Thoracotomy
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Background
- 1st introduced 1882 Dr. Block in his canine heart lac expt., 1889 Tuffier had 1st succesful open massage, Dr. Beck popularized it for the next 50-60 yrs and became the standard of care in the OR, and fell out of favor as external defib and closed heart massage was introduced
- 80% of tamponade d/t SW
- 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
- each hemithorax can contain about 50% of the pts blood volume before it becomes obvious!!
- external cardiac compression can provide 10-20% of baseline cardiac output (reasonable salvage up to 15 min, and diminished survival at 30 min), open cardiac massage deliver up to 60% of baseline (aortic pressure & CO can be kept at 50-70% which allows reasonable salvage at 30 min). also w/ hypovolemia, ext cardiac compression provides inadequate coronay and cerebral perfusion. (chest '77, j. trauma '82)
- 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
- fyi internal mammory vessels are .5-1cm lateral to the sternum, try and avoid:)
- Post aorta clamping sbp <70=survival unlikely. sbp>160-180=strain on LV can lead to acute failure so remove clamp.
- 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
- Penetrating Chest trauma w/ signs of life in field (pulse palp, respirations, cardiac activity on monitor > 40 bpm, pupillary reactivity)
- Stab wounds have better survival than GSWs (19% vs. 8%)
- Some authors recommend thoracotomy in penetrating abd. trauma w/ persistent hypotension or arrest (surv 5%)
- Blunt Trauma w/ signs of life lost in ED. No long term survival in blunt trauma pts who lose signs of life in field.
Thoracotomy in OR
- 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.
2001 ACS-COT Recs on EDT
- 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
Procedure
- Intubate, NGT, sedate at same time
- Left arm overhead, towel under, prepare autotransfuser, incision in L intercostal space, sternum to axilla. Go through skin, tissue & muscle in one pass.
- Cut muscle with scissors, halt respirations and use other hand to widen the hole, push lung out of way. Incise to post axillary line.
- Rib spreader with rachet bar down
- 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
Source
(Fernandez Lec 2003) (Trauma Reports 12/03) -by Lampe