Emergency Department Thoracotomy in the management

of Chest Trauma

Sudhir Sundaresan, MD FRCS(C)Division of Thoracic SurgeryMay 28, 2009

ED Thoracotomy: Historical

Late 1800’s – cardiac wounds, anesthesia-induced arrest

1874 – Schiff – open cardiac massage Until 1960 – “medical” arrests

– 1960 – CPR

– 1965 – external defibrillation

Late 1960’s – resurgence in trauma Currently – selective approach (Injury,

physiologic status)

Definitions

No V/S = No blood pressure - vs -

No “signs of life” (SOL)– No BP

– No resp effort

– No motor effort

– No cardiac electrical activity

– Fixed / non-reactive pupils

ED Thoracotomy: When?

Post-injury Cardiac arrest– Penetrating: witnessed; < 15mins CPR

– Blunt: witnessed; < 5 mins CPR

Persistent shock (SBP<60)– Hemorrhage

– Tamponade

– Air embolism

ED Thoracotomy: When NOT?

Post-injury Cardiac arrest– Penetrating: > 15mins CPR and NO SOL

– Blunt: > 5 mins CPR and NO SOL

Prior chest surgery (sternotomy, thoracotomy)

ED Thoracotomy: Survival correlates with Injury pattern and status of patient

Injury

Pattern

Shock No V/S No S.O.L Overall

Cardiac 35% 19% 3% 16%

Penetr. 14% 8% 1% 10%

Blunt 2% 1% 0 1.4%

ED Thoracotomy: Technical aspects

Supine, Left arm out of the way Incision: left submammary; clamshell Pericardiotomy

ED Thoracotomy: Technical aspects

Pericardiotomy:– Hemorrhage control– Cardiac repair– Foley technique

ED Thoracotomy: Technical aspects

Open massage and resuscitation:– 2-hand technique– Intracardiac epinephrine– Internal defibrillation

ED Thoracotomy: Technical aspects

Occlude thoracic aorta:– Retract lung superiorly, suction

– Dissect out aorta just above diaphragm

ED Thoracotomy: Purpose

Release tamponade Control exsanguinating intrathoracic

hemorrhage Open cardiac massage

– Closed chest CPR: 25% CO, 20% cerebral perfusion – OK for 15 mins at normothermia

Clamp aorta Deal with broncho-venous air embolism

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Chest Trauma:

Pericardial Tamponade

Intrapericardial Pressure (mm Hg)

ED Thoracotomy: Aortic clamping

Redistribute blood flow (brain,heart) Address intra-abdominal hemorrhage Extremity injuries Downside (limit to < 30 mins)

– Paraplegia

– Anaerobic gut metabolism massive ischemia/reperfusion injury

ED Thoracotomy: Air embolism

Pulmonary broncho-venous air emolism Penetrating > blunt injuries Scenario: hypotension/arrest after

intubation/PPV Management:

– ED thoracotomy

– Hilar clamping

– Pericardiotomy, de-air the heart

04/20/23 15

Chest Trauma

NECK

HYPOVOLEMIC

SHOCK

ED Thoracotomy: Downside

Injury to intrathoracic structures Consequences of anaerobic metabolism

– Massive ischemia-reperfusion injury

Post-pericardiotomy syndrome Exposure of HCW’s to blood-borne

pathogens– HIV – 4%

– Hepatitis C – 14%

Reference

Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes World J Emerg Surg. 2006; 1: 4.