Circulation Skills 4:
Emergency Thoracotomy
Emergency thoractomy is a procedure conducted in an all-out attempt to retrieve patients in cardiac arrest or who are moribund and suffered an event or injury that is potentially reversible. When surgical backup is not available, there is no point in performing this procedure. If the patient has signs of life but is moribund, perform emergency thoracotomy. When the patient loses signs of life enroute to the hospital, more judgment must be used depending on the time and distance of transport, probability of an easily reversible cause (stab wound to the heart), and so on. Blunt trauma victims losing signs of life enroute are probably irretrievable, but there is room for judgment here.
The Thoracotomy Procedure
- Place the left arm on an armboard or fold it behind the patient's head; otherwise, it will be inaccessible later for vascular access. Pump up the level of the cart to typical operating table level. Adjust the lighting. After pouring povidone solution over the left chest and framing the left chest with sterile towels, make a skin incision starting at the lateral border of the sternum at the fourth intercostal space level. Extend to the midaxillary line across the chest, just below the nipple line in males and following the reflection of the breast in females. Carry this initial skin incision down to the underlying pectoralis major muscle, but not through it.
- Divide the pectoralis major muscle at the same level. It will contract and separate spontaneously as this is performed, revealing the underlying ribs and intercostal spaces. Select the fifth intercostal space by noting the origin of the pectoralis minor muscle from the upper edge of the fifth rib laterally. Ask the person ventilating the patient to disconnect the ventilating device from the endotracheal tube so that the lung will collapse when the chest is opened.
- Use a blunt curved Mayo scissors to enter the chest over the top of the sixth rib. The lung will collapse away from the chest wall. Use the Mayo scissors to spread enough to allow you to insert a finger. Insert a finger to be sure the lung is not adherent to the chest wall. Reconnect to the ventilating device. Use the Mayo scissors to open the interspace medially to near the costrochondral junction of the ribs and laterally to the midaxillary line trying to stay at the top of the sixth rib rather than on the inferior margin of the fifth rib where the intercostal blood vessels lie.
The fifth intercostal space between the fifth and sixth ribs gives the operator the best exposure for pericardiotomy and internal cardiac massage. Note how a slip of the pectoralis minor arises from the fifth rib.
- Carry the incision laterally to the midaxillary line. Going further posteriorly endangers the long thoracic nerve that lies near the latissimus dorsi. The medial limit of the incision should be near the point where the ribs change direction close to the sternum. The internal mammary artery is located underneath this junction between the cartilaginous and bony rib.
- Insert a rib spreader and open the incision widely. Ribs will crack. Bleeding may occur from the wound edges, especially if the patient develops a blood pressure. Use a large bore sterile sucker tip to evacuate blood from the thorax. If there is a lot of blood present and the autotransfusion apparatus is prepared, it can be salvaged for autotransfusion.
- Insert a silicone tubing shod Ruiz aortic compressor over the surface of the left diaphragm onto the vertebral column where it will compress the aorta against the spine. Cardiac output will be perfusing the heart and brain, and arterial bleeding below the diaphragm will cease. The diaphragm will be prominently seen when the chest is opened.
The Ruiz aortic compressor pressing the descending thoracic aorta
against the vertebral column.
- To compress the hilum of the lung when there is hemorrhage from the lung, pass the index finger of the right hand superiorly and posteriorly around the hilum of the left lung. Then press the hilum against the index finger with the thumb to tamponade the pulmonary vessels in the hilum, stopping or reducing the bleeding from the left lung until surgical repair can take place.
- Pericardiotomy should be avoided if possible. Once the pericardial sac is widely opened, there may be exsanguinating hemorrhage from cardiac wounds. If pericardiocentesis was unsuccessful because the blood causing the tamponade is clotted and the heart is still beating, a window in the pericardium will let you suck out the clot with a sterile sucker tip. Do this by picking up the sac with an Adson dural hook and snipping a small hole with the Mayo scissors. Insert the tips of the scissors and spread so that a hole about 2 to 3 cm long is made. Avoid the phrenic nerve that runs longitudinally on the sac.
If the heart is fibrillating or in asystole and pericardial tamponade is present, it makes sense to go ahead and open the pericardium to evacuate blood and clot to attempt wound closure so that effective internal massage may be conducted. Visualize the phrenic nerve as it courses over the pericardial sac posteriorly. Grasp and tent up the pericardium with an Adson dural hook. Make a 1.5 to 2.0 cm incision into it with Mayo scissors. Place 2 fingers into the incision and tear the sac longitudinally as far as you can. Use this technique to avoid inadvertent injury to the myocardium. The heart will now herniate out of the pericardial sac. If not, insert 2 fingers and use sharp dissection to open the sac further. If bleeding is massive, place the index and ring finger of your left hand behind and below the heart so as to occlude the inferior and superior vena cava. This is called the Sauerbruch grip. It reduces the inflow of blood to the heart. Suck out blood and clot and identify the bleeding site. Do not defibrillate the heart before repairing the wound.
- Cardiac stapling: If the bleeding site can be visualized, stapling may be successful. Apply wide skin staples with a pistol grip stapler. This technique is less perilous to the operator than suture technique and much more rapid. The operator should attempt to occlude the bleeding site with a finger, then expose one end of the laceration just enough for a staple to be applied. Work the entire length of the laceration, applying a staple every 5 mm. Atrial as well as ventricular wounds have been closed with this technique. Avoid stapling across coronary vessels. Replace these staples with sutures in the operating room.
Stapling the right ventricle and atria is like stapling a tomato. Do not use pressure.
- Using a Foley catheter: When the wound is stellate or otherwise not suitable for staple repair, a 20 French Foley catheter with a 30 mL balloon can help to control bleeding. Fill the catheter with saline and clamp it so as to reduce air embolism risk. Insert the catheter into the wound and inflate its balloon with saline. Pull the balloon gently against the heart wall to reduce bleeding. Do not pull too hard or it will pull through. Also, if you attempt stapling or suturing with it in place, temporarily push it into the ventricle so that the balloon is not ruptured.
- Internal cardiac massage and defibrillation: Internal cardiac massage may be conducted left or right handed. Two hands may be used or, if the heart is large, it may be compressed against the sternum with one hand. Ideally, an arterial line will be inserted so each compression’s effect may be seen. Alternatively, an O2 sat monitor may display a pulse. The rate of compression will depend on the rate of refill. It is very easy to puncture the myocardium with a thumb or fingertips, so be careful to use only the flat surface of your fingers.
Internal defibrillation is simply a matter of compressing the heart between anteriorly and posteriorly placed internal paddles. The dose of current is 20 J for adults and (PEDS) 0.2 J/kg for children. If needed, up to 60 J may be used in adults and (PEDS) 0.6J/kg for children. Intracardiac epinephrine injected into the left ventricle can coarsen fibrillation and enable defibrillation.
Arrange a thoracotomy tray in layers so that the instruments stay in place:
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Top layer:
Adson dural hook, 8 inches
Curved Mayo Noble scissors
Ruiz aortic compressor
Four non-penetrating towel clips
Sterile towels
Rienhoff-Finochietto rib spreader
# 10 scalpel - not shown
Two sterile sleeves - not shown
Laparotomy pads - not shown -
Second layer:
Sterile large bore sucker tip and tubing
Two curved forceps
Heavy and fine long needle forceps
00 Silk ties
0 Ethibond silk ties
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Supplies kept separate from the tray:
Auto Suture Multifire Premium skin stapler, 35W
Foley catheter for cardiac wound tamponade, 18 French, 30 cc balloon with a 60 mL catheter tipped syringe
References
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Mahoney BD, Gerdes D, Roller B, Ruiz E. Aortic compressor for aortic occlusion in hemorrhagic shock. Ann Emerg Med. 1984;13:11-16.
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Sauerbruch F. The utilization of the negative pressure procedure during cardiac surgery. Archiv fuer klnische chirurgice. 1908;83:1-9.
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Shamoun JM, Barraza KR, Jurkovich GJ, Salley RK. In extremis use of staples for cardiorrhaphy in penetrating cardiac trauma: case report. J Trauma. 1989;29:1589-1591.
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Karrel R, Shaffer MA, Franaszek JB. Emergency diagnosis, resuscitation and treatment of acute penetrating cardiac trauma. Ann Emerg Med. 1982;11:504-517.
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Bartlett RL. Resuscitative thoracotomy in Clinical procedures in emergency medicine, 3rd ed. Roberts JR, Hedges JR eds. Philadelphia, WB Saunders 1998:264-280.