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
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

Comments
  • Survival rates are uniformly poor with guidelines reporting:[1]
    • 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[2]
  • 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%[2]

See Also

References
  1. Hopson LR et al. Guidelines for withholding or termina- tion of resuscitation in prehospital traumatic cardiopulmonary arrest: Joint Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2003; 196:106.
  2. Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307
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