technique: Open Cardiac Massage (Direct Cardiac Compressions)
    1. Identify heart landmarks
       1. Septum (compressions are perpendicular to septum)
       2. Bypass grafts
       3. Cardiac injuries (identified above)
    2. Position
       1. Fingers of right hand are adducted and placed behind the posterior surface of the heart
       2. Fingers of left hand are adducted and cupped around the anterior surface of the heart
    3. Compression Orientation
       1. Compressions are perpendicular to septum
       2. Heart angled 20-30 degrees into left chest (1:00 to 2:00 position)
    4. Compress heart from apex to base
       1. Start by compressing heel of hands together
       2. Then compress entire palms together
       3. Progressively compress together rest of hand and fingers together
    5. References
       1. Warrington, Barrar and Bosley (2021) Crit Dec Emerg Med 34(9): 8
12. 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
13. 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
14. References
    1. Ringhauser and Thomas (2019) Crit Dec Emerg Med 33(6): 19-25
    2. Pascual (2015) Crit Dec Emerg Med 29(6): 10-7
    3. Spangler and Inaba in Herbert (2016) EM:Rap 16(1): 1-3