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THORACIC TRAUMA
TRAUMA RESUSCITATION

 

 

Emergency Department Thoracotomy
Operative Technique

The primary aims of emergency thoractomy are:

  • Release of cardiac tamponade
  • Control of haemorrhage
  • Allow access for internal cardiac massage

Secondary manoeuvers include cross-clamping of the descending thoracic aorta.

Emergency Thoracotomy

Introduction
Indications
Rationale
Resuscitation
Operative technique
References
 

Once control is achieved and cardiac activity restored, the patient is transferred rapidly to the operating room for defintive management.

Equipment:

Approach:  
Scalpel with 10 blade  
Curved Mayo scissors  
Rib spreader  
Gigli saw or large 'trauma' shears  
   
Haemorrhage control:  
McIndoe / Metzenbaum scissors 3/0 non-absorbable suture (nylon, polypropene) on round-bodied needles - multiple
DeBakey vascular forceps (long) 2/0 absorbable ties (vicryl, pds etc) - multiple
DeBakey aortic clamp Laparotomy packs
Satinsky vascular clamp (large & small) Teflon pledgets - small. (10)
Mosquito / Dunhill artery clips (10)  
Long & short needle holders  
   
High volume, high-displacement suction  
   

Approach

A supine anterolateral thoracotomy is the accepted approach for emergency department thoracotomy. A left sided approach is used in all patients in traumatic arrest and with injuries to the left chest. Patients who are not arrested but with profound hypotension and right sided injuries have their right chest opened first.

In both cases it may become necessary to extend the incision across the sternum to aid access and vision. With a right sided thoracotomy, the left chest will have to be opened if internal cardiac massage becomes necessary.

Gaining access to the thoracic cavity should take no more than 1-2 minutes. After rapid skin preparation with large antiseptic-soaked swabs, a skin incision is made in the 5th intercostal space from the border of the sternum to the mid-axillary line. This is continued down through subcutaneous tissues to reach the intercostal musculature.

The intercostal muscles are incised with a combination of scalpel, heavy scissors and blunt dissection. Take care not to lacerate the lung at this stage. Insert the rib spreaders between the ribs and open.

If the thoracotomy has to be extended to the other side of the chest, repeat the thoracotomy on the other side. To divide the sternum, a large pair of trauma shears (as used to cut the clothes off patients) will easily go through the sternum. Otherwise the Gigli saw is used to divide the sternum. The first time you see a Gigli saw should not be the first time you perform a thoracotomy. Examine one to see how it is put together and practice the action needed to saw through bone. Once through the sternum the rib spreader is moved to the midline to open the chest at the sternum.

Division of the sternum results in transection of the internal mammary arteries. These will start to bleed once blood pressure is restored and will need clipping and ligation subsequently.

Relief of tamponade

The pericardium is opened longitudinally to avoid damage to the phrenic nerve, which runs along its lateral border. It is difficult to visualise the phrenic nerve in the emergency thoracotomy. Make a small incision inthe pericardium with scissors and then tear the pericardium longitunidally with your fingers - this will avoid lacerating the phrenic nerve. Evacuate any blood and clot from the pericardial cavity.

Control of haemorrhage

Cardiac wounds

Cardiac wounds should be controlled initially with direct finger pressure. Large wounds may be controlled temporarily by the insertion of a foley catheter with inflation of the balloon. The balloon may obstruct inflow or outflow tracts however and it may also lead to extension of the laceration if excessive traction is placed on it. Satinsky clamps can be placed across wounds of the atria to control haemorrhage. With extensive cardiac damage it may be necessary to temporarily obstruct venous inflow to allow repair. Take care also not to miss posterior cardiac wounds. Examination of the posterior surface of the heart requires displacing it anteriorly, which may obstruct venous inflow.

Cardiac wounds can be directly sutured using non-absorbable 3/0 sutures such as nylon or polypropene. Bypass is unnecessary, even in the beating heart. Teflon pledgets are unnecessary in the left ventricle but, if available, may be used in the right ventricle. With wounds in the region of the coronary vessels, mattress sutures are used to avoid obstructing coronary flow. Atrial wounds are sutured using a continuous technique.

Pulmonary & Hilar injuries.

Massive haemorrhage from the lung or pulmonary hilum can be temporarily controlled with finger pressure at the pulmonary hilum. This may be augmented by placement of a Satinsky clamp across the hilum. This can however cause laceration of the pulmonary veins when used emergently by the inexperienced surgeon. An alternative is to tie off the pulmonary hilum using tracheal tube tie or tape from a laparotomy pack.

Acute occlusion of the pulmonary hilum often leads to immediate acute right heart failure, especially in the young fit adult. This needs to be recognised early and managed with only partial or intermittent occlusion of the pulmonary hilum.

Lesser haemorrhage from the lung parenchymas can be controlled with a temporary clamp.

Great vessel injuries.

Small aortic injuries can be sutured directly using the 3/0 non-absorbable suture. Larger injuries, especially to the arch may require temporary digital occlusion and insitution of cardiac bypass.

Access to the vascular structures of the superior mediastinum is difficult with an anterolateral thoracotomy. The sternum may have to be split in the midline and/or a supraclavicular incision used to control haemorrhage from subclavian and innominate vessels. Again, control is achieved temporarily with digital pressure or proximal & distal clamp application prior to defintive repair.

Internal cardiac massage

In traumatic arrest, internal cardiac massage should be started as soon as possible following relief of tamponade and control of cardiac haemorrhage. A two-handed technique produces a better cardiac output and avoids the low risk of cardiac perforation with the one-handed manoeuver.

Aortic cross-clamping

Cross-clamping of the descending thoracic aorta is used routinely in some centres and not at all in others during emergency thoracotomy. The rationale for clamping the aorta is to redistribute blood flow to the coronary vessels, lungs and brain, to reduce exsanguination from injuries in the lower torso.

The efficacy of the aortic cross clamp in improving perfusion of the coronary arteries and brain is unclear however. Over-zealous fluid replacement with the aortic clamp in place may lead to a significant rise in afterload and precipitate cardiac failure.Organs distal to the clamp will become ischaemic and this includes the spinal cord when the clamp is placed higher, at the aortic isthmus. Clamp time should ideally be 30 minutes or less. On removal of the clamp there is reperfusion of the ischaemic lower torso, and products of anaerobic metabolism and activated inflammatory mediators are released back into the system. This may lead to myocardial depression and subsequent systemic inflammatory response syndrome.

Cross-clamping of the descending thoracic aorta should possibly be reserved for patients with potential exsanguinating injuries to the distal torso.

Cross-clamping is done ideally at the level of the diaphragm, to maximise spinal cord perfusion. Otherwise just below the left pulmonary hilum. The lung is retracted anteriorly and the mediastinal pleura incised. Blunt disection is used to separate the aorta from the oesophagus and prevertebral fascia. This dissection should be enough to place a clamp across the aorta but not complete, to avoid avulsing aortic branches supplying the cord and thorax.

References
Karim Brohi, trauma.org 6:6, June 2001