Thoracotomy
Goals
- Release tamponade
- Control intrathoracic/cardiac bleeding
- Control air embolism
- Cardiac massage
- Temporary occlusion of descending aorta (optimize flow to brain and heart)
Indications for ED Thoracotomy
- Penetrating chest trauma w/ signs of life in the field
- Pulse, BP, pupil reactivity, purposeful movement, organized rhythm, respiratory effort)
- Blunt chest trauma w/ signs of life lost in ED
- Consider for exsanguinating abdominal vascular injuries
- Thoracotomy (Peds)
Indications for OR Thoracotomy
- Thoracoabdominal trauma pts w/ persistent SBP < 70-80 despite aggressive resus.
- Chest tube drainage > 1500 ml initially or > 200 mL/hr for 2-4hr
- Evidence of cardiac tamponade or progressively inc hemothorax
Procedure
- Intubate and place NGT
- Always start with left-sided approach (even if penetrating injury is on right side)
- 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
- Rib spreader with rachet bar down
- 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
- Foley catheter w/ purse-string suture around it (closes wound when foley removed)
- Horizontal mattress (can be difficult w/ beating heart)
- Cardiac Massage
- one-handed vs two-handed
- Intracardiac epinephrine
- Internal Defibrillation
- Lower voltages than external defibrillation
- 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
- 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
Source
(Fernandez Lec 2003) (Trauma Reports 12/03)