ED Thoracotomy - A Desperate Procedure For Desperate Times

Imagine you're in a large metropolitan area with an uptick in summer gun violence. Let's say you're working an overnight shift on a busy Fourth of July weekend, and your department is already being strained to the limits due to insanely high volumes.  Suddenly, at about 3AM,  you get a frantic EMS call: a patient is coming to you, shot in the face, chest, and back.  He still has vitals in the field and they are currently working on an airway.  At our institution, we would instinctively get our trauma bay ready, alert our surgical team, and then all collectively clench our sphincters.

The patient eventually comes in fast with EMS a bloody mess with GSW's everywhere, yet the paramedics have miraculously been able to place an ETT in the field.  He has already received bilateral needle decompressions of his chest.  You quickly go to confirming the airway placement with a GlideScope (which, in our opinion, is FAR superior to DL in this scenario), but as the trauma surgeons are running through their primary survey the patient suddenly loses his pulses.

Suddenly, the knives are out.  Before you know it the patient has been "clam-shelled", with bilateral anterolateral thoracotomies.  The pericardium is opened, showing tamponade, and the heart is delivered.  Shortly thereafter, ROSC is obtained, and the patient was whisked off to the OR.

Our surgery residents at our institution often do a fantastic job when this procedure is called for, and I am happy we have them around for things like this, but I've realized that we as emergentologists should not be totally exempt from knowing this one.  We have tons of attendings in the academic world who have never done one in their careers but I know that in the community, the buck stops with you.  So let's learn!

First of all, you need to remember the indications.  Traditionally, we are taught that a patient with penetrating trauma with "signs of life" at the scene who loses them shortly prior to arrival or right at arrival needs to get his/her chest opened.  Blunt trauma has more recently been included but has a much lower survival rate (around 2% vs. around 16%).  The evidence is spotty at best for both.

One big disclaimer:  this should not always be considered a mandatory procedure.  If you're getting a pulseless patient status post GSW's, and the voice in the back of your head is telling you that cracking a chest is overkill (not to mention a giant waste of time to you and all of your staff if there's no surgical backup at your institution), you should probably listen.  One should also be aware that the potential for needle/instrument sticks in these scenarios are heightened, so you are also putting yourself and others at risk for something that might be futile.

However, if you're committed to this route you'll need your kit, which usually includes most if not all of the above.  In terms of airway, you'll want to shove the tube down there and deliberately right main-stem the patient so that the left lung can be deflated and moved out of the way.

Try to get as sterile as possible, but do it FAST.  A big splash of betadine on the skin might be all you'll be able to do in terms of prep.  In terms of landmarks, go to the same place you'd go for a chest tube (5th intercostal space), and open them up deep with a scalpel and blunt forceps.

Get the spreaders in there, preferably with the ratchet on the inferior side facing the axilla.  Watch your fingers, because it might be sharp! Once inside the thorax, briefly hold ventilations and move the (hopefully) collapsed L lung out of the way and find the heart. Start your pericardiotomy by cutting into the pericardium anterior and parallel to the L phrenic nerve, which should be fairly visible at this point (and stating the obvious--DON'T CUT THE PHRENIC NERVE!).  You should lift up with toothed forceps and cut with your Mayo scissors.

If you'll need to do open cardiac massage/compressions, you can "deliver" the heart from the pericardium to do so.  This will also make it easier to visualize any cardiac injuries.  In terms of hemorrhage control, you can temporarily use your finger, but you can also place a Foley through as well.  For sutures, you can try throwing some buttressed Vicryl throws in there, but you should ultimately leave the definitive repair to the cardiothoracic surgeons (do you really want to try throwing pledgets into a moving field?).

For cardiac compressions, remember that you want to use your palms, not your fingers.  Make sure that you compress perpendicular to the septum, and that you don't compress the coronaries.  Also relax completely in between cycles.  If there's ROSC but persistent hypotension, you can clamp the descending aorta with a DeBakey or a Kelley clamp but this can be quite challenging even with the chest open as the aorta is often collapsed in these scenarios.

Here's a very slow, methodical demonstration with a cadaver:

Here's how it will probably look in your ED (note the stress level is HIGH here):

Also note that Dr. Mellick is quick to point out that the spreaders are in upside down.

As always, (and especially for this, the most morbid procedure we can do) these procedure posts are for EDUCATIONAL PURPOSES ONLY!  Do your own research and be smart.  Cautious always wins over cavalier in the long run.

jps

Sources:

Wise, D., Davies, G., Coats, T., Lockey, D., Hyde, J., & Good, A. (2004). Emergency thoracotomy: “how to do it.” Emergency Medicine Journal, 22(1), 22–24. doi:10.1136/emj.2003.012963

Roberts and Hedges' Clinical Procedures in Emergency Medicine.  Chapter 18

Life in the Fastlane - ED Thoracotomy: Is it Just the First Part of the Autopsy?  http://lifeinthefastlane.com/ed-thoracotomy-is-it-just-the-first-part-of-the-autopsy/

University of Maryland EM's YouTube Page

Larry Mellick's YouTube Page