Trauma thoracotomy

ED thoracotomy - bottom of page

Indications for urgent OT thoracotomy (not ED thoracotomy)

• Massive haemothorax (>1500mL bloody pleural effusion or >200ml/hr for first 4 hours)
• Penetrating truncal trauma and need for proximal vascular control
• Cardiac tamponade/haemopericardium on USS
• Acute haemodynamic deterioration and arrest in the trauma centre
• Massive air leak from chest tube
• Radiological indications:
  • Demonstration of tracheal or bronchial injury
  • Oesophageal injury
  • Great vessel injury

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

ED Thoracotomy

• Two broad reasons:
  • Access chest for direct surgical intervention (release tamponade, haemorrhage control)
  • Optimise resuscitation (open massage, cross clamping)
• Indications:
  • Best indication is for a patient with a single stab wound to 'cardiac box' and evidence of pericardial tamponade and witnessed loss of vital signs in ED (survival as high as 35%!)
  • Penetrating is favourable compared to blunt
  • Witnessed loss of vital signs in ED is favourable

• Technique:
  • Fully abduct left arm
  • Basic clean to chest
  • Ideally there would be an NGT in situ to help differentiate from aorta
  • Open the chest - left anterolateral thoracotomy - from left sternocostal margin in 4th intercostal space (inframammary line in woman or just below nipple in male). Aim to target the inferior margin of pectoralis major, as far back as mid-axillary line.
  • Cut down through subcutaneous tissue, go through serratus muscle, and finally through intercostal muscles (blunt entry through here with Mayo scissors, then put finger through to protect lung, and extend incision with Mayos). Open chest wall well beyond medial border of latissimus dorsi, but don't actually cut through it (bleeds).
    • Avoid internal mammary artery when approaching lateral sternum
  • Finochietto rib spreader placed with handle down, and opened as far as possible.
  • Immediate inspection:
    • Pericardium opened routinely after nick with scalpel (incision anterior to phrenic nerve and parallel, which is usually quite posterior)
    • If cardiac injury, prompt control with finger pressure. Consider Foley placement vs staples vs vascular clamps vs suture control until definitive control can be made in OT.
  • Incise inferior pulmonary ligament to mobilise lung and access posterior thorax and allow access to descending aorta (grasp inferior lobe from below with left hand and slip a finger posteromedially to the left lobe, but be sure to stop short of hilar vessels)
  • If significant haemothorax is found without evidence of cardiac or aortic injury, evacuate blood and immediately explore for source, temporising the source when it's found.
  • Then you can:
    • Open the pericardium and staple (or suture) a cardiac laceration
    • Perform open cardiac massage
      • Bimanual 'hinge-clapping' approach is best, commencing at apex and finishing at base
    • Clamp the pulmonary hilum or twist (last ditch effort - massive phsyiological response to this) a massively bleeding lung
    • Clamp the thoracic aorta
      • This is done at distal descending thoracic aorta, after releasing inferior pulmonary ligament
      • Overlying mediastinal pleura needs to be opened - can be difficult to get started
      • Clamp aorta, need to be very fast as clamp time >40 minutes will probably be fatal
  • If patient is still alive, move to OT