Thoracotomy

  • Indications: penetrating trauma was signs of life infield or an emergency department. Blunt trauma with loss of life in emergency department. 10% survival rate for penetrating trauma 1% survival rate for blunt trauma.
  •  Procedure:
  • Intubate , advance ET tube to 30 cm thereby blindly right mainstem so therefore left along is not inflated. Have assistant place OG tube. 
  • Incision from sternum lateral at the inframammary line. Use scissors then to bluntly dissect the muscle. Use thoracotomy retractors to open with the ratchet downward thereby allowing the ability to cross-clamp or extend to right-sided chest if necessary.
  •  Find heart, make incision from inferiorly to cephalad so as to minimize risk to coronary arteries. Incise anteriorly immediately to avoid hydroponic. Cut with scissors pericardial sac. Deliver the pericardium.
  • If there is a rhythm which would normally require defibrillation , ventricular fibrillation, venture, tachycardia use internal pad at 10 to 50 jewels 
  • Inspection aquarium for laceration.
  • Laceration into the myocardium and inflate the balloon with sailing. You remove the tube with blood. ” suture around and tighten them to move forward from Mafolie and retract phone out. 
  • Alternative use staples.
  •  if extensive bleeding precludes repair laceration, can with hand or clamp occlude blood flow to the myocardium temporarily so as to allow for closer laceration. 
  •  Avoid three charges in this email. No cardiac motion internal cardiac massage inferior to cephalad vision so as to normal anatomic direction. 
  •  if hypoperfusion or haven’t regained pulses or concern for intra-abdominal injury or preparing for exploratory laparotomy of the on-demand, cross-clamp aorta. Distinguish a order from esophagus and that aorta is just anterior to spinal processes bronchiole for 
  • PlayStation Trendelenburg  position embolism to stranger 
  •  significant bleeding on the right side extend using e.g. saw or trauma shears to right-sided chest . 
  • Indications with oncotomy also include nothing greater than 1.5 L thoracostomy upon immediate insertion of thoracostomy 
  •  In children, same indications and procedure apply. 
  • Indications:
      • Penetrating chest trauma with signs of life in the field
      • Pulse, BP, pupil reactivity, purposeful movement, organized rhythm, respiratory effort)
      • Blunt chest trauma with signs of life lost in ED
      • Consider for exsanguinating abdominal vascular injuries
  • Procedure
    • Incise 4th or 5th intercostal space, Cut through skin, soft tissue, and muscle in one pass, Rib spreader with rachet bar down, Push lung out of way to access pericardium
      1. Pericardiotomy
        • Pick up pericardium just anterior to phrenic nerve
        • Incise from apex to root of aorta parallel to phrenic nerve
      2. Inspect myocardium for lacerations
        • Digital occlusion
        • Skin stapler – if coronary artery stapled, it can be removed in the OR
        • Foley catheter w/ purse-string suture around it (closes wound when foley removed)
        • Horizontal mattress (can be difficult w/ beating heart)
      3. Cardiac Massage
        • one-handed vs two-handed
        • Intracardiac epinephrine
      4. Cross Clamp Aorta
        • Up to 30 min is tolerated
        • Indicated after persistent hypotension after pericardiotomy and fluid resus
        • Aorta posterior to NGT
      5. If no evidence of injury to L-side, but possible R-sided injury, extend to R side (clam shelling)

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