Editing Trauma thoracotomy (section)

== Technique ==

=== Incision ===

* Crash thoracotomy in unstable patient - best is anterolateral thoracotomy in 4th intercostal space
** Will be able to reach all parts of ipsilateral lung, but will be hard to reach posterior chest wall bleeder or posterior mediastinal injury
** Supine, both arms out, rolled towel under scapula to elevate the side in question
** Need to isolate the ipsilateral lung to deflate it
** Cut below the pectoralis major from sternal border to midaxillary line
** Identify and ligate transected ends of internal mammary artery
** Insert Finochietto rib spreader with handle superiorly to prevent it hitting the bed when opened
* Median sternotomy
** Vertical incision from 2cm above sternal notch to 3cm below xiphoid process
** Get down to anterior sternum, and define superior and inferior edges
** Bluntly develop retrosternal planes superiorly and inferiorly
** Take sternal saw and divide sternum
** Insert sternal spreader
* Oesophageal injury upper or midthoracic - right posterolateral thoracotomy in 4th intercostal space
* Oesophageal injury lower - left posterolateral thoracotomy 7th intercostal space

=== Mobilisation ===

* If lung is not deflated, need to mobilise it
* First: divide inferior pulmonary ligament
* Remove blood
** If blood and bubbles - likely from lung
** If just blood - more likely chest wall
* Need to check pericardium - can easily hide tamponade
* If there is tamponade and you're operating from the right thoracotomy, need to extend to left - can't fix heart from the right

=== '''Injuries:''' ===

* '''Pulmonary laceration'''
** Obtain control at the hilum by hand/finger pressure
** Penetrating wound - non-anatomic stapled resection (tractotomy) - Endo-GIA purple
***
** Bleeding not amenable to local control methods: non-anatomic wedge resection or lobectomy
** Last resort for major central lacerations with massive bleeding: pneumonectomy. Do not do lightly, mortality >60%
* '''Fixing cardiac laceration'''
** Open pericardium longitudinally, anterior to phrenic nerve
** Release tamponade
** Temporary haemostasis with finger or Foley or vascular clamp
** Close laceration by oversewing (hard, but can be done using 4-0 non-absorbable, interrupted simple, not full thickness but deep, don't tighten too much or you will tear the muscle) or stapling
** Could use haemostatic agent
** Could get inflow occlusion by either clamping IVC + SVC or pressing RA lateral-to-medial
* '''Restarting heart'''
** Manual compressions
** Cross-clamp descending thoracic aorta
** Adrenaline 1mg
** Cardioversion using internal paddles applied directly to the heart at 10-30 Joules