Emergent Thoracotomy

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Grenade blast. mid twenties male with multiple pellet wounds. Significantly 
Rt and Lt infraclavicular region, Lt parasternal, epigastric and suprapubic.

Combatative, shocked, air hunger. Rt chest tube 1800 ml blood. Rapid 
downhill gasping as wheeled into theater. Arrested in theater.

Lt ant thoracotomy: Large clot and blood spurt as pericardium opened. 
Puncture wound 3mm x 3mm in ant wall Lt vent closed. Heart revived with DC 
shock and cardiac massage continued as thoracotomy converted to clamshell. 
Arrest again. Massage continued

Exit wound in posterior wall of vent as well as exit into diaphragm seen. Rt 
chest azygos v inj. Abdo: puncture through liver with trickle of blood. 
Before post cardiac wound repair heart could not be revived. Patient 
expired.

Total time from arrival to death declared 34 min
Injury to arrival +/- 30 min.

Questions:

comment on choice of approach/extension
Any other maneuver to get to the post wall of the heart from the left?
Any other comments

Thanks in advance.

S Muzammil, FRCS
Combined Military Hospital
Lahore Pakistan

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