Trauma: Resuscitative Thoracotomy

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina | Adult Resus:Basic Life Support | Adult Resus: Advanced Life Support |Resus:Acute Haemorrhage

Introduction

• Resuscitative thoracotomy should only be performed by appropriately trained and credentialed medical practitioners in settings where there is access to necessary systems and equipment to manage or stabilise myocardial injury or pericardial tamponade.
• Ideally it should be performed in the operating room where equipment and theatre-trained nursing staff are available. If the patient has lost output however, it should be performed immediately in the emergency department.

Indications

• Decompression of tension pneumothoraces
• Release of pericardial tamponade
• Closure of cardiac wounds
• Intrathoracic haemorrhage control
• Effective open cardiac massage
• It can be life saving
• RCEM states this procedure is definitely within the remit of the Emergency Physician.

Acute Management

1. Assign team member to call Cardiothoracic Consultant (switchboard) THEN fast bleep Cardiothoracic SpR (bleep xxx)
2. Request ED Thoracotomy Kit
3. INDICATIONS:
   • Penetrating injury to chest or epigastrium resulting in cardiac arrest
   • Non-head injury patient with significant haemorrhage below diaphragm for aortic control
4. CONTRAINDICATIONS
   • Definitive loss of cardiac output for more than 10 minutes
   • Any patient with a cardiac output even if hypotensive
   • Blunt truncal trauma (except if potential tamponade seriously suspected)
5. Perform bilateral thoracostomies (4cm incision in 5th intercostal space in the mid axillary line). Use spencer wells to puncture pleura.
6. If this intervention relieves a tension pneumothorax and cardiac output returns STOP here
7. Broad clamshell incision in the 5th intercostal space joining 2 thoracostomies with extension past originals to improve access; breach sternum with Tuff Cut Scissors/Gigli Saw
8. With suction ready open chest. Open & evacuate pericardial sac.
9. Obtain DIGITAL CONTROL OF BLEEDING & consider:
   • Suture of cardiac wound (4-0 Prolene on a 26mm needle)
   • Packing/Foley Catheter
   • Clamping or pressure for other identified sites of bleeding

Relevant Thoracic anatomy

Surgical approaches for those who have training