Thoracotomy (peds)

Indications

• Chest tube output
  • >10-15mL/kg evacuated
  • >2-4mL/kg/hr continuous
• Continuous air leak

ED Thoracotomy

Penetrating chest trauma

• Signs of Life (pre or in-hospital)
  • Pulse, BP, pupil reactivity, purposeful movement, respiratory effort
  • Cardiac Activity
    • PEA is acceptable
• Unresponsive hypotension
  • SBP<70 despite treatment

Blunt chest trauma

• Witnessed signs of life (pre or in-hospital)
• Rapid exsanguination
  • >1000-1500mL initial drainage or >200mL/hr from Chest tube
• Consider for exsanguinating abdominal vascular injuries with witnessed signs of life
• Unresponsive hypotension
  • SBP<70 despite treatment

OR Thoracotomy

• Thoracoabdominal trauma patients with persistent SBP < 70-80 despite aggressive resuscitation
• Evidence of cardiac tamponade or progressively increasing hemothorax
• Chest tube drainage
  • > 20ml/kg initially (> 1500ml in adult)
  • > 3 ml/kg/hr for 2-4hrs (> 200 mL/hr for 2-4hr in adult)
  • Persistent bleeding > 7 ml/kg/hr
  • Persistent air leak (bronchopleural fistula)

Goals

• Release tamponade
• Control intrathoracic/cardiac bleeding
• Control air embolism
• Cardiac massage
• Temporary occlusion of descending aorta (optimize flow to brain and heart)

Contraindications

• No absolute contraindications to ED thoracotomy (emergent procedure)
• Relative Contraindications
  • Blunt injury without witness cardiac activity
  • Penetrating abdominal trauma without cardiac activity
  • Non-traumatic cardiac arrest
  • Severe head injury
  • Severe multi-system injury
  • Improper Setting
    • Understaffed ER/Improperly trained staff/Insufficient equipment

Equipment Needed

• PPE
• Thoracotomy Tray
  • Rib Spreader
  • #10 or #21 Scalpel, Scissors, Forceps
  • Vascular Clamps, Curved Artery Forceps, Needle Driver
  • Internal Defibrillation Paddles
  • Skin Stapler, Suture Material

Procedure

ED thoracotomy

1. Intubate and place NGT
2. Always start with left-sided approach (even if penetrating injury is on right side)
   • If possible, should have concurrent right sided chest tube being placed
3. Incise from sternum to to posterior axillary line (4th or 5th intercostal space)
   • Cut through skin, soft tissue, and muscle in one pass
   • May scissors can be used to cut the intercostal muscle
4. Rib spreader with rachet bar down
5. Push lung out of way to access pericardium
6. Pericardiotomy
   • Pick up pericardium just anterior to phrenic nerve
   • Incise from apex to root of aorta parallel to phrenic nerve
7. Inspect myocardium for lacerations
   • Digital occlusion
   • Skin stapler - if coronary artery stapled, it can be removed in the OR
   • Foley catheter with purse-string suture around it (closes wound when foley removed)
   • Horizontal mattress (can be difficult with beating heart)
8. Cardiac Massage
   • one-handed vs two-handed
   • Intracardiac epinephrine
9. Internal Defibrillation
   • Lower voltages than external defibrillation
   • Start at 5J to a max of 50J
10. Cross Clamp Aorta
    • Up to 30 min is tolerated
    • Indicated after persistent hypotension after pericardiotomy and fluid resus
    • Aorta posterior to NGT
11. Autotransfuse thoracic blood
12. If no evidence of injury to L-side, but possible R-sided injury, extend to R side (clam shelling)

See Also

• Thoracotomy
• Thoracic trauma