Thoracotomy

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. Push lung out of way to access pericardium
6. Pericardiotomy
   1. Pick up pericardium just anterior to phrenic nerve
   2. Incise from apex to root of aorta parallel to phrenic nerve
7. Inspect myocardium for lacerations
   1. Digital occlusion
   2. Skin stapler
   3. Foley catheter w/ purse-string suture around it (closes wound when foley removed)
   4. Horizontal mattress (can be difficult w/ beating heart)
8. Cardiac Massage
   1. one-handed vs two-handed
9. Internal Defibrillation
10. 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
11. Autotransfuse thoracic blood
12. If no e/o injury to L-side but poss R-sided injury extend to R side (clam shelling)

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)