Emergency Department Thoracotomy

imagesPenetrating Chest Trauma

   imagesTraumatic arrest with witnessed signs of life* in the field

   imagesPersistent hypotension (systolic blood pressure (SBP) <60 mm Hg) despite resuscitative efforts

imagesBlunt Trauma

   imagesTraumatic arrest that occurs in the emergency department (ED)

   imagesPersistent hypotension (SBP <60 mm Hg) despite resuscitative efforts

imagesPulmonary Trauma

   imagesChest tube drainage >1,500 mL

   imagesPersistent hypotension or cardiac arrest with known lung laceration

imagesAir Embolism

   imagesPersistent signs of hypovolemic shock

   imagesHemoptysis and cardiac arrest after intubation and ventilation

imagesNontraumatic Hypothermic Cardiac Arrest

   imagesIn settings where cardiopulmonary bypass is not immediately available


   imagesRelief of cardiac tamponade

   imagesSupport of cardiac function with open massage, cross-clamping the aorta, and/or internal cardiac defibrillation

   imagesControl of hemorrhage

   imagesDiagnosis and management of air embolism

   imagesMediastinal irrigation and rewarming (for hypothermic cardiac arrest)


imagesNo signs of life and prehospital cardiopulmonary resuscitation (CPR) performed:

   images>15 minutes after penetrating trauma

   images>10 minutes after blunt trauma

imagesMultisystem blunt trauma

imagesSevere head injury

imagesAsystole as an initial rhythm without tamponade

imagesInability to provide definitive care after procedure


imagesThis is an emergent procedure and does not require written consent


imagesLeft-sided supine anterolateral approach over the 5th rib, in the fourth intercostal space

   imagesIn males incise below the nipple

   imagesIn females below the inframammary fold


FIGURE 15.1 Thoracotomy landmark.

imagesGeneral Basic Steps


   imagesDissection and rib spreading


   imagesCardiac massage

   imagesHemorrhage control

   imagesAortic cross-clamping


imagesPatient Preparation

   imagesPatient should be intubated and a nasogastric tube should be placed (this should not delay the procedure!)

   imagesPlace towels under the left chest and place left arm above the head

   imagesSterilize the incision area with copious povidone–iodine solution


   imagesUsing a no. 20 blade, incise from the sternal border to the posterior axillary line

   imagesDuring the primary incision, cut firmly through subcutaneous tissue to the intercostal muscle

imagesDissection and Rib Spreading

   imagesUsing scissors, cut the intercostal muscles above the 5th rib to avoid the neurovascular bundle

   imagesTemporarily stop ventilation just before exposing the pleura to avoid lacerating the lung

   imagesInsert rib spreader with the ratchet placed toward the axilla and handlebar down

   imagesUse a Gigli saw, Lebsche knife, or trauma shears to cut the sternum for right-sided exposure


   imagesHold the pericardium with forceps, and use scissors to cut from the cardiac apex to the aortic root (FIGURE 15.2)

   imagesThe incision should be made anterior and lateral, avoiding the left phrenic nerve

   imagesEvacuate blood and clots from the pericardium

   imagesDeliver the heart from the pericardium if cardiac repair is required


FIGURE 15.2 Pericardium.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Emergency Department Thoracotomy
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