Thoracotomy: Difference between revisions

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==Background==
==Goals==
* 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
#Release tamponade
* each hemithorax can contain about 50% of the pts blood volume before it becomes obvious!!
#Control intrathoracic/cardiac bleeding
* 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
#Control air embolism
* internal mammory vessels are .5-1cm lateral to the sternum, try and avoid
#Cardiac massage
* Post aorta clamping sbp <70=survival unlikely. sbp>160-180=strain on LV can lead to acute failure so remove clamp.
#Temporary occlusion of descending aorta (optimize flow to brain and heart)
* 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)
* One study of 4520 EDTs had 15% of survivors w/ severe neurologic defecits.


==Indications==
==Indications for ED Thoracotomy==
# Penetrating Chest trauma w/ signs of life in field (pulse palp, respirations, cardiac activity on monitor > 40 bpm, pupillary reactivity)
#Penetrating chest trauma w/ signs of life in the field
##Stab wounds have better survival than GSWs (19% vs. 8%)
##Pulse, BP, pupil reactivity, purposeful movement, organized rhythm, respiratory effort)
##Some authors recommend thoracotomy in penetrating abd. trauma w/ persistent hypotension or arrest (surv 5%)
#Blunt chest trauma w/ signs of life lost in ED
# 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
#[[Thoracotomy (Peds)]]


For pediatric indications see [[Thoracotomy (Peds)]]
==Indications for OR Thoracotomy==
 
===Thoracotomy in OR===
#Thoracoabdominal trauma pts w/ persistent SBP < 70-80 despite aggressive resus.
#Thoracoabdominal trauma pts w/ persistent SBP < 70-80 despite aggressive resus.
#Chest tube drainage > 1500 ml initially or > 200 mL/hr for 2-4hr
#Chest tube drainage > 1500 ml initially or > 200 mL/hr for 2-4hr
#Evidence of cardiac tamponade or progressively inc hemothorax.
#Evidence of cardiac tamponade or progressively inc hemothorax


===2001 ACS-COT Recs on EDT===
==Procedure==
# Rarely in pts sustaining cardiopulmonary arrest secondary to blunt trauma due to the unacceptably low survival rate and poor neurologic outcomes
#Intubate and place NGT
#Should be limited to those that arrive with vital signs at the TC & have a witnessed cp arrest
#Always start with left-sided approach (even if penetrating injury is on right side)
# Best applied to pts sustaining penetrating cardiac injuries who arrive at a TC after a short transport with witnessed signs of life
#Incise from sternum to to posterior axillary line (4th or 5th intercostal space)
# Should be done on pts with penetrating, non-cardiac thoracic injuries
##Cut through skin, soft tissue, and muscle in one pass
# Should be done in pts with exsanguinating abdominal vascular injuries, although these pts have a low survival rate
##May scissors can be used to cut the intercostal muscle
 
#Rib spreader with rachet bar down
^level 2 recs and applies to peds
#Pericardiotomy
##Pick up pericardium ant to phrenic nerve
##Start incision near diaphragm & open pericardium parallel to phrenic nerve
##Clamp sites of active bleeding
#Internal Defibrillation
#Cardiac Massage
##one-handed vs two-handed
#Inspect myocardium for lacerations
##Close with Foley and purse-string stitch or 2 horizontal mattresses
#Cross Clamp Aorta
##Up to 30 min is tolerated
##Indicated after persistent hypotension after pericardiotomy and fluid resus
##Aorta posterior to NGT
#Autotransfuse thoracic blood


==Procedure==
==Prognosis==
# Intubate, NGT, sedate at same time
*11.2% survival for penetrating trauma
# Left arm overhead, towel under, prepare autotransfuser, incision in L intercostal space, sternum to axilla. Go through skin, tissue & muscle in one pass.
**31.1% for penetrating cardiac injury
# Cut muscle with scissors, halt respirations and use other hand to widen the hole, push lung out of way. Incise to post axillary line.
*1.6% for blunt trauma
# Rib spreader with rachet bar down
*15% of survivors had severe neurologic defecits
# 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
# Clamp sites of active bleeding
# Internally Defibrillate
# 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.
# Cross Clamp the Aorta, indicated after persistent hypotension after pericardiotomy and fluid resus. NGT in esophagus, thus, aorta post ngt. (see facts #8)
# Autotransfuse thoracic blood


==See Also==
==See Also==
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==Source==
==Source==
(Fernandez Lec 2003)
(Fernandez Lec 2003)
(Trauma Reports 12/03) -by Lampe
(Trauma Reports 12/03)


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 05:40, 18 July 2011

Goals

  1. Release tamponade
  2. Control intrathoracic/cardiac bleeding
  3. Control air embolism
  4. Cardiac massage
  5. Temporary occlusion of descending aorta (optimize flow to brain and heart)

Indications for ED Thoracotomy

  1. Penetrating chest trauma w/ signs of life in the field
    1. Pulse, BP, pupil reactivity, purposeful movement, organized rhythm, respiratory effort)
  2. Blunt chest trauma w/ signs of life lost in ED
  3. Consider for exsanguinating abdominal vascular injuries
  4. Thoracotomy (Peds)

Indications for OR Thoracotomy

  1. Thoracoabdominal trauma pts w/ persistent SBP < 70-80 despite aggressive resus.
  2. Chest tube drainage > 1500 ml initially or > 200 mL/hr for 2-4hr
  3. Evidence of cardiac tamponade or progressively inc hemothorax

Procedure

  1. Intubate and place NGT
  2. Always start with left-sided approach (even if penetrating injury is on right side)
  3. Incise from sternum to to posterior axillary line (4th or 5th intercostal space)
    1. Cut through skin, soft tissue, and muscle in one pass
    2. May scissors can be used to cut the intercostal muscle
  4. Rib spreader with rachet bar down
  5. Pericardiotomy
    1. Pick up pericardium ant to phrenic nerve
    2. Start incision near diaphragm & open pericardium parallel to phrenic nerve
    3. Clamp sites of active bleeding
  6. Internal Defibrillation
  7. Cardiac Massage
    1. one-handed vs two-handed
  8. Inspect myocardium for lacerations
    1. Close with Foley and purse-string stitch or 2 horizontal mattresses
  9. Cross Clamp Aorta
    1. Up to 30 min is tolerated
    2. Indicated after persistent hypotension after pericardiotomy and fluid resus
    3. Aorta posterior to NGT
  10. Autotransfuse thoracic blood

Prognosis

  • 11.2% survival for penetrating trauma
    • 31.1% for penetrating cardiac injury
  • 1.6% for blunt trauma
  • 15% of survivors had severe neurologic defecits

See Also

Thoracotomy (Peds)

Source

(Fernandez Lec 2003) (Trauma Reports 12/03)

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