Thoracotomy

Indications

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

Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.

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)

Complications

• Risk of percutaneous injury and exposure to blood-borne pathogens to operator

Comments

• Survival rates are uniformly poor with guidelines reporting:
  • 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
• Best outcomes occur if the patient arrested less than 15 minutes before the procedure.
• For blunt trauma survival rate may be closer to 0.8%

See Also

• Thoracotomy (Peds)

External Links

• EMCrit: Crack to Cure
• REBEL EM: The Clamshell Thoracotomy
• CriticalCareNow: A Cracking Way to Start the New Year