Emergency department thoracotomy

Essential equipment

AntisepticScalpelScissorsLarge forceps Rib SpreaderSutures or surgical staplesAortic clamp or compressorTrauma shears

Steps

  1. Appropriately position the patient with left arm above the head.

  2. Clean and prepare the field as you are able.

  3. Make an anterolateral incision at the 4th or 5th intercostal space. Begin at the right side of the sternum and extend the incision past the posterior axillary line.

  4. Cut the intercostal muscles with scissors. Incise along the top of the rib to avoid the neurovascular bundle.

  5. Use scissors to incise the parietal pleura and gain entry into the thoracic cavity.

  6. Place a rib spreader between the ribs with the handle and ratchet bar facing downward. Carefully spread the ribs open. Ribs may be broken during spreading, so be careful to not get cut on the sharp bone edges.

    • Massive Hemothorax: Remove the clots manually, suction out the blood, and use towels to absorb any blood spilling from the chest.

    • Pericardiotomy: Lift the pericardial sac with forceps, and cut the pericardium with scissors. Incise in a caudal-to-cephalad direction. Stay anterior and parallel to the phrenic nerve. Deliver the heart out of the sac.

    • Control of Hemorrhagic Cardiac Wounds: Place one finger over wound to control active bleeding and use other hand to stabilize the heart. Surgical staples can be used to rapidly close the ventricular wound or place several horizontal mattress sutures under the tamponading finger.

    • Aortic Cross-Clamping/Compression: Bluntly dissect the surrounding fascia and temporarily apply an aortic clamp or compressor. Be sure to identify the esophagus to avoid clamping the incorrect organ.

    • Internal Cardiac Defibrillation: Place internal paddles on the anterior and posterior aspects of the heart. Less energy (10-20J) will be needed than with standard defibrillation.

    • Direct Cardiac Compressions: use one-handed compression, one-handed sternal compression, or two-handed (bimanual) compression. Ensure use of palmar surface of fingers, adjust force of compression so that it is perpendicular to the plane of the septum, position your fingers so that the coronary arteries will not be occluded, maintain a relatively normal anatomic position of the heart to prevent kinking of the vena cava and pulmonary veins, and allow the heart to completely relax between compressions to allow complete refilling.

    • Control of hemorrhagic lung wound: When a lung injury is suspected of being the source of hemorrhage, compress the entire lung down on the hilum. If the patient is intubated, push the endotracheal tube down to preferentially ventilate the uninjured lung.

  7. If the site of injury is to the right of the heart and cannot be reached or you need better exposure, extend the incision into the right side of the chest. This can be accomplished with sturdy trauma shears or more specialized equipment such as a Gigli saw, Liebsche knife, or sternal osteotome.