Trauma thoracotomy

Question 1

What are the outcomes of trauma thoracotomies?

Answer 1

Penetrating cardiac trauma with signs of life - 50% benefit

Penetrating cardiac trauma with no signs of life - 2% benefit

Penetrating non-cardiac trauma with signs of life - 25% benefit

Penetrating non-cardiac trauma with no signs of life - 3% benefit

Blunt trauma - 1-2% benefit

Question 2

What is emergency thoracotomy?

Answer 2

A desperate measure performed to try to save ‘agonal’ patients; most die (70-90%)

It is primarily performed in life-threatening situations when immediate intervention is necessary.

Question 3

What is the role of emergency department thoracotomy (EDT) in trauma?

Answer 3

EDT only has a role in penetrating trauma; >99% die in blunt trauma cases

This highlights the limited effectiveness of EDT in blunt trauma situations.

Question 4

What are the aims of performing an emergency thoracotomy?

Answer 4

Aims include:
* Release tamponade
* Control haemorrhage
* Control air embolism
* Massage the heart

These aims are critical to stabilize the patient and address life-threatening conditions.

Question 5

What is an indication for performing an emergency thoracotomy?

Answer 5

Won’t survive trip to OR
* Blunt: Unresponsive hypotension PEA + exsanguinating haemorrhage from ICC (>1.5L)
* Penetrating: vital signs were present within the previous 15mins but are now absent; BP <60mmHg
* witnessed cardiac arrest with recent commencement of CPR

These criteria help assess the necessity of the procedure in critical scenarios.

Question 6

What are the contraindications for performing an emergency thoracotomy?

Answer 6

> 10min CPR with ETT in
* blunt trauma with no witnessed cardiac activity/no trauma
* severe head injury
* ?multiple blunt injuries

These contraindications indicate situations where the procedure may not be beneficial or could be harmful.

Question 7

What is the initial step in the procedure of emergency thoracotomy?

Answer 7

Airway doctor advances ET tube into R main bronchus

Ensuring the airway is secured is crucial before proceeding with the surgical intervention.

Question 8

What is the incision location for a long left thoracotomy?

Answer 8

Initially at the costochondral junction (1-2cm from edge of sternum) to mid-axillary line ± extended across sternum if required

This incision allows access to the thoracic cavity for necessary intervention.

Question 10

What is the initial incision location for a long L thoracotomy?

Answer 10

Costochondral junction (1-2cm from edge of sternum) to mid-axillary line

The incision may be extended across the sternum if required.

Question 11

What tool is used to retract during a thoracotomy procedure?

Answer 11

Finochietto retractor

The handles/bar of the retractor should point downward to allow access to the right-hand side if needed.

Question 12

What should the anaesthetist do during the thoracotomy procedure?

Answer 12

Collapse the lung

This is done after displacing the lung medially.

Question 13

What are the surface markings for making a thoracotomy incision?

Answer 13

3 fingerbreadths below the nipple, 2 fingerbreadths below the tip of the scapula, midpoint between medial border of scapula & vertebral column

This approximates the edge of the erector spinae muscles.

Question 14

What is the sequence of injuries examined during a thoracotomy?

Answer 14

Chest wall → lungs → heart & great vessels

This sequence helps prioritize the examination of injuries.

Question 15

What should be examined on the chest wall during a thoracotomy?

Answer 15

Intercostal or internal thoracic bleeding

Identifying these injuries is crucial for patient management.

Question 16

True or False: The thoracotomy incision can be extended across the sternum if required.

Answer 16

True

This allows for better access depending on the situation.

Question 17

Fill in the blank: The long L thoracotomy incision is made in the _______.

Answer 17

5th space

Question 18

What anatomical structures are displaced medially during a thoracotomy?

Answer 18

Lung

This is required to gain access to the thoracic cavity.

Question 19

What should be done to the ET tube during the procedure?

Answer 19

Advance it into the right main bronchus

This ensures proper ventilation during the surgery.

Question 20

How do you manage pericardial tamponade in a trauma thoracotomy?

Answer 20

Pericardial tamponade: identify phrenic nerve, open pericardium anterior to phrenic nerve in craniocaudal fashion (can make a small nick & tear – less likely to damage nerve), evacuate clot, plug hole in heart (finger, IDC, suture, skin stapler)

Question 21

How should you close cardiac defects after evacuating pericardial tamponade? How should tears close to coronary arteries be closed?

Answer 21

Close cardiac defect with 3/0 or 4/0 Prolene (on SH needle) – Teflon pledgets/ horizontal mattress suture

Tears close to coronary arteries must be sutured with vertical mattress suture so don’t oversew artery

Satinsky clamp to bleeding atria

Not essential to close pericardium on completion of procedure

Question 22

How should a lung laceration be closed?

Answer 22

Lung laceration: aortic/Satinsky clamp across area of bleeding (hilum if necessary); tell the airway doc so that ventilation can be adjusted, control bleeding lung

attempt at repair x2 if no success → stapled pneumonectomy

tractotomy with suture ligation of blood and air leaks is an option

Question 23

Management of hypovolaemic asystole?

Answer 23

clamp descending aorta just above diaphragm

Incise pleura ant & post to aorta, separate from oesophagus, clamp just the aorta at the level of the diaphragm – no more than 30 minutes

Reduces exsanguination & increases flow to coronaries

 

internal cardiac massage: use the flat of your hands, one in front one behind (as using your fingertips can penetrate the heart); use internal paddles if defibrillation is required

±aspirate RA for air

Question 24

When should you stop your trauma thoracotomy?

Answer 24

injuries are irreparable (eg blunt cardiac rupture)

volume replacement not achieved within 15mins of thoracotomy (ie heart remains empty)

heart is not in a self-sustaining rhythm after 30mins

Question 25

Operating room thoracotomy:

Answer 25

Indications (typically following penetrating trauma) massive hemothorax (>1500ML blood drained immediately from chest tube) on-going bleeding (>200mL/hour for 2-4hrs, on-going transfusion requirement) cardiac tamponade, confirmed by echo, pericardiocentesis or subxiphoid window sig undrained hemothorax following chest drain insertion warrants thoracoscopy or thoracotomy to evaluate specific injury requiring surgical intervention (eg tracheobronchial, oesophageal) persistent air leak Retained FB Procedure: (NB useful to place an NG (to aid in palpation of the oesophagus, cf flat aorta)) pt supine, L thoracotomy ±can “clam shell” across to RHS to cut across sternum: use heavy scissors or Leibsche knife (pronounced “Lipshi”; looks like a chisel, that you “hammer” to cause it to cut) and be aware of internal mammary a’s (tie them off) alternative: median sternotomy (using Leibsche knife or circular saw) use Finochietto retractor (with handles/bar pointing downward, to allow access to RHS if required) the supradiaphragmatic aorta can be cross-clamped (after first dividing & clearing the mediastinal pleura that covers it; the inferior pulmonary ligament may also have to be divided to gain access)