ED ThoracotomyIndications &

ProcedureJeremy Mason

6th November 2015

25% – 50% all traumatic injuries involve thorax

Thoracotomy is an integral part of resuscitation in selected patients

Need to decide quickly if thoracotomy is indicated to increase chance of survival

Patients may deteriorate prehospital or in the ED and this may be the only option to restore life

Thoracic trauma

Release cardiac tamponade

Control haemorrhage

Perform open cardiac massage

Cross clamp the descending thoracic aorta

Control air embolism

Aims of thoracotomy

Penetrating thoracic injury

◦ Haemodynamic instability (SPB <70mmHg despite vigorous fluid resuscitation)

◦ Traumatic arrest with previously witnessed cardiac activity (prehospital or ED)

Indications;

Blunt thoracic injury

◦ Cardiac tamponade diagnosed rapidly on USS with no obvious non survivable injury

◦ Unresponsive hypotension (SPB < 70mmHg)

◦ >1500ml from chest tube immediately returned

Indications;

Penetrating chest injury – traumatic arrest without witnessed cardiac activity

Penetrating non thoracic injury (abdominal or peripheral) with previously witnessed cardiac activity

Blunt thoracic injuries with traumatic arrest with previously witnessed cardiac activity

Relative indications

Penetrating injuries

◦ Patient has no signs of life at injury scene

◦ Asystole with no pericardial tamponade

◦ Prolonged pulselessness (>15 mins)

◦ Other massive nonsurvivable injuries have occurred

Poor outcome measures;

Blunt injury

◦ Patient requires >10 minutes prehospital CPR

◦ Patient has no signs of life at scene of injury

◦ Patient has other massive non survivable injuries

Poor outcome measures

Non traumatic cardiac arrest

Severe head or multisystem injury

Improperly trained team

Insufficient equipment

Contraindications

Eastern Association for the Surgery of Trauma USA - Journal of Acute Care Surgery – 2015

Reviewed 72 studies – 10,238 ED Thoracotomies

Patients presenting pulseless to the ED – ED Thoracotomy vs Resus without EDT

Measured signs of life as◦ Pupillary response

◦ Spontaneous ventilation

◦ Palpable carotid pulse

◦ Measurable BP

◦ Moving extremities

◦ Cardiac electrical activity

Guidelines

Best outcome in patients presenting pulseless with penetrating thoracic injury

◦ With signs of life – strongly recommend EDT 21.3% survival (8x higher) 11.7% neurologically intact survival (5x higher)

◦ Without signs of life – conditionally recommend EDT 8.3% survival (41 x higher) 3.9% neurologically intact survival (20 x higher)

Guidelines

Penetrating extrathoracic injury

◦ Signs of life – Conditionally recommend EDT Survival 15.6% (9x higher) Neurologically intact survival 16.5% (11 x higher)

◦ No signs of life – Conditionally recommend EDT Survival 2.9% (29 x higher) Neurologically intact survival 5% (56 x higher)

Guidelines

Pulseless Blunt Injury

◦ With signs of life – Conditionally recommend EDT Survival 4.6% (9x higher) Neurologically intact survival 2.4% (8x higher)

◦ Without signs of life – Recommend against EDT Survival 0.7% Neurologically intact survival 0.1%

Guidelines

Anatomy

www.instantanatomy.netMoore Anatomy

https://calsprogram.org/manual/volume2/Section7_Circulation%20Skills/05-CirSk4EmergThoracotomy13.html

Located in T2

Ribspreaders in tray

Scalpel + Blade – need to get from FT cupboard

Tuffcut scissors mounted on wall of T2

SCGH ED Thoracotomy Kit

Scalpel + Blade Retractor – Finochietto’s rib spreader or Balfour abdominal

retractor Gigli Saw / Tuffcut Scissors Curved Mayos Scissors Toothed forceps DeBakey Aortic Clamp Mosquito artery forceps Foley catheter Satinsky large vascular clamps Needle holders Internal defibrillator clamps Sutures, sternal wires

Thoracotomy Kit

All you really need

Trauma Call

Universal precautions

Intubate and ventilate patient◦ Intubate right main bronchus to collapse left lung

Fluid resucitation + Blood Products / Massive Transfusion Protocol

15 degree headup

Surgically prep the area

Antibiotic prophylaxis

Preparation

Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study Simms ER, Flaris AN, Franchino X, et al.. World J Surg 2013; 37:1277.

Looked at 6 different thoracotomy incisions on cadavers

Left and Right Anterolateral, Left 2nd intercostal incision, Left 3rd Intercostal incision, median sternotomy & Clamshell

◦ Clamshell fastest for access and best for control of thoracic structures in Emergency Thoracotomy

Research

Procedure “Clamshell Incision”

A – 5th intercostal space thoracostomy bilaterally midaxillary line

B – Incise skin and subcut fat

C & D – Extend to sternum

E – Cut sternum

F – Finochietto retractor (Bar on right)

Simms et al 2013

https://www.youtube.com/watch?v=8BlPxQI2C90

Penetrating cardiac injury◦ Direct digital pressure◦ Staple cardiac defect closed◦ Suture closure of injury◦ Pass Foley catheter through defect, inflate balloon, apply traction

Abdominal Haemorrhage / Hypoperfusion◦ Cross clamp thoracic aorta to redistribute blood to myocardium and

brain (Doubles MAP and Cardiac Output)◦ Pass NG Tube to help identify Oesophagus vs Descending Aorta◦ Ideally clamp just above diaphragm – maximize spinal cord perfusion

Haemorrhage from pulmonary parenchyma or major pulmonary vasculature◦ Clamp pulmonary Hilum / Injured tissue / Bleeding vessel◦ Hilar twist

Once in the chest

Pericardiotomy◦ If no other obvious injuries and cannot see myocardium

through pericardium◦ Identify phrenic nerve anterolateral surface of pericardium◦ Grasp pericardium anterior to phrenic nerve with tooth

forceps – extend incision parallel to phrenic nerve◦ Evacuate blood clots / Pericardial fluid◦ Deliver heart from pericardial sac to inspect or fix defects

Air Embolism◦ Air in coronary vessels, heart or aorta is diagnostic◦ Clamp hilum of affected lung◦ Ventilate unaffected lung only

Once in the chest

Open cardiac massage ◦ Start open cardiac massage immediately after

placing thoracic aorta clamp◦ 2 Hand “clapping” technique – wrists together at

apex◦ Internal massage better at maintaining Cardiac

Output + Cerebral perfusion in animal studies that external compressions

Internal Defibrillation◦ VF – Shock 10J, repeat up to 50J (AP Paddles)

Once in the chest

https://youtu.be/A57ZB_J4FuY

SMACC Chicago 2015 John Hinds

https://www.youtube.com/watch?v=GFX_tocJShA

Intention to perform procedure should be quick

Give a lead in – state from the outset the plan so everyone knows what is coming

Rules in the sick obtunded trauma patient◦ 1) Dont dick about with a duff anaesthetic◦ 2) If they do arrest - dont dick about with a duff

resuscitation attempt

Learn indications and evidence as you wont have time to look these up when you need to perform the procedure!

“Crack the Chest; Get Crucified”

Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study Simms ER, Flaris AN, Franchino X, et al.. World J Surg 2013; 37:1277.

An evidenced based approach to patient selection for emergency department thoracotomy: A practice management guideline for the Eastern Association for the Surgery of Trauma Seamon et al. Journal of Trauma Acute Care Surgery. 2015, Volume 79, Number 1 159:173

Emergency thoracotomy in thoracic trauma-a review. Hunt et al. Injury. 2006 Jan;37(1):1-19. Epub 2005 Apr 20

Western Trauma Association Critical Decisions in Trauma: Resuscitative thoracotomy, Cburlew et al, 2012 Guideline

http://lifeinthefastlane.com/ed-thoracotomy-is-it-just-the-first-part-of-the-autopsy/, Kane Guthrie

http://www.uptodate.com/contents/resuscitative-thoracotomy-technique

SMACC Chicago, June 2015, “Crack The Chest; Get Crucified”, John Hinds

References