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


imagesGoals


   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)


CONTRAINDICATIONS



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


RISKS/CONSENT ISSUES



imagesThis is an emergent procedure and does not require written consent


LANDMARKS (FIGURE 15.1)



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



images


FIGURE 15.1 Thoracotomy landmark.



imagesGeneral Basic Steps


   imagesIncision


   imagesDissection and rib spreading


   imagesPericardotomy


   imagesCardiac massage


   imagesHemorrhage control


   imagesAortic cross-clamping


TECHNIQUE



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


imagesIncision


   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


imagesPericardiotomy


   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



images


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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