Abstract
- The major muscles that are divided during resuscitative thoracotomy include the pectoralis major, the pectoralis minor, and the serratus anterior muscles.
- Pectoralis major muscle: It originates from the anterior surface of the medial half of the clavicle, the anterior surface of the sternum, and the cartilages of all of the true ribs (the first seven ribs which are directly attached to the sternum). The 5-cm wide tendon inserts into the upper humerus.
- Pectoralis minor muscle: It arises from the third, fourth, and fifth ribs, near their cartilages, and inserts into the coracoid process of the scapula.
- Serratus anterior muscle: It originates from the first eight or nine ribs and inserts into the medial part of the scapula.
- Pectoralis major muscle: It originates from the anterior surface of the medial half of the clavicle, the anterior surface of the sternum, and the cartilages of all of the true ribs (the first seven ribs which are directly attached to the sternum). The 5-cm wide tendon inserts into the upper humerus.
- The left phrenic nerve descends on the lateral surface of the pericardium.
- The lower thoracic aorta is situated to the left of the vertebral column. The esophagus descends on the right side of the aorta to the level of the diaphragm, where it moves anterior and to the left of the aorta. The aorta is the first structure felt while sliding your fingers along the left posterior wall anterior to the spine.
Surgical Anatomy
The major muscles that are divided during resuscitative thoracotomy include the pectoralis major, the pectoralis minor, and the serratus anterior muscles.
Pectoralis major muscle: It originates from the anterior surface of the medial half of the clavicle, the anterior surface of the sternum, and the cartilages of all of the true ribs (the first seven ribs which are directly attached to the sternum). The 5-cm wide tendon inserts into the upper humerus.
Pectoralis minor muscle: It arises from the third, fourth, and fifth ribs, near their cartilages, and inserts into the coracoid process of the scapula.
Serratus anterior muscle: It originates from the first eight or nine ribs and inserts into the medial part of the scapula.
The left phrenic nerve descends on the lateral surface of the pericardium.
The lower thoracic aorta is situated to the left of the vertebral column. The esophagus descends on the right side of the aorta to the level of the diaphragm, where it moves anterior and to the left of the aorta. The aorta is the first structure felt while sliding your fingers along the left posterior wall anterior to the spine.
General Principles
External cardiac compressions can produce approximately 20% of the baseline cardiac output and tissue perfusion. Open cardiac massage can produce approximately 55% of the baseline cardiac output. In traumatic cardiac arrest, external cardiac compression has little or no role, especially in the presence of cardiac tamponade or an empty heart due to severe blood loss.
Trauma patients arriving in the emergency room in cardiac arrest, or imminent cardiac arrest, are candidates for resuscitative thoracotomy. The indications and contraindications are controversial, with many surgeons supporting strict criteria and others supporting liberal criteria for the procedure. Those supporting strict criteria cite the futility of the operation and the risks to staff. Those practicing liberal criteria, including the USC trauma program, cite those that do survive, the opportunity for organ donation, and the educational value of the procedure.
The emergency room resuscitative thoracotomy allows release of cardiac tamponade, control of bleeding, direct cardiac massage and defibrillation, aortic cross-clamping, and management of air embolism.
Endotracheal intubation, intravenous line placement, and resuscitative thoracotomy can be performed simultaneously. The endotracheal tube may be advanced into the right bronchus in order to collapse the left lung and make the procedure easier. However, this may cause oxygenation problems in the presence of injuries to the right lung.
Special Surgical Instruments
The resuscitative thoracotomy tray should be kept simple and include only a few absolutely essential instruments, which include a scalpel, Finochietto retractor, two Duval lung forceps, two vascular clamps, one long Russian forceps, four hemostats, one bone cutter, and one pair of long scissors. In addition, good lighting, working suction, and an internal defibrillator should be ready before patient arrival. All staff should wear personal protective equipment.
Figure 4.2 The emergency room resuscitative thoracotomy tray should include only the absolutely essential instruments (scalpel, Finochietto retractor, two Duval lung forceps, two vascular clamps, one long Russian forceps, four hemostats, one bone cutter, and long scissors).
Positioning
Supine position with the left arm abducted at 90° or above the head. Antiseptic skin preparation may be performed; however, rapid entry with release of tamponade and control of hemorrhage trumps sterility, and should take precedence over meticulous antiseptic precautions. Draping is not required, as it is time-consuming.
Incision
The left anterolateral incision is the standard incision for resuscitative thoracotomy. It does not need special patient positioning, provides good exposure to the heart and the left lung, and allows cross-clamping of the thoracic aorta. If necessary, it can be extended as a clamshell incision into the right chest through a mirror incision and division of the sternum.
The incision is performed through the fourth to fifth intercostal space, at the nipple line in males or inframammary fold in females. It starts at the left parasternal border and ends at the posterior axillary line. Follow the curve of the ribs by aiming towards the axilla. The pectoralis major and pectoralis minor are encountered and divided in the anterior part of the incision, and the serratus anterior in the posterior part of the incision.
Figure 4.3 (a, b) The resuscitative thoracotomy incision is placed just below the nipple in males or in the inframammary crease in females (through the fourth to fifth intercostal space). It starts at the left parasternal border and extends to the midaxillary line, with a direction towards the axilla.
The intercostal muscles are divided close to the superior border of the rib, in order to avoid the neurovascular bundle, and the pleural cavity is entered with the use of scissors, taking care to avoid injury to the underlying inflated lung. Right mainstem intubation or holding ventilation during entry into the pleural cavity can reduce the risk of lung injury. A Finochietto retractor is then inserted and the ribs are spread. The left lower lobe of the lung is grasped with Duval forceps and retracted towards the patient’s head and laterally to improve the exposure of the heart and the thoracic aorta.
Figure 4.4
(a) Division of the pectoralis major and the underlying pectoralis minor muscles.
(b) The intercostal muscles are divided at the superior border of the rib with scissors, taking care to avoid injury to the lung.
