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Emergency Thoracotomy
Aka: Emergency Thoracotomy, Resuscitative Thoracotomy, Clamshell Thoracotomy, Open Cardiac Massage, Direct Cardiac Compressions
- See Also
- Emergency Pericardiocentesis
- Cardiac Tamponade
- Indications
- Traumatic Cardiac Arrest with no signs of life
- CPR <10 minutes in blunt Trauma, CPR <15 minutes in Penetrating Trauma
- Massive Hemothorax or extrathoracic non-compressible Hemorrhage
- 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
- Contraindications
- No signs of life in the field
- Lacking pupil response, respirations, extremity movement, cardiac eletrical activity
- Loss of Vital Signs >10 minutes in blunt Trauma, >15 minutes in Penetrating Trauma
- Asystole
- Bedside Ultrasound without cardiac activity or Cardiac Tamponade
- Inaba (2015) Ann Surg 262(3): 512-8 +PMID:26258320 [PubMed]
- 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
- Incise medially to avoid phrenic nerve
- Identify and control source of bleeding (see below)
- 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
- On transfer, cover the thoracotomy with moist, sterile towels
- Prevents dessication and contamination
- Technique: Left Chest Exposure
- Raise left arm above head to expose the left chest
- Prep the chest with Chlorhexidine or Povidone-Iodine
- Left lateral incision at the 5th intercostal space (nipple line in men, inframammary fold in women)
- Incision from Sternum to posterior-axillary line (bed level), following the rib margin
- 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
- Follow immediately over the top of the rib to avoid the neurovascular bundle
- Avoid lung Laceration
- Insert rib spreader with hinge positioned toward bed (avoids blocking Sternum)
- Expand the rib spreader
- Explore left chest
- Advance Endotracheal Tube into right mainstem Bronchus to maximize left chest visibility
- Follow overall protocol (as above) and Hemorrhage Management (as below)
- Technique: Right Chest Exposure
- Approach
- Right Chest Tube (consider placement by other provider during left thoracotomy) OR
- Right Thoracotomy
- Right Thoracotomy (Clamshell Thoracotomy)
- Divide Sternum with Lebsche knife, Gigli Saw or heavy scissors
- Perform lateral incision at the 5th intercostal space (using same technique as used for left chest exposure)
- Divide intercostal Muscles just above fifth rib down to posterior right axilllary line
- Technique: Hemorrhage Evaluation and Management
- Precautions
- Do not remove impaled foreign bodies (defer to operating room)
- Always open Pericardium
- Document time of aorta cross clamping
- Bleeding from below diaphragm
- Cross-clamp aorta (distinguish from esophagus) with an atraumatic clamp
- Bleeding from hilum or subclavian
- Cross-clamp vessel with an atraumatic clamp
- 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
- Suture with 2-0 to 4-0 non-absorbable monofilament (e.g. Prolene) in figure-of-eight stitch
- Consider teflon pledgets for reinforcement
- Myocardial Muscle is fragile and tears easily (even with pulling Suture closed)
- Technique: Restart the heart
- Preparation
- Administer Intravenous Fluid boluses
- Follows bleeding control as above
- Cross-clamp aorta with an atraumatic clamp
- Cardiac massage (Direct Cardiac Compressions)
- See below
- 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
- Technique: Open Cardiac Massage (Direct Cardiac Compressions)
- Identify heart landmarks
- Septum (compressions are perpendicular to septum)
- Bypass grafts
- Cardiac injuries (identified above)
- Position
- Fingers of right hand are adducted and placed behind the posterior surface of the heart
- Fingers of left hand are adducted and cupped around the anterior surface of the heart
- Compression Orientation
- Compressions are perpendicular to septum
- Heart angled 20-30 degrees into left chest (1:00 to 2:00 position)
- Compress heart from apex to base
- Start by compressing heel of hands together
- Then compress entire palms together
- Progressively compress together rest of hand and fingers together
- References
- Warrington, Barrar and Bosley (2021) Crit Dec Emerg Med 34(9): 8
- 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
- Trauma.org
- http://www.trauma.org/index.php/main/article/361/
- Emedicine
- http://emedicine.medscape.com/article/82584-overview#showall
- References
- Ringhauser and Thomas (2019) Crit Dec Emerg Med 33(6): 19-25
- Pascual (2015) Crit Dec Emerg Med 29(6): 10-7
- Spangler and Inaba in Herbert (2016) EM:Rap 16(1): 1-3