This document discusses emergency thoracotomy for traumatic injuries. It outlines indications for the procedure including hemodynamic instability from penetrating chest injuries or cardiac tamponade. Steps of the procedure are described including a clamshell incision and interventions like controlling hemorrhage, cardiac massage, and aortic clamping. Contraindications include prolonged downtime or signs of unsurvivable injuries. Studies show improved survival in penetrating injuries with signs of life when thoracotomy is performed in the ED. Proper training and equipment are needed to perform this critical lifesaving procedure.

1. Jeremy Mason
6th November 2015

2.  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

3.  Release cardiac tamponade
 Control haemorrhage
 Perform open cardiac massage
 Cross clamp the descending thoracic aorta
 Control air embolism

4.  Penetrating thoracic injury
◦ Haemodynamic instability (SPB <70mmHg despite
vigorous fluid resuscitation)
◦ Traumatic arrest with previously witnessed cardiac
activity (prehospital or ED)

5.  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

6.  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

8.  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

9.  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

10.  Non traumatic cardiac arrest
 Severe head or multisystem injury
 Improperly trained team
 Insufficient equipment

12.  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

13.  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)

14.  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)

15.  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%

18. www.instantanatomy.net
Moore Anatomy

19. https://calsprogram.org/manual/volume2/Sec
tion7_Circulation%20Skills/05-
CirSk4EmergThoracotomy13.html

20.  Located in T2
 Ribspreaders in tray
 Scalpel + Blade –
need to get from FT
cupboard
 Tuffcut scissors
mounted on wall of
T2

21.  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

23.  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

24.  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

25.  “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

28.  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

29.  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

30.  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)

31. https://youtu.be/A57ZB_J4FuY

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

33.  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!

34.  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