ADVANCING SCIENCE, ENHANCING LIFE ED Thoracotomy Patrick Dolan, PGY-1 9/22/14 ADVANCING SCIENCE, ENHANCING LIFE
Indications/Contraindications Penetrating trauma: Hemodynamically unstable on arrival Pulseless < 15min Available resources for definitive management Contraindications: No pulse or BP in field Asystole w/out pericardial tamponade Pulseless of >15 min at any time Non-survivable injuries Blunt trauma: No clear indication (survival is poor, 1-2%) Contraindication: >15min pre-hospital CPR
Technique Positioning/setup Incision Left anterolateral thoracotomy Supine, arms overhead or on arm boards if extremity injuries are present Leave penetrating objects in situ (unless it interferes with thoracotomy Skin quickly prepped w/ iodine poured over entire thorax Incision Left anterolateral thoracotomy 4th or 5th intercostal space, from the sternum to the posterior axillary line, following the curve of the rib Clamshell, if needed
Enter the thoracic cavity laterally with 1-2cm incision Curved mayo scissors used to open the intercostal space anteriorly and posteriorly Rib spreader opened as wide as possible One-sided ventilation (either right-sided mainstem the ETT or occlude the ipsilateral mainstem) Damage control (packing or direct clamping) Pulm hemorrhage: Directly clamp tissue (Duval clamp) Pulmonary hilum (clamp or twist)
Pericardiotomy Only if tamponade or cardiac injuries suspected Phrenic nerve Grasp pericardium w/ toothed forcep, opened through a small incision anterior to the phrenic nerve Evacuate fluid and/or blood clots Inspect heart and great vessels Digital compression
Cross-clamping Redistributes available blood volume Also reduces sub-diaphragmatic blood loss Left lung retracted superiorly, inferior pulmonary ligament divided OG/NG tube Dissection in an inter-vertebral space, plane perpendicular to the aorta Dissection around the aorta to place clamp Clamp just above the diaphragm >30 min clamp time superior to visceral vessels worsens outcomes.
Open cardiac massage/internal defib Immediately after placement of clamp Two-hand “clapping” technique Superior to closed chest compressions Closed chest: 25% baseline CO10% of normal cerebral and coronary flow Open: 60-70% baseline CO Small, ten patient study showed coronary perfusion pressures were 4x greater Anterior/dorsal surface paddles
Hemorrhage control Penetrating cardiac injuries Digital pressure Temporize Definitive repair with pledgeted 3-0 double-armed prolene sewn in a horizontal mattress fashion Venous or atrial wounds can be repaired in a running fashion with 4-0 or 3-0 sutures Clamped bladder catheter (balloon occlusion)
Definitive Management ED thoracotomy is a temporizing measure Next step is always OR w/ trauma, cardiac, thoracic and vascular surgery, as needed Definitive closure vs. temporary closure Temp closure has no specific advantage. Infectious complications (24 vs 25%) Hemorrhagic complications (18 vs 14%) Survival (47 vs 57%)
Outcomes Not well-studied Largest study was a review of 24 nonrandomized studies from 2000 that included 4620 ED thoracotomies. Overall survival: 7.4% (2.5-27.5%) Many factors: Mechanism Location of major injury Signs of life
Outcomes 7% of survivors suffer permanent neurologic sequelae Neurologically intact surival: 5% of those in shock 1% of those without vitals 0% without signs of life in field Mechanism of injury very important Isolated penetrating cardiac injuries 19.4% survival Survival 37 to 60% for penetrating injury compared to 0-10% for blunt Gunshot wounds two to four times worse than stab wounds Clinical condition on arrival Nonreactive pupils associated with no survival, 30% survival for those w/ reactive pupils