ADVANCING SCIENCE, ENHANCING LIFE

1. ED Thoracotomy Patrick Dolan, PGY-1 9/22/14 ADVANCING SCIENCE, ENHANCING LIFE

2. Indications/Contraindications • Penetrating trauma: • Hemodynamically unstable on arrival • Pulseless < 15min • Available resources for definitive management • Contraindications: • No pulse or BP in field • Asystole w/out pericardial tamponade • Pulseless of >15 min at any time • Non-survivable injuries • Blunt trauma: • No clear indication (survival is poor, 1-2%) • Contraindication: >15min pre-hospital CPR

3. Technique • Positioning/setup • Supine, arms overhead or on arm boards if extremity injuries are present • Leave penetrating objects in situ (unless it interferes with thoracotomy • Skin quickly prepped w/ iodine poured over entire thorax • Incision • Left anterolateral thoracotomy • 4th or 5th intercostal space, from the sternum to the posterior axillary line, following the curve of the rib • Clamshell, if needed

4. Enter the thoracic cavity laterally with 1-2cm incision • Curved mayo scissors used to open the intercostal space anteriorly and posteriorly • Rib spreader opened as wide as possible • One-sided ventilation (either right-sided mainstem the ETT or occlude the ipsilateral mainstem) • Damage control (packing or direct clamping) • Pulm hemorrhage: • Directly clamp tissue (Duval clamp) • Pulmonary hilum (clamp or twist)

5. Pericardiotomy • Only if tamponade or cardiac injuries suspected • Phrenic nerve • Grasp pericardium w/ toothed forcep, opened through a small incision anterior to the phrenic nerve • Evacuate fluid and/or blood clots • Inspect heart and great vessels • Digital compression

6. Cross-clamping • Redistributes available blood volume • Also reduces sub-diaphragmatic blood loss • Left lung retracted superiorly, inferior pulmonary ligament divided • OG/NG tube • Dissection in an inter-vertebral space, plane perpendicular to the aorta • Dissection around the aorta to place clamp • Clamp just above the diaphragm • >30 min clamp time superior to visceral vessels worsens outcomes.

7. Open cardiac massage/internal defib • Immediately after placement of clamp • Two-hand “clapping” technique • Superior to closed chest compressions • Closed chest: 25% baseline CO10% of normal cerebral and coronary flow • Open: 60-70% baseline CO • Small, ten patient study showed coronary perfusion pressures were 4x greater • Anterior/dorsal surface paddles

8. Hemorrhage control • Penetrating cardiac injuries • Digital pressure • Temporize • Definitive repair with pledgeted 3-0 double-armed prolenesewn in a horizontal mattress fashion • Venous or atrial wounds can be repaired in a running fashion with 4-0 or 3-0 sutures • Clamped bladder catheter (balloon occlusion)

9. Definitive Management • ED thoracotomy is a temporizing measure • Next step is always OR w/ trauma, cardiac, thoracic and vascular surgery, as needed • Definitive closure vs. temporary closure • Temp closure has no specific advantage. • Infectious complications (24 vs 25%) • Hemorrhagic complications (18 vs 14%) • Survival (47 vs 57%)

10. Outcomes • Not well-studied • Largest study was a review of 24 nonrandomized studies from 2000 that included 4620 ED thoracotomies. • Overall survival: 7.4% (2.5-27.5%) • Many factors: • Mechanism • Location of major injury • Signs of life

11. Outcomes • 7% of survivors suffer permanent neurologic sequelae • Neurologically intact surival: • 5% of those in shock • 1% of those without vitals • 0% without signs of life in field • Mechanism of injury very important • Isolated penetrating cardiac injuries 19.4% survival • Survival 37 to 60% for penetrating injury compared to 0-10% for blunt • Gunshot wounds two to four times worse than stab wounds • Clinical condition on arrival • Nonreactive pupils associated with no survival, 30% survival for those w/ reactive pupils