Thoracotomy (peds)

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  • Chest tube output
    • >10-15mL/kg evacuated
    • >2-4mL/kg/hr continuous
  • Continuous air leak

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)


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


  • 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


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)


See Also

External Links