Ministry of Health

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 Published: 28/11/2011

ED Thoracotomy

This procedure is a desperate measure performed to try and save "agonal" patients. Most patients will die (70 to 90%). In blunt trauma 99% will die.

Indications: A penetrating injury to the chest, where the patient is dying in front of you (will not survive the trip to theatre) and vital signs were present either on arrival in the ED or within the previous 15 minutes but are now absent. Vital signs include a palpable pulse, electrical cardiac activity on an ECG monitor, spontaneous respiration, or reactive pupils.

Procedure:

Tell the consultant surgeon on call this is happening. The airway doctor advances the ET tube into the right main bronchus. The operating doctor makes a long left thoracotomy incision (5th space) Extend across the sternum if required. Use the Finochietto retractor. Have good access before proceeding.

Then (dependent upon findings):
Pericardial tamponade
Identify the phrenic nerve. Open the pericardium anterior to the phrenic nerve. Evacuate the clot. Plug the hole in the heart (finger, IDC, suture, skin stapler).

Lung laceration
Aortic clamp across the area of bleeding (hilum if necessary). Tell the airway doctor (so ventilation can be adjusted).

Hypovolaemic asystole
Clamp the descending Aorta just above diaphragm. Incise the pleura anterior and posterior to the aorta, separate from the oesophagus. Clamp just the Aorta. Check the clamp will not fall off.

Internal cardiac massage
Use the flat of your hands, one in front one behind, as using your fingertips can penetrate the heart. Use the internal paddles if defibrillation is required.

When to stop:
The injuries are found to be irreparable (e.g. blunt cardiac rupture), volume replacement is not achieved within 15 minutes of thoracotomy (i.e. the heart remains empty) or the heart is not in a self sustaining rhythm after 30 minutes

Last updated on 28/11/2011