Wise et al 2005 - Emergency Thoracotomy

Question 1

Give an overview of the Wise et al - Emergency Thoracotomy paper

Answer 1

Published in the ‘Emergency Medicine Journal’

Outlines a simple approach to the procedure of emergency thoracotomy performed in the pre-hospital environment and resuscitation room (where immediate thoracic surgical assistance may not be available).

Aims to provide maximal access to intrathoracic structures to facilitate life saving interventions.

Focus of the paper is on penetrating trauma to relieve cardiac tamponade

Question 2

What is the listed indication for thoracotomy in the Wise et al paper?

Answer 2

Penetrating chest/epigastric trauma associated with cardiac arrest (any rhythm).

Question 3

What are the listed contraindications for thoracotomy in the Wise et al paper?

Answer 3

• Definite loss of cardiac output for greater than 10 minutes.
• Any patient who has a cardiac output, including hypotensive patients.
• Blunt trauma.

Question 4

What are the alternatives to a clamshell approach and why don’t we use them?

Answer 4

Left anterolateral - limited access to the heart to correct pathology
Median sternotomy - requires kit that we don’t have

Question 5

Describe the procedure for thoracotomy as detailed in Wise et al 2005

Answer 5

1. Position patient supine, delegate all other tasks
2. Rapid skin prep application
3. Bilateral thoracostomies 5th IC - reassess
4. Deep skin incision following 5th IC
5. Tough cuts
6. Gigli saw
7. Clam shell the chest - rib spreaders or assistant - posterior extension if required
8. Tent pericardium, large midline incision - avoids phrenic nerve
9. Evacuate blood/clot and examine heart
10. Three possibilities a. ROSC, b. slow PEA - close wounds, needs massage, c. asystole - close wounds, needs massage, maybe a flick
11. Two handed massage, 80 beats per minute - keep horizontal - with aortic compression
12. Control bleeding - finger, foley catheter, suture
13. Defibrillate (internal or external)
14. Anaesthesia if wakes up
15. Control bleeding of vessels
16. Theatre

Question 6

What does figure 1 of the Wise et al 2005 paper show?

Answer 6

Equipment required to perform thoracotomy
- Gigli saw
- Large clamp/forceps
- Large scalpel
- Large scissors

Question 7

What does figure 2 of the Wise et al 2005 paper show?

Answer 7

Clam shell incision line along 5th IC

Question 8

What does figure 3 of the Wise et al 2005 paper show?

Answer 8

Open chest with rib spreaders