Makindo Medical Notes

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina |Adult Resus:Basic Life Support |Adult Resus: Advanced Life Support |Resus:Acute Haemorrhage

Introduction

• Resuscitative thoracotomy is a critical, life-saving procedure reserved for extreme trauma cases. It should only be performed by trained and credentialed medical professionals, particularly in settings with access to advanced equipment and systems for managing cardiac or thoracic injuries.
• Ideally, the procedure is conducted in an operating room with full access to surgical tools and theatre-trained staff. However, when a patient loses cardiac output, it must be performed immediately in the emergency department to maximize chances of survival.

Indications for Resuscitative Thoracotomy

The primary goal is to address and stabilize conditions that directly threaten life in severe trauma. Indications include:

• Decompression of Tension Pneumothorax: Release of trapped air in the pleural space to restore lung function.
• Relief of Pericardial Tamponade: Evacuation of blood or fluid from the pericardial sac to restore normal cardiac output.
• Repair of Cardiac Wounds: Direct suturing of penetrating cardiac injuries.
• Control of Intrathoracic Hemorrhage: Management of major bleeding within the chest cavity.
• Open Cardiac Massage: Direct manual compression of the heart to maintain circulation.
• According to RCEM guidelines, this procedure is within the scope of practice for trained Emergency Physicians in critical situations.

Acute Management Protocol

Resuscitative thoracotomy requires a structured approach. Follow these steps:

1. Contact Cardiothoracic Support: Assign a team member to call the Cardiothoracic Consultant via switchboard, then urgently bleep the Cardiothoracic SpR (bleep xxx).
2. Prepare the Thoracotomy Kit: Ensure all necessary instruments and sterile equipment are readily available in the emergency department.
3. Indications to Proceed:
   • Penetrating trauma to the chest or upper abdomen with cardiac arrest.
   • Severe hemorrhage below the diaphragm in non-head injury patients, requiring aortic control.
4. Contraindications:
   • Absence of cardiac output for more than 10 minutes without response to resuscitation.
   • Presence of cardiac output, even if hypotensive, indicating the patient may respond to other interventions.
   • Blunt truncal trauma, except when tamponade is highly suspected and no other interventions are effective.
5. Bilateral Thoracostomies: Make a 4 cm incision in the 5th intercostal space at the mid-axillary line. Use Spencer Wells forceps to puncture the pleura and release air or fluid.
6. Reassess Cardiac Output: If cardiac output is restored after decompression, halt further interventions. If not, proceed.
7. Clamshell Incision: Create a broad clamshell incision in the 5th intercostal space, joining the thoracostomies and extending to optimize access. Use Tuff Cut Scissors or a Gigli Saw to breach the sternum.
8. Open Chest and Manage Bleeding: With suction ready, open the pericardium and evacuate any fluid or blood. Gain digital control of bleeding, using:
   • Suture of Cardiac Wounds: Use 4-0 Prolene on a 26mm needle for direct suturing.
   • Packing/Foley Catheter: Consider packing or catheter placement for temporary hemostasis.
   • Clamping Major Vessels: Apply clamps or direct pressure for significant arterial bleeds.

Relevant Thoracic Anatomy

Knowledge of thoracic anatomy is crucial for effective thoracotomy. Key structures include:

• Heart and Great Vessels: The heart, aorta, pulmonary arteries, and veins are primary targets for management during thoracotomy.
• Lungs and Pleura: Understand the anatomy of the pleural space to manage pneumothoraces effectively.
• Diaphragm: Awareness of diaphragm position is important when managing injuries extending into the abdominal cavity.

Surgical Approaches

Various surgical techniques may be employed based on the patient's condition and injury location:

• Clamshell Incision: Provides excellent access to both sides of the chest and the mediastinum for direct control of bleeding.
• Left Anterolateral Thoracotomy: Allows access to the left chest, heart, and descending aorta, commonly used in emergency settings.
• Median Sternotomy: Preferred for cardiac injuries when performed in a controlled setting like an operating room.

Post-Procedure Considerations

• Stabilization: Once bleeding is controlled, stabilize the patient for transfer to the operating room or intensive care unit.
• Ongoing Monitoring: Continuous monitoring of hemodynamic status, oxygenation, and potential complications such as arrhythmias or re-bleeding.
• Documentation: Record all procedural details, time of intervention, findings, and patient response to inform further treatment decisions.

References

• Cervical Spine Immobilisation and Management – Adult and Paediatric
• Royal College of Emergency Medicine (RCEM) Guidelines