Tag Archives: thoracotomy

The Societal Cost of ED Thoracotomy

ED thoracotomy can be a dramatic, life-saving procedure. From the patient’s perspective, there is only an upside to performing it; without it there is 100% mortality. But to trauma professionals, there is considerable downside risk, including accidental injury, disease transmission and wasted resources. What is the societal risk/cost if ED thoracotomy is performed for weak indications?

The trauma group at Sunnybrook in Toronto looked at this question by retrospectively reviewing 121 patients who underwent the procedure over a 17 year period. They looked at appropriateness, resource use and the safety of the trauma professionals involved. They used the following criteria to determine appropriateness:

  • Blunt trauma with an ED arrival time < 5 minutes
  • Penetrating torso injury with an ED arrival time < 15 minutes with signs of life

Most of the patients were young men (avg age 30) with 78% penetrating injury and 22% blunt. About half (51%) underwent thoracotomy for inappropriate indications. The vast majority of inappropriate cases were for penetrating injuries with long transport times. Only 3 of the inappropriate thoracotomies were for blunt trauma, yet 24 of the “appropriate” procedures were done in the face of blunt trauma.

Resource use in the 63 inappropriate cases included 433 lab tests, 14 plain images and 9 CT scans (!!!?), 6 cases in the OR, 244 units of packed red cells and 41 units of plasma. Accidental needlestick injuries occurred in 6% of the inappropriate thoracotomies. None of the patients receiving inappropriate thoracotomy survived.

Bottom line: ED thoracotomy remains a very dangerous procedure. I’ve previously written about guidelines to determine which ones are appropriate (see link below). In this study, many of the procedures were performed on patients with blunt trauma. That means that the number of inappropriate thoracotomies would have been much higher if today’s standards had been applied. So use the guidelines and save your own health, safety and hospital resources. Is it really worth it if you know the patient will not survive?

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Reference: Societal costs of inappropriate emergency department thoracotomy. J Amer Col Surg 214(1):18-26, 2012.

Emergency Thoracotomy Video

I did get a lead on a decent video of an emergency thoracotomy that combines most of the principles I laid out last week. It shows a nicely done thoracotomy with exposure of the heart. Aortic crossclamping is not performed, but overall it’s pretty good. All narration is in Thai, so many of you may not be able to follow the conversations.

ED Thoracotomy Part 3: Clamping The Aorta

Finally, the chest is open and the tamponade has been relieved. But your patient has little volume. In order to conserve any circulating blood and pump it only to the heart and the head, it’s time to cross clamp the aorta. This task is best left to the surgeon, because it is not a simple matter.

First, you have to locate the aorta, ideally somewhere just above the diaphragm. Unfortunately, if the patient is hypovolemic it’s very difficult to distinguish the aorta from the esophagus, which lie right next to each other (see picture above). In order to make them feel different, insert a gastric tube through the mouth or nose.

Next, separate the aorta and esophagus. They are both covered by pleura. The structure nearest you without the tube in it will be the aorta. Sometimes it’s possible to use a finger to dissect through the pleura and around the aorta. However, the younger the patient, the tougher this tissue is. It may be necessary to incise the pleura with scissors while your assistant holds the lung anteriorly, our of the way.

Finally, once you can pass a finger completely around the aorta, use it to guide the placement of a gently curved DeBakey type clamp (see picture on the left). Squeeze it until it clicks once, and you are done! Now rapidly infuse warmed blood into the patient and run to the OR!

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ED Thoracotomy Part 2: The Heart

Once the chest is open, the first item of business is to check the heart. In some patients, the inferior pulmonary ligament may prevent you from pushing the lung laterally and superiorly, out of the way. This ligament is a piece of pleura that attaches the lower lobe to the medial diaphragm and mediastinum. Locate it with your fingers and carefully cut it (blindly) with your scissors.

Now look at the heart. What is the rhythm? Put your hands around it. What is the patient’s volume status? If there is the possibility of a penetrating injury, open the pericardium. This structure is tough, and if tamponade is present it will be stretched tight. I find it very difficult to grab the pericardium with forceps and make the initial incision with scissors. Toothed forceps may work, but I just make a very small nick, carefully and directly, with a scalpel. The incision should be placed anterior to the phrenic nerve and vessels, which are usually plainly visible. See the picture on the left, above. The color of the pericardial fluid will immediately indicate whether a cardiac injury is present.

Next, extend the incision (parallel to the bed) to the top and bottom of the ventricle and eviscerate the heart. This will allow careful inspection of all but the atria. If an injury is present, a finger can be used to occlude it until preparations for a repair are made.

Holding the heart is both diagnostic and potentially therapeutic. The “fullness” of this organ is an excellent indicator of the volume status, and if a finger is being used to plug a hole, the temperature of the blood and infused fluids can be determined quickly. All volume resuscitation in this situation should be warmed fluids. And if need be, open cardiac massage is very effective for augmenting circulation.

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Image from my personal archive. Not treated at Regions Hospital.

ED Thoracotomy Part 1: Getting In

Performing a proper emergency thoracotomy is more difficult than you think. There are lots of details to consider, and the learning curve is steep. I’m going to split the process into three parts: getting in, dealing with the heart, and clamping the aorta.

The most important part of getting in is setting up your team. Someone has to be assigned to make sure the chemical and volume resuscitation part is carried out, because the person actually doing the thoracotomy is going to be busy. The most experienced person in the room will actually perform the procedure, or assist the physician who will be learning the procedure.

Next, protect yourself! This is a dangerous procedure. Emotions run high, and people are holding sharp objects. You don’t know where your patient has been or what is circulating in the little blood they may have left, so be careful and make sure you are wearing your personal protective equipment.

Finally, make the incision. This is usually placed along the fifth intercostal space, which is just under the nipple in men. Don’t start too close to the sternum, or you may cut the internal mammary artery. This won’t bleed until circulation is restarted, but it takes some effort to stop it later. Some people prefer a straight incision down toward the table, but I prefer a curved incision that follows the ribs, as illustrated.

Use the scalpel to incise skin, subcutaneous tissue and muscle. However, stop short of the pleura while you are incising the intercostal muscles. If you try to cut through the pleura with the knife, it’s alarmingly easy to injure the lung, or even the diaphragm. Use scissors instead.

Now it’s time to insert the retractor. I prefer to place it with the handle pointing down toward the feet so it doesn’t get jammed against the arm. This is not nice, polite thoracic surgery. You don’t open it a few turns and wait, trying to avoid rib fractures. Open it fast and all the way. Ribs will break, so be careful from this point onward so you don’t cut yourself on their sharp edges.

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Tomorrow, I’ll describe what you need to do with the heart.

Image from my personal archive. Not treated at Regions Hospital.