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Zaf Qasim
Dr Zaf Qasim is an attending physician in Emergency Medicine and Critical Care based at the University of Pennsylvania in the United States. He has particular interests in trauma, prehospital care and advanced resuscitation including endovascular techniques. You can find him on Twitter as @ResusOne
The Pre-brief
A few posts ago, I spoke about the evolving evidence supporting a clamshell approach to a resuscitative thoracotomy as being the fastest way to a (newly dead) person’s heart – but when push comes to shove how do you actually do it as an ED physician?
What Are the Goals?
Remember – as an ED physician, your purpose with the thoracotomy is to:
- Relieve a tamponade, if present
- Identify and temporize a cardiac injury
- Perform internal cardiac massage
- Occlude/cross-clamp the aorta
- Temporize a major lung/hilar injury
What Equipment Do I Need?
Think about simplifying your thoracotomy set to the bare necessities:
- #10 scalpel
- Heavy scissors (could be Mayo scissors or even trauma shears – these can be sterilized by your central supply folk)
- Finochietto retractors (rib spreaders) – consider having two
- Mosquito clamps
- Heavy blunt forceps (such as Spencer Wells forceps)
- Atraumatic vascular clamp
- Skin stapler
- Consider adding a Lebsche knife for the sternum
What Should Be Happening in Parallel?
- Advanced airway management – it may be beneficial for a deliberate right mainstem intubation so the left lung collapses and provides a better visualization of the mediastinum
- Ongoing fluid resuscitation – and by fluids, I mean blood
- Expedite a means of getting the patient to the OR – this path should already have been discussed with your surgeons well before you come across a case that may need the thoracotomy
How Do I Proceed?
- If you’ve followed your approach to addressing traumatic arrest, you’ll have performed an open/finger thoracostomy bilaterally in the 4th or 5th intercostal space. Think about going one space higher on the right to account for the liver and the relatively higher hemidiaphragm on the right side.
- If you get ROSC at this point – stop and continue the rest of the resuscitation!
- Using the #10 blade, make an anterior incision that connects to two thoracostomy incisions.
- This should be generous, cutting through the skin, subcutaneous tissue and down to the muscle
- It should follow the curvature of the ribs rather than proceeding straight across
- Extend the incision posteriorly beyond the thoracostomy incisions, curving up into each axilla to the posterior axillary lines
- Using the heavy scissors, cut through the intercostal muscle on both sides until you reach the sternum
- The sternum can be cut with the heavy scissors, in particular trauma shears, but you may need the Lebsche knife
- Open the thoracic cavity and maintain it open by placing your Finochietto retractors laterally and opening them generously
- Inspect the pericardium, and identify the phrenic nerves on either side
- Lift the pericardium with forceps (this may be difficult to do if it very tensely distended
- Open the pericardium using your curved scissors
- Extend this incision from the apex to the base of the heart
- Remove any clots
- Deliver the heart
- Be careful not to obstruct the great vessel outflow
- Inspect the anterior and posterior surfaces for wounds
- If you encounter a wound these can be closed temporarily with:
- Sutures
- Skin stapler (preferred)
- If ROSC is not achieved, proceed with occluding the aorta
- This can be done simply by having an assistant compress the aorta against the vertebral column
- If you decide the clamp the aorta
- Identify and release the inferior pulmonary ligament on the left side (this runs from the hilum to the dome of the hemidiaphragm)
- Push the lung out of the way to identity the aorta against the vertebral column
- Bluntly dissect the fascia around the aorta to isolate it
- Place the atraumatic vascular clamp across the entire circumference of the aorta
- If there is a major lung hilar injury
- It can be difficult to clamp the hilar structures
- Instead, collapse the entire lung in your hands and compress it against the hilum to achieve temporary hemorrhage control
- What about internal cardiac massage
- This may be required until ROSC is achieved
- Remember: you need to allow the heart to fill, then push the blood up to the aorta
- A hand should be placed on either surface and the heart is squeezed from the apex upwards
- Keep the heart horizontal or you may end up occluding the inflow, preventing the heart from filling
- If the heart is fibrillating, use internal paddles. Place a paddle on either side of the heart and begin with 10-20J of energy. Use the same safety precautions as with external paddles
- Sometimes flicking the heart can coax it into starting to beat
The Debrief
The ED physician may need to do a resuscitative thoracotomy in select circumstances.
- Think about whether the system would support you doing this prior to proceeding – ultimately this patient will need the OR. Have a plan set up with your surgeons well beforehand
- Have a tray set-up that is simple and does not fluster you when you need to be on top of your game.
- Continue your blood product resuscitation.
- Address other obstructive pathologies like tension pneumothorax first.
- Finally, if the need arises, follow the steps above for the best chance of success.
Hope you had a happy Valentine’s Day!
