Emergency Room Thoracotomy

Marc Pelletier, MDHead, Department of Cardiac Surgery

New Brunswick Heart Centre

CFPC MAINPRO Declaration of Conflict of Interest

Edwards Lifesciences: Proctor, consultant

Today’s goals

What is an ER thoracotomy?

Review determinants of survival

Review indications and contraindications

Realistic goals of ERT

Technique and expectations

“The surgeon who should attempt to suture a wound of the heart would lose the respect of his surgical colleagues.”

Theodore Bilroth, 1882

Ludwig Rehn, 1896, 1st documented successful repair of cardiac laceration.

Blatchford JW. Ludwig Rehn: the first successful cardiorraphy. Ann Thorac Surg 1985;39:492–5.

What is an ER thoracotomy?

What is an ER thoracotomy?

What is an ER thoracotomy?

Why ERT?

ERT is a controversial treatment option

Low chance of survival (4-33%)

Significant resources, risk to health care workers must be considered

Risk to health care workers

Exposure to blood/fluids

One of most “exciting” ER events“Even a 1% chance in a 20 y.o. is worth it!”

Who can survive with ERT?

Mechanism of Injury

Location of Injury

Presence of Vital Signs

Mechanism of Injury

Penetrating thoracic injurySurvival 18-33%

Stab wounds better than gun shot wounds (GSW)

Isolated stab wounds are best (up to 70%)

Blunt traumaSurvival 0-2.5%

Best in those with hypotension with ongoing chest tube losses

Location of Injury

Best chances:Isolated injury to thorax

Cardiac injuries

Single cardiac chamber (versus multiple chambers)

Injuries to great vessels and pulmonary hila carry high mortality

Injuries to abdomenGoal to cross clamp aorta to control bleeding

Penetrating abdo trauma much better than blunt

Presence of Vital Signs

Presence of cardiac activity, or the amount of time since activity, is crucial to survival

0% for arrest at scene

4% when arrest in ambulance

19% when arrest in ED

27% when deterioration but not arrest in ED

When there is “No sign of life”Blunt 0%

Penetrating 0-5%

What are signs of life?

Pupillary response

Spontaneous ventilation

Presence of carotid pulse

Cardiac electrical activity

Measurable or palpable blood pressure

Extremity movement

Accepted Indications

Penetrating Thoracic InjuryTraumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Unresponsive hypotension (BP < 70 mmHg)

Blunt Thoracic InjuryUnresponsive hypotension (BP < 70 mmHg)

Rapid exsanguination from chest tube (>1500 ml)

Relative Indications

Penetrating Thoracic InjuryTraumatic arrest without previously witnessed cardiac activity

Penetrating Non-thoracic Injury (i.e. peripheral, abdominal)Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Blunt Thoracic InjuryTraumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Contraindications

Blunt Injuries

Blunt thoracic injuries with no witnessed cardiac activity

Multiple blunt trauma

Severe head injury

Severe multisystem injury

Improperly trained team

Insufficient equipment

Also consider…

2011 prospective multicenter study revealed no survivors:

Blunt trauma with > 10 minutes of pre-hospital CPR

Penetrating trauma with > 15 minutes of pre-hospital CPR

Asystole without cardiac tamponade

Moore et al. Journal of Trauma-Injury Infection and Critical Care. Feb 2011

What are the goals of ER thoracotomy?

Control bleeding

Release cardiac tamponade

Facilitate internal/open cardiac massage

Prevention of air embolism

Exposure of descending aorta for cross-clamping

Repair cardiac or pulmonary injury

Before thoracotomy

Primary causes of traumatic arrest (very different than cardiac arrest)

Hypoxia

Hypovolemia due to hemorrhage

Tension pneumothorax

Cardiac tamponade

Before thoracotomy

Hypoxic arrestIntubation and ventilation

Tension pneumothoraxNeedle decompression or chest tubesPresume bilateral

Massive hemorrhageChest tubes may help localize side of bleedingControl bleeding is more important than massive fluid transfusion

Cardiac tamponadeClassic signs often absentFAST can be helpful

ER Thoracotomy

Need to be prepared

Consult surgical teams in preparing equipment and supplies

Run mock ERT codes twice/year

Ensure ERT algorithm is posted and visible in Trauma bay

Equipment

Incision Decision

Position of patient

Technique – Enter chest

Don’t forget suction!

Incision StepsPosition, prep, drape

Scalpel (No. 10 blade) used to make incision down to ribs.

Skin, subcutaneous fat, pectoralis and serratus muscles

Find intercostal space (4th or 5th ICS ideal)

Hold ventilation while thoracic cavity entered

Incise intercostal muscle

Use scissors to go backwards then frontwards toward sternum

Insert retractor

What now?

Look around, check for bleeding, retract lung

Evacuate blood from left chest

Locate pericardium and assessBulging?

Blood visible?

Assess aorta

Assess lung

What are the goals of ER thoracotomy?

Control bleeding

Release cardiac tamponade

Facilitate internal/open cardiac massage

Prevention of air embolism

Exposure of descending aorta for cross-clamping

Repair cardiac or pulmonary injury

Pericardotomy

Always should be opened

Grasp pericardium and open with scissors

Open above (anterior) to phrenic nerve

Cardiac repair

Start with digital occlusion

Pledgetted mattress suturesLarge needle, large pledgets

3-0 or 4-0 Prolene

Foley catheter

Ventricular Repair

3-0 polypropylene sutures tied over pledgets

Bites 1 cm into normal myocardium

Very little tension is needed

Injury near coronary artery

Place sutures beneath artery (preserve coronary as an “island”)

Other option is to ligate artery and perform bypass

Typical exam question

Injury near coronary artery

Small Atrial Wound

Finger pressure to control bleeding

Mattress suture repair of 3-0 or 4-0 polypropylene with pledget

Purse string

Large Atrial Wound

Edges grasped with Babcock or Allis clamps

Closure with running 4-0

Aortic Cross-clamping

Clamping descending aorta redistributes blood flow to coronary and cerebral arteries

Clamping near aorta can control abdominal hemorrhage

Retract lung superiorly

Aorta and esophagus are next to each other

NG tube may help

Aortic Injury

Usually small wound, sealed off

Finger pressure

Side-biting clamp

Repair with 3-0 or 4-0 with pledget

Internal Cardiac Massage

Perform with 2-handed technique to avoid perforation of the ventricle

Much more efficient (55% of cardiac output versus 20% with external CPR)

Give it a good chance (>15-20 minutes)

Defibrillate at 20 Joules

PearlsBe prepared. Have an algorithm.

Penetrating trauma has a much better chance. Is it even worth it in blunt trauma?

Get a surgeon involved ASAP.

Left anterolateral approach is usually best place to start.

4th ICS is best. Below nipple in men, breast crease in women.

Place handle of retractor downwards

Don’t make incision too low

Pearls (cont…)

Make incision above the rib (avoid neurovascular bundle)

Access to thoracic cavity should take < 2 minutes

Use OR or surgeons if at all possible

You will need a lot of blood!

“Better lucky than good”

“The more I practice, the luckier I get!”

GOOD LUCK!