1. ADVANCING SCIENCE, ENHANCING LIFE
ED Thoracotomy
Patrick Dolan, PGY-1
9/22/14
ADVANCING SCIENCE, ENHANCING LIFE

2. 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

3. 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

4. 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)

5. 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

6. 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.

7. Open cardiac massage/internal defib
Immediately after placement of clamp
Two-hand “clapping” technique
Superior to closed chest compressions
Closed chest: 25% baseline CO10% 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

8. 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)

9. 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%)

10. Outcomes Not well-studied
Largest study was a review of 24 nonrandomized studies from 2000 that included 4620 ED thoracotomies.
Overall survival: 7.4% ( %)
Many factors:
Mechanism
Location of major injury
Signs of life

11. 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