Thoracotomy

Question 1

What is the indication for a resuscitative thoracotomy?

Answer 1

Cardiac arrest following trauma

Question 2

What are successful outcomes for a resuscitative thoracotomy associated with?

Answer 2

Penetrating trauma and the presence of cardiac tamponade

Question 3

What are the predictors of survival following a resuscitative thoracotomy?

Answer 3

Mechanism of injury
Anatomical injury location
Physiological derangement
Performance of pre-hospital CPR
Patients presenting with signs of life or presence of vital signs

Question 4

What is a sign of life?

Answer 4

Pupillary response
Spontaneous ventilation
The presence of carotid pulse
Measurable or palpable blood pressure
Extremity movement
Any cardiac electrical activity

Question 5

When are patients more likely to have a better outcome from a resuscitative thoracotomy?

Answer 5

Patient that present to ED with a sustainable cardiac rhythm and obtainable vital signs

Question 6

Can a resuscitative thoracotomy be performed on patients who have non-cardiac thoracic injuries?

Answer 6

Yes, especially suspected abdominal exsanguination

Question 7

What is the procedure of a thoracotomy?

Answer 7

• patient in supine position, intubated, IV access and ongoing transfusion
• rapid application of skin prep
• scalpel and forceps crest bilateral thoracostomies (procedure stops if tension pneumothorax decompressed and return of circulation)
• connect the thoracostomies following the 5th intercostal space
• cut through all the layers of the of the pleura and intercostal muscles towards the sternum with tuff cuts, keeping the lungs out the way
• cut the sternum with tuff cuts, a gigli saw can be used
• manually open the clam shell with gloves assistants or a retractor should be opened completely
• tent the pericardium with clamps/forceps and make a large midline longitudinal incision using scissors
• evacuate all blood and clot and inspect the heart for site of bleeding

Question 8

What 3 scenarios will happen after a thoracotomy has been started?

Answer 8

• return of spontaneous circulation
• the heart will begin to beat slowly and will appear empty. Any wounds should be rapidly closed and rapid transfusion to support circulating volume should be continued
• the heart remains asystolic, wounds should be quickly closed and cardiac massage commenced

Question 9

How to control bleeding during a thoracotomy?

Answer 9

• holes less than 1cm can normally be occluded using a finger
• large defects: Foley catheter can be passed through the hole and gently inflated
• closure with large sutures

Question 10

If defibrillation is required during a thoracotomy, how is it delivered and at what energy?

Answer 10

Internal paddles and initial energy of 10 joules

Question 11

If circulation is restored during a resuscitative thoracotomy, what happens next?

Answer 11

Move patient directly to theatre