1. Emergency ThoracotomyEmergency Thoracotomy
in the EDin the ED
Mark CordenMark Corden
Sir Charles Gairdner EmergencySir Charles Gairdner Emergency
66thth
March 2014March 2014

4. Emergency ThoracotomyEmergency Thoracotomy
 Definition:Definition:

““occurring either immediately at the site of
injury, or in the emergency department or
operating room as an integral part of the initial
resuscitation process”.
• P.A. Hunt, I. Greaves, W.A. Owens – 2005.

5. Thoracic TraumaThoracic Trauma
 One of the leading causes of death in all
age groups, accounts for 25-50% of all
traumatic injuries.
 The majority of patients with thoracic
trauma can be managed non-operatively,
with or without tube thoracostomy.

6. IntroductionIntroduction
Roberts and Hedges – 6Roberts and Hedges – 6thth
EditionEdition
 Given the circumstances surrounding theGiven the circumstances surrounding the
procedure and the associated injuries, fewprocedure and the associated injuries, few
patients survive.patients survive.
 The poor overall survival rates, however,The poor overall survival rates, however,
should not discourage performance of theshould not discourage performance of the
procedure in the correct setting and whenprocedure in the correct setting and when
appropriate surgical backup is availableappropriate surgical backup is available
for definitive care.for definitive care.

7. BackgroundBackground
 Emergency Thoracotomy (ET) initiallyEmergency Thoracotomy (ET) initially
proposed as treatment for penetratingproposed as treatment for penetrating
cardiac injuries in 1966.cardiac injuries in 1966.
 Approx. 16% survival in penetratingApprox. 16% survival in penetrating
trauma but varying rates per institutions.trauma but varying rates per institutions.
 ~2% survival of patients with blunt trauma.~2% survival of patients with blunt trauma.

8. Might it work then?Might it work then?
 Factors associated with increased chance ofFactors associated with increased chance of
success:success:

Signs of Life – in ED.Signs of Life – in ED.

Penetrating thoracic injury (vs. blunt)Penetrating thoracic injury (vs. blunt)

Stab wounds (vs. gunshot or explosive wounds)Stab wounds (vs. gunshot or explosive wounds)

Thoracic Injuries (vs. abdominal injuries)*.Thoracic Injuries (vs. abdominal injuries)*.

Blunt injury WITH: <5 mins CPR + signs of life.Blunt injury WITH: <5 mins CPR + signs of life.

Cardiac Rhythm: VF, VT or PEA vs. Asystole, severeCardiac Rhythm: VF, VT or PEA vs. Asystole, severe
bradycardia.bradycardia.

9. Thus. Indications.Thus. Indications.
 Release of pericardial tamponade:Release of pericardial tamponade:

improves cardiac output and control of cardiac haemorrhage.improves cardiac output and control of cardiac haemorrhage.
 Control of intrathoracic vascular or cardiac haemorrhage:Control of intrathoracic vascular or cardiac haemorrhage:

Penetrating thoracic trauma withPenetrating thoracic trauma with
• signs of life and CPR <15 minssigns of life and CPR <15 mins
• Sys BP<70mmHg despite vigorous fluid resuscitation.Sys BP<70mmHg despite vigorous fluid resuscitation.

Blunt thoracic trauma withBlunt thoracic trauma with
• signs of life and CPR <5mins.*signs of life and CPR <5mins.*
• Post ICC with >1500mls rapid drainage/exsanguination.Post ICC with >1500mls rapid drainage/exsanguination.
 Aorta cross clamping in blunt or penetrating abdominalAorta cross clamping in blunt or penetrating abdominal
traumatrauma

Those NOT in cardiac arrest.Those NOT in cardiac arrest.
 Open cardiac massageOpen cardiac massage

Witnessed, in-hospital arrest where CPR may be ineffective.Witnessed, in-hospital arrest where CPR may be ineffective.
 Air Embolus **Air Embolus **

10. Contraindications.Contraindications.
 pre-hospital CPR performed for >15 minutespre-hospital CPR performed for >15 minutes
after penetrating chest injury without responseafter penetrating chest injury without response
 pre-hospital CPR performed for >10 minutespre-hospital CPR performed for >10 minutes
after blunt chest injury without responseafter blunt chest injury without response
 asystole is the presenting rhythm, no pericardialasystole is the presenting rhythm, no pericardial
tamponadetamponade
 Severe head injurySevere head injury
 Severe multisystem injurySevere multisystem injury
 Improperly trained teamImproperly trained team
 Insufficient equipmentInsufficient equipment

11. ProcedureProcedure
 LOOK for and treat:LOOK for and treat:

Tension PTxTension PTx

TamponadeTamponade

Neurogenic ShockNeurogenic Shock

Cardiogenic ShockCardiogenic Shock

13. RequirementsRequirements
 Patient Intubated.Patient Intubated.
 Paralysed and Sedated.Paralysed and Sedated.
 NG placed.NG placed.
 Arrest or Shock with suspected correctable intrathoracicArrest or Shock with suspected correctable intrathoracic
pathology.pathology.
OROR
 Specific Diagnosis (tamponade, aortic injury, penetratingSpecific Diagnosis (tamponade, aortic injury, penetrating
cardiac injury)cardiac injury)
OROR
 Ongoing thoracic haemorrhaging.Ongoing thoracic haemorrhaging.

14. Thoracotomy Kit.Thoracotomy Kit.
 Where is it?Where is it?
T2T2

17. Finochietto
Retractor
Bonneys
Forcep
Debakey
Forceps
Mayo
Metzenbaum
Nelson
Needle
Holder
Potts
Clamp(s)
Satinsky Clamp
Debakey
Aortic
Calmp

19. TechniqueTechnique
 ‘‘traditional’ Left Anterolateral Thoracotomytraditional’ Left Anterolateral Thoracotomy
 VSVS
 Clamshell Thoracotomy.Clamshell Thoracotomy.

21. addit.addit.
 It may be difficult to definitively rule outIt may be difficult to definitively rule out
pericardial tamponade by visual inspectionpericardial tamponade by visual inspection
alone. If in doubt, use forceps to elevate aalone. If in doubt, use forceps to elevate a
portion of pericardium and carefully inciseportion of pericardium and carefully incise
it to assess for haemopericardium.it to assess for haemopericardium.

23. Complications.Complications.
 Significant and variable exist.Significant and variable exist.
 Most related to the primary injury.Most related to the primary injury.
 Left phrenic nerveLeft phrenic nerve and coronary arteries duringand coronary arteries during
procedure.procedure.
 Bleeding.Bleeding.
 Infection.Infection.
 Injury to or transmission of disease to staff. CutsInjury to or transmission of disease to staff. Cuts
from needle, scalpel, scissors or rib edge.from needle, scalpel, scissors or rib edge.

24. References:References:
 http://lifeinthefastlane.com/ruling-the-http://lifeinthefastlane.com/ruling-the-
resus-room-005-2/resus-room-005-2/
 http://lifeinthefastlane.com/ed-http://lifeinthefastlane.com/ed-
thoracotomy-is-it-just-the-first-part-of-the-thoracotomy-is-it-just-the-first-part-of-the-
autopsy/autopsy/
 Roberts and Hedges’ ClinicalRoberts and Hedges’ Clinical
Procedures in Emergency MedicineProcedures in Emergency Medicine,,
Sixth Ed.Sixth Ed.
 www.trauma.orgwww.trauma.org