This document discusses emergency thoracotomy procedures for traumatic thoracic injuries. It notes that 25-50% of all traumatic injuries involve the thorax, and that emergency thoracotomy may be necessary for patients experiencing deterioration in the pre-hospital or emergency department setting. The document outlines indications and contraindications for emergency thoracotomy based on whether the injury is penetrating or blunt, lists necessary equipment, describes the procedure steps, and notes factors involved in determining when to terminate the procedure.

1. Emergency
Thoracotomy
Johnny Iliff

3. Thoracic Trauma
 25-50% of all traumatic injuries.
 Most thoracic trauma patients managed conservatively.
 Deterioration in pre-hospital or ED leads to Emergency
Thoracotomy.
 “occurring either immediately at the site of injury, or
in the emergency department or operating room as
an integral part of the resuscitation process”.

4. Increased Chance of Survival
 Signs of life in the ED
 Penetrating>Blunt thoracic injury
 Stab wounds > Gun Shots
 Thoracic injuries:
 However, some studies suggest there is up to a 10%
neurologically intact survival rate for patients with
penetrating abdominal injury undergoing cross
clamping of the descending aorta as part of emergency
thoracotomy.

5. Aims of the procedure
 Resuscitation of a patient in extremis with a penetrating
injury by:
  Release cardiac tamponade
  Control haemorrhage
  Perform open cardiac massage
  Cross clamp the descending thoracic aorta
  Control air embolism

6. Indications- Penetrating Injury
 Previously witnessed cardiac activity (pre-hospital
or in-hospital)
 Unresponsive hypotension (SBP <70mmHg) despite
vigorous resuscitation

7. Indications- Blunt injury
 Rapid exsanguination from chest tube (>1,500mL
immediately returned)
 Unresponsive hypotension (SBP <70mmHg) despite
vigorous resuscitation

8. Relative Indications
 Penetrating thoracic injury with traumatic arrest without
previously without previously witnessed cardiac activity
 Penetrating non-thoracic injury (e.g. abdominal,
peripheral) with traumatic arrest with previously
witnessed cardiac activity (pre-hospital or in-hospital)
 Blunt thoracic injuries with traumatic arrest with
previously witnessed cardiac activity (pre-hospital or in-hospital)

9. Contraindications
 Blunt injury without witnessed cardiac activity (pre-hospital)
 Penetrating abdominal trauma without cardiac activity (pre-hospital)
 Non-traumatic cardiac arrest
 Severe head injury
 severe multisystem injury
 Improperly trained team
 Insufficient equipment

10. Lorenz et al (1992
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Lorenz et al (1992 Hunt et al (2005)

12. Equipment- Thoracotomy tray
in T2
 Scalpel–—no. 10 blade
Suitable retractor, such as Finochietto’s rib spreader, or
Balfour abdominal retractor
Lebschke’s knife and mallet, or Gigli saw
Curved Mayo’s scissors
Toothed forceps
Large vascular clamps, such as Satinsky
DeBakey aortic clamp
Mosquito/Dunhill artery forceps
Foley catheter
Long and short needle holders
Internal defibrillator paddles
Sutures, Teflon pledgets, sternal wires

13. MAJOR TRAUMA CALL
 Anaesthetics
 Orthopedics
 General Surgeons
 Cardiothoracics
 Radiology

16. Procedure
 Intubated and Ventilated (Airway Doc and Nurse)- discussion for
right main bronchus intubation
*seek and treat Pneumothorax in Blunt chest trauma
 Fluid Resus with blood products (Circ Doc and Nurse)
*Ultrasound if qualified staff available
 Mask, visor, scrub, gown and glove (Proceduralist)
 Appropriate area
 15* head up- left arm abducted and lights on
 Prep area
 Incise through skin, subcut tissue in 5th Intercostal Space above
6th Rib- costochondral junction to MAL

17.  Divide the muscle, periosteum and parietal pleura in
one layer with scissors and blunt dissection
 Insert a rib-spreading retractor with the handle towards
the axilla
 To extend the incision to the right side, use strong
scissors, bone cutters or a Gigli saw to cut through the
sternum and into the right fifth intercostal space,
mirroring the incision above.
 TAMPONADE- Pericardiotomy- Anterior to Phrenic
Nerve

19.  CARDIAC DEFECT- Finger/Foley catheter with gentle
traction to repair defect
 MAJOR ABDO HAEMORRHAGE or HYPOPERFUSION
Cross clamp aorta- passage of NGT helps identify
Oesophagus
 SIGNIFICANT LUNG LACERATION OR AOR EMBOLISM
FROM BRONCHIAL_VASCULAR COMMUNICATION-Cross
clamp Hilum
 Cardiac Arrest- Compression with paddles
 VF/VT- Shock 15-30J

24.  http://www.trauma.org/arch
ive/atlas/images/clamshell
04.jpg

26.  Book a bed

27. When to Stop??
  Irreparable damage
  Massive head injuries
  Pulseless electrical activity (PEA)
  Systolic BP<70after15-20mins
  Asystolic arrest

28.  https://www.youtube.com/watch?v=8BlPxQI2C90
 https://www.youtube.com/watch?v=A57ZB_J4FuY

29. Resources
 http://lifeinthefastlane.com/ed-thoracotomy-is-it-just-the-first-part-of-the-autopsy/
 Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma
— a review. Injury. 2006 Jan;37(1):1-19. Epub 2005 Apr 20. Review. PMID:
16410079.
 Lorenz HP, Steinmetz B, Lieberman J, Schecoter WP, Macho JR. Emergency
thoracotomy: survival correlates with physiologic status. J Trauma. 1992
Jun;32(6):780-5; discussion 785-8. PMID: 1613839.
 http://www.trauma.org/index.php/main/article/361/
 http://emedicine.medscape.com/article/82584-overview
 The Royal Hospital Melbourne
http://clinicalguidelines.mh.org.au/brochures/TRM04.02.pdf