Trauma: ED Resuscitative Thoracotomy

General Approach

• Incision
• Open Pericardial Sac – Typically the First Step
• ACLS Measures as Indicated
  • Cardiac Massage
  • Internal Defibrillation
  • Intracardiac Epinephrine
• Cross-Clamp Aorta
• Control Any Overt Hemorrhage
• Aspiration if Air Embolism Suspected
• *Order May Vary Depending on Presentation

Incision

• Left Anterolateral Thoracotomy (Some Prefer “Clamshell” Bilateral Anterolateral Thoracotomy)
• Place Left Arm Above the Head
• Incision at the Left Intercostal Space #4-5
  • Just Under the Nipple or Inframammary Fold
  • Extend from the Sternum All the Way Down to the Bed Along the Curvature of the Rib
• Enter Along Superior Margin of Lower Rib Using Curved Mayo Scissors to Cut Through Intercostals
• Use a Rib Spreader (Finochietto Retractor)

Pericardiotomy/Open Pericardial Sac

• Open Pericardium Parallel & Anterior to Phrenic Nerve
• Evacuate Any Pericardial Clot
• Control Any Active Bleeding
  • Digital Pressure on Ventricles or Vascular Clamps on Atrium
  • Definitive Repair May Be Delayed Until Initial Resuscitation Complete
• *Always Open – Some Consider it Acceptable to Skip if No Tamponade or There Are Obvious Non-Cardiac Injuries

Cardiac Massage & Internal Defibrillation

• Cardiac Massage
  • Two-Hand Hinged “Clapping” Technique
  • Do Not Use Finger Tips or One-Hand with Thumb Which May Penetrate Myocardium
  • Induced Cardiac Output:
    • External Compressions: 20-25% of Baseline
    • Internal Massage: 60-70% of Baseline
• Internal Defibrillation If in Ventricular Fibrillation
  • One Paddle on Anterior Surface and One on Posterior Surface
  • Maximum of 50 J – Do Not Need to “Clear” from Touching the Patient Due to Low Energy
• Also Consider Intracardiac Epinephrine to the Left Ventricle

Cross-Clamp Aorta

• Indicated if Hypotension (SBP < 70 mmHg) Persists After Pericardiotomy
• Retract Left Lung Superiorly/Anteriorly
  • May Need to Divide Inferior Pulmonary Ligament (Risks Injury to Inferior Pulmonary Vein)
• Dissect the Thoracic Aorta
  • Incise the Mediastinal Pleura
  • Bluntly Separate the Esophagus from the Aorta
    • Esophagus Lies Anterior to Aorta – Take Care to Avoid Cross-Clamping the Esophagus
    • Both May Appears Flaccid in Hypotensive Patient Making Identification Difficult
  • Bluntly Separate the Aorta from the Posterior Vertebrae
• Clamp Aorta Just Above the Diaphragm
  • Use a Large DeBakey or Satinsky Clamp

Additional Measures

• Anesthesiology Can Right Main-Stem ET Tube to Reduce Left Lung Ventilation
• Control Hemorrhage & Repair
  • Cardiac Injury
    • Control Injury to the Heart First
    • Often Use 3-0 Prolene (Non-Absorbable)
    • Often Perform Simple Running in Atrium & Vertical Mattress in Ventricles
    • May Require Buttressing with Teflon Pledgets
  • Lung Injury
    • Options if Hemorrhaging from Lung:
      • Clamp Parenchyma
      • Clamp Hilum (From Superior to Inferior – Does Not Require Mobilization)
      • “Pulmonary Hilar Twist”
        • First Divide Inferior Pulmonary Ligament
        • Rotate the Lower Lobe Anteriorly Over the Upper Lobe
        • *Last Choice – Will Most Likely Require Pneumonectomy if Maintained for Prolonged Period of Time During Resuscitation in the ICU
  • Control Any Other Obvious Sites of Bleeding
• Evacuate Air Embolism
  • *From Traumatic Bronchovenous Communications
    • Due to Relatively High Bronchoalveolar Pressure & Low Pulmonary Venous Pressure
    • Often Seen as Acute Decompensation Shortly After Intubation & Positive-Pressure Ventilation
  • Cross-Clamp the Hilum of the Suspected Source – Prevent Propagation
  • Trendelenburg Position & Aspirate Air from Apex of Left Ventricle & Aortic Root