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Circulation - Thoracotomy (resuscitative)

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We recommend a clamshell approach to maximise access to the thoracic cavity

Experienced surgical providers may prefer a left lateral approach

Indications

Cardiac arrest with loss of output for <15 minutes

and either

Penetrating trauma to chest or epigastric injury

or

Blunt trauma with confirmed or suspected cardiac tamponade

Contraindications (absolute in bold)

Non-survivable injuries

Alternatives

Non-surgical resuscitation

Informed consent

Medical emergency

Consent is not required

Potential complications

Failure

Bleeding

Neurovascular and visceral injury (phrenic nerve, large vessels, heart, lungs)

Procedural hygiene

Standard precautions

PPE: gloves and gown, surgical mask, eye protection

Area

Resuscitation bay

Staff

Procedural clinician (two preferred) and assistant

Resuscitation team (for airway and arrest management)

Equipment

Scalpel

Trauma shears

Skin stapler

Artery forceps

Rib spreader (useful if available)

Gigli saw (occasionally required)

Positioning

Patient supine with both arms abducted at right angles

Medication

Nil

Sequence

Confirm traumatic cardiac arrest

Simultaneously control external haemorrhage, oxygenate (LMA or ETT) and ongoing transfusion

Perform bilateral thoracostomies (ceasing procedure if resulting in return of spontaneous circulation)

Cut skin and subcutaneous tissue along fifth intercostal space connecting the thoracostomies

Cut through all layers of the intercostal muscles using trauma shears (from thoracostomy to sternum)

Cut through the sternum using the trauma shears (if unsuccessful proceed to using the Gigli saw)

Open the thoracic cavity using an assistant (or rib spreaders)

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

Compress the descending aorta against vertebral column with fingers or closed fist

Consider internal cardiac massage (two-hand technique)

Consider 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 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 while considering the procedure

Discussion

Emergency department resuscitative thoracostomy is not a simple procedure. Identifying specific structures in a chest cavity full of blood and addressing reversible pathology is formidable.

While 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. Tamponade is much more common in penetrating trauma, hence ultrasound confirmation of pericardial fluid is not required. In blunt trauma cardiac tamponade is rare, thoracotomy is not indicated unless this is suspected, or pericardial fluid is confirmed on ultrasound.

Acting quickly to perform the procedure following cardiac arrest is imperative. A favourable outcome is rarely possible (even in penetrating trauma) if thoracotomy is initiated more than 10 minutes after the onset of cardiac arrest.

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.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

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. Available from https://resus.org.au/guidelines/

Ambulance Service of NSW. Traumatic cardiac arrest. Report HELI.CLI.06. Sydney: ASNSW; 2013. 6pp. Available from: https://sydneyhems.com/resources/policies-and-procedures/

Royal Melbourne Hospital. Emergency department thoracotomy guideline. 2011 Sept (updated 2018 Nov). Available from: https://www.thermh.org.au/sites/default/files/media/documents/clinical/Emergency%20Department%20Thoracotomy%20Guideline.pdf

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

Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A. Emergency thoracotomy: "how to do it". Emerg Med J. 2005;22(1):22-24. doi:10.1136/emj.2003.012963

Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors?. Ann Emerg Med. 2006;48(3):240-244. doi:10.1016/j.annemergmed.2006.03.015

Moore EE, Knudson MM, Burlew CC, et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011;70(2):334-339. doi:10.1097/TA.0b013e3182077c35

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;65(3):297-307.e16. doi:10.1016/j.annemergmed.2014.08.020

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;42(6):677-685. doi:10.1007/s00068-015-0559-z

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;48(9):1865-1869. doi:10.1016/j.injury.2017.04.002

Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015;108(1):11-16. doi:10.1177/0141076814560837

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