Emergency Thoracotomy for Trauma

Published on 16/04/2015 by admin

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Chapter 44

Emergency Thoracotomy for Trauma

Amy McDonald

Introduction

Injury to the thoracic cavity is second only to brain injury as a leading cause of trauma deaths. Most thoracic injuries are managed with nonsurgical therapies. Emergency thoracotomy is a lifesaving procedure only used in select circumstances. Knowledge of the appropriate indications for thoracotomy and thoracic anatomy are paramount. The American College of Surgeons (ACS) Committee on Trauma has summarized indications for use of thoracotomy in the ED as follows (Fig. 44-1, A):

FIGURE 44–1 Entry into thoracic cavity: “clamshell” and left anterolateral thoracotomy.

Emergency Department Thoracotomy is best applied to patients sustaining penetrating cardiac injuries who arrive at trauma centers after a short scene and transport time with witnessed or objectively measured physiologic parameters (signs of life): pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, and cardiac electrical activity.

Surgical Principles

The most expeditious entry into the thoracic cavity is through a left anterolateral thoracotomy incision performed in the 4th or 5th intercostal space (Fig. 44-1, B). This incision can be performed easily with a scalpel and then Mayo scissors, if available. A right anterolateral thoracotomy incision does not provide adequate exposure for control of most cardiac injuries but is useful for penetrating injuries to the right chest cavity.

The patient should be placed in the supine position with the arms stretched out. If time allows, a wedge should be placed under the left side of the chest, creating an approximately 15-degree tilt for better exposure. The 4th or 5th intercostal space is located just below the nipple in men and, with the breast retracted, at the inframammary fold in women. The incision should extend from the left sternal edge to the midaxillary line. The inferior portion of the pectoralis major and minor, serratus anterior, and intercostal muscles are divided (Fig. 44-1, C).

If necessary, the incision can be extended across the sternum to the right midaxillary line as a “clamshell” thoracotomy. Dividing the sternum transversely also will divide the internal mammary arteries, which can lead to troublesome bleeding if they are not ligated (Fig. 44-1, D).

Placement of a rib retractor with the handle toward the left axilla allows for easier extension of the incision into the right side of the chest. Assisted ventilation should be stopped during incision of the pleura to minimize iatrogenic injury to the lung. The emergent nature of the thoracotomy does not allow time for placement of a double-lumen endotracheal tube (ETT) before pleural incision.

Thoracotomy Technique

After ventilation is resumed, the inflated left lung can inhibit further progress. Deflation of the left lung can be facilitated by advancing the ETT into the right main bronchus, which can help improve exposure to the underlying structures. Five major maneuvers can be performed, depending on the findings, as follows:

1. Mobilization of the left lung

2. Relief of cardiac tamponade and control of the cardiac defect

3. Performance of open cardiac massage

4. Control of the pulmonary hilum

5. Clamping of the descending thoracic aorta

Placement of a nasogastric or orogastric tube can facilitate identification of the aorta (Fig. 44-4, C). The mediastinal pleura is opened anteriorly and the parietal pleura posteriorly by using either blunt or sharp dissection. A cross-clamp is then placed. The aorta is not completely encircled because injury to the intercostal vessels may occur. The aortic cross-clamp should be removed as soon as practical to prevent ongoing cardiac strain and visceral ischemia.