ADVANCING SCIENCE, ENHANCING LIFE

ED ThoracotomyPatrick Dolan, PGY-1

9/22/14

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– 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