Thoracotomy: Difference between revisions

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==Background==
==Background==
At best there is an estimated 1.5% favorable neurologic outcome after thoracotomy, and best outcomes occur if the patient receives less than 15 minutes of [[CPR]] before the procedure.  For penetrating chest trauma with cardiac tamponade the survival rate may be closer to 0.07%<ref>Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307</ref>
At best there is an estimated 1.5% favorable neurologic outcome after thoracotomy, and best outcomes occur if the patient receives less than 15 minutes of [[CPR]] before the procedure.  For penetrating chest trauma with cardiac tamponade the survival rate may be closer to 0.07%<ref name="slessor">Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307</ref>


==Goals==
==Goals==
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**Blunt trauma survival as great as 2%
**Blunt trauma survival as great as 2%
**Penetrating trauma survival as great 16%
**Penetrating trauma survival as great 16%
*Meta-analysis reports overall rates closer to 1.5% with favorable neurologic outcome<ref>Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307</ref>
*Meta-analysis reports overall rates closer to 1.5% with favorable neurologic outcome<ref name="slessor"></ref>


==See Also==
==See Also==

Revision as of 20:07, 19 April 2015

Background

At best there is an estimated 1.5% favorable neurologic outcome after thoracotomy, and best outcomes occur if the patient receives less than 15 minutes of CPR before the procedure. For penetrating chest trauma with cardiac tamponade the survival rate may be closer to 0.07%[1]

Goals

  1. Release tamponade
  2. Control intrathoracic/cardiac bleeding
  3. Control air embolism
  4. Cardiac massage
  5. Temporary occlusion of descending aorta (optimize flow to brain and heart)

Indications for ED Thoracotomy

  1. Penetrating chest trauma w/ signs of life in the field
    1. Pulse, BP, pupil reactivity, purposeful movement, organized rhythm, respiratory effort)
  2. Blunt chest trauma w/ signs of life lost in ED
  3. Consider for exsanguinating abdominal vascular injuries
  4. Thoracotomy (Peds)

Indications for OR Thoracotomy

  1. Thoracoabdominal trauma pts w/ persistent SBP < 70-80 despite aggressive resus.
  2. Chest tube drainage > 1500 ml initially or > 200 mL/hr for 2-4hr
  3. Evidence of cardiac tamponade or progressively inc hemothorax

Procedure

ED thoracotomy
  1. Intubate and place NGT
  2. Always start with left-sided approach (even if penetrating injury is on right side)
    1. 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
    • Foley catheter w/ purse-string suture around it (closes wound when foley removed)
    • Horizontal mattress (can be difficult w/ beating heart)
  8. Cardiac Massage
    • one-handed vs two-handed
    • Intracardiac epinephrine
  9. Internal Defibrillation
    • Lower voltages than external defibrillation
  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 e/o injury to L-side but poss R-sided injury extend to R side (clam shelling)

Prognosis

  • Survival rates are uniformly poor with guidelines reporting:[2]
    • Blunt trauma survival as great as 2%
    • Penetrating trauma survival as great 16%
  • Meta-analysis reports overall rates closer to 1.5% with favorable neurologic outcome[1]

See Also

Thoracotomy (Peds)

References

  1. 1.0 1.1 Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307
  2. Hopson LR et al. Guidelines for withholding or termina- tion of resuscitation in prehospital traumatic cardiopulmonary arrest: Joint Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2003; 196:106.