Thoracotomy
2001 ACS-COT Recs on EDT
1) Rarely in pts sustaining cardiopulmonary arrest secondary to blunt trauma due to the unacceptably low survival rate and poor neurologic outcomes
2) Should be limited to those that arrive with vital signs at the TC & have a witnessed cp arrest
3) Best applied to pts sustaining penetrating cardiac injuries who arrive at a TC after a short transport with witnessed signs of life
4) Should be done on pts with penetrating, non-cardiac thoracic injuries
5) Should be done in pts with exsanguinating abdominal vascular injuries, although these pts have a low survival rate
- level 2 recs and applies to peds
THORACOTOMY INDICATIONS
(Fernandez Lec 2003)
1. Penetrating Chest trauma w/ signs of life in field (pulse palp, respirations, cardiac activity on monitor > 40 bpm, pupillary reactivity)
- Stab wounds have better survival than GSWs (19% vs. 8%)
- Some authors recommend thoracotomy in penetrating abd. trauma w/ persistent hypotension or arrest (surv 5%)
2. Blunt Trauma w/ signs of life lost in ED. No long term survival in blunt trauma pts who lose signs of life in field.
Thoracotomy in OR
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.
- Fascinating Facts
1) 1st introduced 1882 Dr. Block in his canine heart lac expt., 1889 Tuffier had 1st succesful open massage, Dr. Beck popularized it for the next 50-60 yrs and became the standard of care in the OR, and fell out of favor as external defib and closed heart massage was introduced
2) 80% of tamponade d/t SW
3) 5 goals of EDT are to release tamponade, control intrathoracic/caridac bleeding, control air embolism, open massage, temporary occlusion of the desc aorta= optimizing blood flow to brain and heart
4) each hemithorax can contain about 50% of the pts blood volume before it becomes obvious!!
5) external cardiac compression can provide 10-20% of baseline cardiac output (reasonable salvage up to 15 min, and diminished survival at 30 min), open cardiac massage deliver up to 60% of baseline (aortic pressure & CO can be kept at 50-70% which allows reasonable salvage at 30 min). also w/ hypovolemia, ext cardiac compression provides inadequate coronay and cerebral perfusion. (chest '77, j. trauma '82)
6) cross clamp aorta can incr afterload & O2 demand on heart. Up to 30 min is tolerated, >30min=isch & anaeorobic metab=acidemia=multi organ dysf(x), removing clamp=wash out of metabolic by-products & inflamm mediator, =shock=organ failure
7) fyi internal mammory vessels are .5-1cm lateral to the sternum, try and avoid:)
8) Post aorta clamping sbp <70=survival unlikely. sbp>160-180=strain on LV can lead to acute failure so remove clamp.
9) survival rate of 7035 EDTs was 7.8% (11.2% for penetr, & 1.6% for blunt, 31.1% for penetr cardiac inj). 142 peds had overall surv of 6.3%. (j. surg 2001)
10) One study of 4520 EDTs had 15% of survivors w/ severe neurologic defecits.
TECHNIQUE
1. Intubate, NGT, sedate at same time
2. Left arm overhead, towel under, prepare autotransfuser, incision in L intercostal space, sternum to axilla. Go through skin, tissue & muscle in one pass.
3. Cut muscle with scissors, halt respirations and use other hand to widen the hole, push lung out of way. Incise to post axillary line.
4. Rib spreader with rachet bar down
5. Relieve Tamponade - by a pericardiotomy, pick up pericardium anterior to phrenic nerve, start incision (nick w/ scalpel) near diaphragm & open pericardium parallel to phrenic nerve
6. Clamp sites of active bleeding
7. Internally Defibrillate
8. Internal Cardiac Massage - one- handed vs. two-handed, inspect myocardium for lacerations, may close with a Foley and purse-string stitch or 2 horizontal mattresses.
9. Cross Clamp the Aorta, indicated after persistent hypotension after pericardiotomy and fluid resus. NGT in esophagus, thus, aorta post ngt. (see facts #8)
10. Autotransfuse thoracic blood
(Trauma Reports 12/03) -by Lampe