ED Thoracostomy


 INDICATIONS 
■ Patients with penetrating chest or abdominal trauma who are pulseless but have electrical cardiac activity may benefit.
■ Blunt trauma patients with vital signs in the field and organized electrical activity in the ED may benefit from ED thoracotomy.
■ Goals are to relieve cardiac tamponade, cross-clamp descending aorta for control of abdominal hemorrhage, control hemorrhage from heart or great vessels, and provide effective cardiac compressions.

 CONTRAINDICATIONS 
■ Blunt trauma patients who require over 15 minutes of prehospital CPR and any trauma patient who is apneic, pulseless, and in asystole are unlikely to benefit from this intervention.

 TECHNIQUE 
■ Patient should be intubated and, if possible, analgesia and deep sedation should be provided.
■ NGT should be placed to help differentiate esophagus from aorta.
■ Incision using No. 20 blade is made into the left chest between fourth and fifth ribs: Just inferior to the nipple in men or along the inframammary fold in women (see Figure 19.3A).
■ Incision extends from sternum to posterior axillary line cutting down through pectoralis and serratus muscles.
■ Once the pleural space is entered, ventilations are temporarily stopped to allow the lung to collapse away from chest wall.
■ Place chest wall retractor (rib spreader) to spread ribs. The crank should be placed laterally, so that the incision can be extended across the sternum into the right chest if necessary.
■ If exam suggests any possibility of tamponade, perform pericardiotomy: Lift pericardial sac near diaphragm with forceps, make a small incision with scissors, and extend the incision cephalad along anterior pericardium parallel to the phrenic nerve (see Figure 19.3B).
■ Aortic cross-clamping used when SBP <70 mm Hg: Identify aorta which lies anterior to vertebral column. Place a vascular clamp around the aorta or occlude aorta with digital pressure (see Figure 19.3B).
■ Retract pericardium to examine heart for injury and repair with staples or sutures.

 COMPLICATIONS 
■ Injury to intrathoracic structures (internal mammilary artery, phrenic nerve, coronary arteries, aorta, esophagus)
■ Ischemia of spinal cord, liver, bowel, and kidneys with cross clamping aorta or of cerebral hemorrhage or LVF if pressure elevation is excessive
■ Infection
■ Injury or disease transmission to healthcare workers.

 INTERPRETATION OF RESULTS 
■ SBP after the first 30 minutes of resuscitation predicts outcome. Patients with SBP >110 mm Hg within 30 minutes have good survival rates and neurologic outcomes. Those with SBP >85 mm Hg will likely have brain damage, and those with SBP <70 mm Hg will likely not survive.


(A) Site of incision for thoracotomy.
(B) Clamping of descending thoracic aorta and site of pericardial window.
(C) Visualization of the heart for repairs.

NOTE:
The ideal candidate for ED thoracotomy is a victim of a stab wound to the anterior chest or abdomen who arrests after arriving in the ED due to cardiac tamponade. Get into the chest and relieve the tamponade. If the patient regains a pulse, sedate the patient - this hurts!