Procedure: Thoracotomy

Procedure, instructions and discussion

Resuscitative Thoracotomy

Possibly the most terrifying emergency procedure, but also one which carries a high chance of saving a life. This is one to prepare for inside out.

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Instructions

Indications

PRIMARY INDICATION

• Traumatic cardiac arrest
• Loss of output for <10 minutes

AND

• Penetrating chest or epigastric injury

AND

• Cardiothoracic surgery accessible post procedure
• Either specialist, trauma surgeon or via retrieval

SECONDARY INDICATION

• Traumatic cardiac arrest
• Loss of output for <10 minutes

AND

• Blunt Trauma
• With ultrasound confirmed pericardial fluid

AND

• Cardiothoracic surgery accessible post procedure
• Either specialist, trauma surgeon or via retrieval

ONLY PERFORMED IN TRAUMA ARREST

RARELY INDICATED IN BLUNT TRAUMA

SEE DISCUSSION

Contraindications (ABSOLUTE/relative)

• NON-SURVIVABLE INJURIES

Alternatives

• Non-surgical resuscitation

Consent

• CONSENT IS NOT REQUIRED
• This is an emergency procedure to save a life

Potential complications

• Failure
• Bleeding
• Neurovascular injuries (phrenic nerve, large vessels)
• Visceral injury (heart, lungs)

Infection control

• Standard precautions
• PPE: gloves and gown, surgical mask, eye protection

Area

• Resuscitation bay

Staff

• Procedural clinician (two preferred)
• Assistant
• Resuscitation team (airway and arrest management)

Equipment

• Scalpel
• Trauma shears
• Skin stapler
• Artery forceps
• Rib spreader (Left lateral approach only)
• Gigli saw (rarely required)

Positioning

• Patient supine
• both arms abducted to 90 degrees

Medication

• Nil

Sequence (Thoracotomy – Clamp shell approach)

• Confirm traumatic cardiac arrest
• Simultaneously control external haemorrhage, oxygenate (LMA or ETT) and ongoing transfusion
• Perform bilateral thoracostomies at the mid-arm point (midway between the acromion and the olecranon process)
• Cease the procedure if bilateral thoracostomies results in the return of spontaneous circulation
• Extend the skin incisions anteriorly to the midline and posteriorly toward the bed
• Attempt to curve your incision to follow the rib
• Pause ventilation prior to separating intercostal muscles to allow the lung to collapse away from the chest wall.
• Cut through all layers of the intercostal muscles using trauma shears (from thoracostomy to sternum)
• Cut through the sternum using the trauma shears
• Open the thoracic cavity using an assistant 
• Grasp and lift the pericardium using forceps
• Make a 10cm anterior midline longitudinal incision using scissors avoiding the phrenic nerve (running laterally)
• Remove blood clot from pericardium and deliver heart out of the pericardium
• Inspect the heart for any lacerations ensuring to view all surfaces
• If cardiac laceration is present occlude the wound using digital occlusion
• If closure for transport is required apply interrupted staples to wound
• Consider digital compression of the lung parenchyma or other injuries if bleeding identified
• Consider compression of the descending aorta against vertebral column with fingers slid laterally along the ribs to the spine
• Consider internal cardiac massage (two-hand technique)
• Consider flicking the heart apex or administering intravenous adrenaline to stimulate cardiac activity
• If ROSC, control bleeding from internal mammary and intercostal vessels with artery forceps
• If no ROSC, cease resuscitation after adequate volume resuscitation

Post-procedure care

• Analgesia, sedation, and intubation
• Warm blood product resuscitation
• Cephazolin 2g IV
• Transfer to theatre for definitive repair
• Debrief team
• Document (completion, technique, complications)

Tips

• Thoracotomy is primarily treating pericardial tamponade as the cause of death
• The perceived time of cardiac arrest may not be the time circulation ceases.
• Consider the possibility of low-flow states with apparent pulseless electrical activity arrest

Discussion

Emergency department resuscitative thoracostomy is one of the most challenging emergency procedures.

PATHOLOGY

Resuscitative thoracotomy primarily a treatment for penetrating right ventricular injury resulting in pericardial bleeding and death caused by cardiac tamponade. 

PENETRATING TRAUMA

There is a clear consensus that emergency physicians should proceed to urgent resuscitative thoracotomy for penetrating trauma to the chest or epigastric region which has resulted in recent cardiac arrest, provided it is possible to access a surgeon post procedure.

Cardiac tamponade in this situation is a likely cause of death. Ultrasound confirmation of tamponade prior to thoracotomy in penetration injury is not recommended or required.  It may waste vital minutes better spent performing the procedure.

BLUNT TRAUMA

Thoracotomy should not be undertaken unless tamponade is suspected, and pericardial effusion seen on ultrasound. 

Ultrasound confirmation of tamponade prior to thoracotomy in blunt trauma is recommended. If pericardial effusion is not present, performing a thoracotomy is likely to cause harm and detract from interventions more likely to save a life such as massive transfusion, and control of haemorrhage. We note it may be more difficult to diagnose tamponade on ultrasound in traumatic cardiac arrest as concomitant chest injury may make adequate sonographic visualisation difficult.

Our reviewing trauma experts have varying opinion on thoracotomy in blunt trauma. Some feel it is best avoided entirely due to the rarity of tamponade in blunt trauma and potential difficulty in ultrasound visualisation of pericardial fluid. Others feel we should not dismiss a potentially lifesaving intervention or reinforce a myth that thoracostomy is never useful in blunt traumatic arrest.  We have attempted to balance these viewpoints.

PROCEDURAL

Experienced surgical providers may be comfortable with a left lateral approach (reducing morbidity and complications); our opinion is that emergency physicians will have better results with the increased simplicity and working space of a clamshell approach.

Similarly, while experienced surgeons may be able to treat different pathologies in the chest, our opinion is that emergency physician thoracotomy is primarily a procedure to find and treat cardiac tamponade in cardiac arrest after penetrating trauma.

Ideally, repair of cardiac and pulmonary injuries post thoracotomy would be by a cardiothoracic surgeon. In regional areas cardiothoracic surgery may not be available, but general surgeons operating on trauma may have the skills necessary, or there may be the possibility of retrieval to a major trauma centre with ongoing resuscitation.

TIME FRAME

10 minutes post arrest is often quoted as a reasonable time frame to perform the procedure, but we should consider the possibility of low flow states (low cardiac output with no palpable pulse) which may occur as cardiac tamponade develops. If there was a possibility of a low flow state within the last 10 minutes, perform the procedure.

INFECTION CONTROL

Acting quickly to perform the procedure following cardiac arrest is imperative. For this reason, asepsis is not required for resuscitative thoracotomy. The risk of infection is insignificant compared to the increased risk of further tissue hypoxia with any delay to the procedure.

A high standard of PPE is required, and providers should be aware of a high risk of sharps injury.

References

• Groombridge C, Maini A, O’Keeffe F, Noonan M, Smit V, Mathew J, Fitzgerald M. Resuscitative thoracotomy. Emerg Med Australas. 2021 Feb;33(1):138-141.
• Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 11.10.1 – management of cardiac arrest due to trauma. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2016. 11pp.
• EAST: Emergency Department Thoracotomy: J Trauma. 79(1):159–173, July 2015
• Ambulance Service of NSW. Traumatic cardiac arrest. Report HELI.CLI.06. Sydney: ASNSW; 2013. 6pp.
• Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
• Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.
• Eidt JF. Resuscitative thoracotomy: technique. In: UpToDate. Waltham (MA): UpToDate. Accessed April 2019. Available from: https://www.uptodate.com/contents/resuscitative-thoracotomy-technique
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• Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med. 2006 Sep;48(3):240-4. 
• Moore EE, Knudson MM, Burlew CC, Inaba K, Dicker RA, Biffl WL, Malhotra AK, Schreiber MA, Browder TD, Coimbra R, Gonzalez EA, Meredith JW, Livingston DH, Kaups KL; WTA Study Group. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011 Feb;70(2):334-9.
• Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307.e16.
• Narvestad JK, Meskinfamfard M, Søreide K. Emergency resuscitative thoracotomy performed in European civilian trauma patients with blunt or penetrating injuries: a systematic review. Eur J Trauma Emerg Surg. 2016 Dec;42(6):677-685. 
• Van Vledder MG, Van Waes OJF, Kooij FO, Peters JH, Van Lieshout EMM, Verhofstad MHJ. Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma. Injury. 2017 Sep;48(9):1865-1869.
• Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015 Jan;108(1):11-6.
• Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, Fox N, Jawa RS, Khwaja K, Lee JK, Magnotti LJ, Mayglothling JA, McDonald AA, Rowell S, To KB, Falck-Ytter Y, Rhee P. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jul;79(1):159-73
• Fitzgerald MC, Yong MS, Martin K, Zimmet A, Marasco SF, Mathew J, Smit V, Yeung M, Tan GA, Marquez M, Cheung Z, Boo E, Mitra B. Emergency department resuscitative thoracotomy at an adult major trauma centre: Outcomes following a training programme with standardised indications. Emerg Med Australas. 2020 Aug;32(4):657-662.

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