Thoracotomy: Difference between revisions

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==Background==
==Indications==
* 5 goals of EDT are to release tamponade, control intrathoracic/caridac bleeding, control air embolism, open massage, temporary occlusion of the desc aorta= optimizing blood flow to brain and heart
===ED Thoracotomy===
* each hemithorax can contain about 50% of the pts blood volume before it becomes obvious!!
====Penetrating [[chest trauma]]====
* cross clamp aorta can incr afterload & O2 demand on heart. Up to 30 min is tolerated, >30min=isch & anaeorobic metab=acidemia=multi organ dysf(x), removing clamp=wash out of metabolic by-products & inflamm mediator, =shock=organ failure
*Signs of Life (pre or in-hospital)
* internal mammory vessels are .5-1cm lateral to the sternum, try and avoid
**Pulse, BP, pupil reactivity, purposeful movement, respiratory effort
* Post aorta clamping sbp <70=survival unlikely. sbp>160-180=strain on LV can lead to acute failure so remove clamp.
**Cardiac Activity
* survival rate of 7035 EDTs was 7.8% (11.2% for penetr, & 1.6% for blunt, 31.1% for penetr cardiac inj). 142 peds had overall surv of 6.3%. (j. surg 2001)
***PEA is acceptable
* One study of 4520 EDTs had 15% of survivors w/ severe neurologic defecits.
*Unresponsive [[hypotension]]
**SBP<70 despite treatment


==Indications==
====Blunt chest trauma====
# Penetrating Chest trauma w/ signs of life in field (pulse palp, respirations, cardiac activity on monitor > 40 bpm, pupillary reactivity)
*Witnessed signs of life (pre or in-hospital)
##Stab wounds have better survival than GSWs (19% vs. 8%)
*Rapid exsanguination
##Some authors recommend thoracotomy in penetrating abd. trauma w/ persistent hypotension or arrest (surv 5%)
**>1000-1500mL initial drainage or >200mL/hr from Chest tube
# Blunt Trauma w/ signs of life lost in ED. No long term survival in blunt trauma pts who lose signs of life in field.
*Consider for exsanguinating abdominal vascular injuries with witnessed signs of life
*Unresponsive hypotension
**SBP<70 despite treatment


For pediatric indications see [[Thoracotomy (Peds)]]
===OR Thoracotomy===
*Thoracoabdominal trauma patients with persistent SBP < 70-80 despite aggressive resuscitation
*Evidence of [[cardiac tamponade]] or progressively increasing [[hemothorax]]
*[[Chest tube]] drainage
**> 20ml/kg initially (> 1500ml in adult)
**> 3 ml/kg/hr for 2-4hrs (> 200 mL/hr for 2-4hr in adult)
**Persistent bleeding > 7 ml/kg/hr
**Persistent air leak (bronchopleural fistula)


===Thoracotomy in OR===
==Goals==
#Thoracoabdominal trauma pts w/ persistent SBP < 70-80 despite aggressive resus.
*Release [[tamponade]]
#Chest tube drainage > 1500 ml initially or > 200 mL/hr for 2-4hr
*Control intrathoracic/cardiac bleeding
#Evidence of cardiac tamponade or progressively inc hemothorax.
*Control air embolism
*Cardiac massage
*Temporary occlusion of descending aorta (optimize flow to brain and heart)


===2001 ACS-COT Recs on EDT===
{{Thoracotomy contraindications}}
# Rarely in pts sustaining cardiopulmonary arrest secondary to blunt trauma due to the unacceptably low survival rate and poor neurologic outcomes
#Should be limited to those that arrive with vital signs at the TC & have a witnessed cp arrest
# Best applied to pts sustaining penetrating cardiac injuries who arrive at a TC after a short transport with witnessed signs of life
# Should be done on pts with penetrating, non-cardiac thoracic injuries
# Should be done in pts with exsanguinating abdominal vascular injuries, although these pts have a low survival rate


^level 2 recs and applies to peds
==Equipment Needed==
*PPE
*Thoracotomy Tray
**Rib Spreader
** #10 or #21 Scalpel, Scissors, Forceps
**Vascular Clamps, Curved Artery Forceps, Needle Driver
**Internal Defibrillation Paddles
**Skin Stapler, Suture Material


==Procedure==
==Procedure==
# Intubate, NGT, sedate at same time
[[File:Gray530.png|thumb|Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.]]
# Left arm overhead, towel under, prepare autotransfuser, incision in L intercostal space, sternum to axilla. Go through skin, tissue & muscle in one pass.
[[File:1459269 1749-7922-1-4-4.png|thumb|ED thoracotomy]]
# Cut muscle with scissors, halt respirations and use other hand to widen the hole, push lung out of way. Incise to post axillary line.
#[[Intubate]] and place NGT
# Rib spreader with rachet bar down
#Always start with left-sided approach (even if penetrating injury is on right side)
# Relieve Tamponade - by a pericardiotomy, pick up pericardium anterior to phrenic nerve, start incision (nick w/ scalpel) near diaphragm & open pericardium parallel to phrenic nerve
#*If possible, should have concurrent right sided chest tube being placed
# Clamp sites of active bleeding
#Incise from sternum to to posterior axillary line (4th or 5th intercostal space)
# Internally Defibrillate
#*Cut through skin, soft tissue, and muscle in one pass
# Internal Cardiac Massage - one- handed vs. two-handed, inspect myocardium for lacerations, may close with a Foley and purse-string stitch or 2 horizontal mattresses.
#*May scissors can be used to cut the intercostal muscle
# Cross Clamp the Aorta, indicated after persistent hypotension after pericardiotomy and fluid resus. NGT in esophagus, thus, aorta post ngt. (see facts #8)
#Rib spreader with rachet bar down
# Autotransfuse thoracic blood
#Push lung out of way to access pericardium
#Pericardiotomy
#*Pick up pericardium just anterior to phrenic nerve
#*Incise from apex to root of aorta parallel to phrenic nerve
#Inspect myocardium for lacerations
#*Digital occlusion
#*Skin stapler - if coronary artery stapled, it can be removed in the OR
#*Foley catheter with purse-string suture around it (closes wound when foley removed)
#*Horizontal mattress (can be difficult with beating heart)
#Cardiac Massage
#*one-handed vs two-handed
#*Intracardiac epinephrine
#Internal Defibrillation
#*Lower voltages than external defibrillation
#*Start at 5J to a max of 50J
#Cross Clamp Aorta
#*Up to 30 min is tolerated
#*Indicated after persistent hypotension after pericardiotomy and fluid resus
#*Aorta posterior to NGT
#[[pRBCs|Autotransfuse]] thoracic blood
#If no evidence of injury to L-side, but possible R-sided injury, extend to R side (clam shelling)
 
==Complications==
*Risk of percutaneous injury and exposure to blood-borne pathogens to operator
 
==Comments==
*Survival rates are uniformly poor with guidelines reporting:<ref>Hopson LR et al. Guidelines for withholding or termina- tion of resuscitation in prehospital traumatic cardiopulmonary arrest: Joint Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2003; 196:106.</ref>
**Blunt trauma survival as great as 2%
**Penetrating trauma survival as great 16%
*Meta-analysis reports overall rates closer to 1.5% with favorable neurologic outcome<ref name="slessor">Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307</ref>
*Best outcomes occur if the patient arrested less than 15 minutes before the procedure.
*For blunt trauma survival rate may be closer to 0.8%<ref name="slessor" />


==See Also==
==See Also==
[[Thoracotomy (Peds)]]
*[[Thoracotomy (Peds)]]
 
==External Links==
*[https://emcrit.org/emcrit/procedure-of-thoracotomy/ EMCrit: Crack to Cure]
*[https://rebelem.com/if-youre-going-to-do-the-thoracotomydo-a-clamshell/ REBEL EM: The Clamshell Thoracotomy]
*[https://criticalcarenow.com/2021/01/05/a-cracking-way-to-start-the-year/ CriticalCareNow: A Cracking Way to Start the New Year]


==Source==
==References==
(Fernandez Lec 2003)
<references/>
(Trauma Reports 12/03) -by Lampe


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Critical Care]]

Latest revision as of 13:58, 16 July 2021

Indications

ED Thoracotomy

Penetrating chest trauma

  • Signs of Life (pre or in-hospital)
    • Pulse, BP, pupil reactivity, purposeful movement, respiratory effort
    • Cardiac Activity
      • PEA is acceptable
  • Unresponsive hypotension
    • SBP<70 despite treatment

Blunt chest trauma

  • Witnessed signs of life (pre or in-hospital)
  • Rapid exsanguination
    • >1000-1500mL initial drainage or >200mL/hr from Chest tube
  • Consider for exsanguinating abdominal vascular injuries with witnessed signs of life
  • Unresponsive hypotension
    • SBP<70 despite treatment

OR Thoracotomy

  • Thoracoabdominal trauma patients with persistent SBP < 70-80 despite aggressive resuscitation
  • Evidence of cardiac tamponade or progressively increasing hemothorax
  • Chest tube drainage
    • > 20ml/kg initially (> 1500ml in adult)
    • > 3 ml/kg/hr for 2-4hrs (> 200 mL/hr for 2-4hr in adult)
    • Persistent bleeding > 7 ml/kg/hr
    • Persistent air leak (bronchopleural fistula)

Goals

  • Release tamponade
  • Control intrathoracic/cardiac bleeding
  • Control air embolism
  • Cardiac massage
  • Temporary occlusion of descending aorta (optimize flow to brain and heart)

Contraindications

  • No absolute contraindications to ED thoracotomy (emergent procedure)
  • Relative Contraindications
    • Blunt injury without witness cardiac activity
    • Penetrating abdominal trauma without cardiac activity
    • Non-traumatic cardiac arrest
    • Severe head injury
    • Severe multi-system injury
    • Improper Setting
      • Understaffed ER/Improperly trained staff/Insufficient equipment

Equipment Needed

  • PPE
  • Thoracotomy Tray
    • Rib Spreader
    • #10 or #21 Scalpel, Scissors, Forceps
    • Vascular Clamps, Curved Artery Forceps, Needle Driver
    • Internal Defibrillation Paddles
    • Skin Stapler, Suture Material

Procedure

Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.
ED thoracotomy
  1. Intubate and place NGT
  2. Always start with left-sided approach (even if penetrating injury is on right side)
    • If possible, should have concurrent right sided chest tube being placed
  3. Incise from sternum to to posterior axillary line (4th or 5th intercostal space)
    • Cut through skin, soft tissue, and muscle in one pass
    • May scissors can be used to cut the intercostal muscle
  4. Rib spreader with rachet bar down
  5. Push lung out of way to access pericardium
  6. Pericardiotomy
    • Pick up pericardium just anterior to phrenic nerve
    • Incise from apex to root of aorta parallel to phrenic nerve
  7. Inspect myocardium for lacerations
    • Digital occlusion
    • Skin stapler - if coronary artery stapled, it can be removed in the OR
    • Foley catheter with purse-string suture around it (closes wound when foley removed)
    • Horizontal mattress (can be difficult with beating heart)
  8. Cardiac Massage
    • one-handed vs two-handed
    • Intracardiac epinephrine
  9. Internal Defibrillation
    • Lower voltages than external defibrillation
    • Start at 5J to a max of 50J
  10. Cross Clamp Aorta
    • Up to 30 min is tolerated
    • Indicated after persistent hypotension after pericardiotomy and fluid resus
    • Aorta posterior to NGT
  11. Autotransfuse thoracic blood
  12. If no evidence of injury to L-side, but possible R-sided injury, extend to R side (clam shelling)

Complications

  • Risk of percutaneous injury and exposure to blood-borne pathogens to operator

Comments

  • Survival rates are uniformly poor with guidelines reporting:[1]
    • Blunt trauma survival as great as 2%
    • Penetrating trauma survival as great 16%
  • Meta-analysis reports overall rates closer to 1.5% with favorable neurologic outcome[2]
  • Best outcomes occur if the patient arrested less than 15 minutes before the procedure.
  • For blunt trauma survival rate may be closer to 0.8%[2]

See Also

External Links

References

  1. ↑ Hopson LR et al. Guidelines for withholding or termina- tion of resuscitation in prehospital traumatic cardiopulmonary arrest: Joint Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2003; 196:106.
  2. ↑ 2.0 2.1 Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307
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