Resuscitative Thoracotomy Guidelines
VBMC TRAUMA CARE SERVICES GUIDELINE
ED Thoracotomy/Emergency Resuscitative Thoracotomy (ERT)
EMERGENCY RESUSCITATIVE THORACOTOMY AND
TERMINATION OF RESUSCITATION ON THE BASIS OF PREHOSPITAL CRITERIA
Emergency resuscitative thoracotomy (ERT) has a poor salvage rate with a high risk of iatrogenic blood borne pathogen exposure and/or injury to health care providers.
Indications:
The American College of Surgeons (ACS) position in resuscitative thoracotomy, taught in Advanced Trauma Life Support (ATLS), is simple. For blunt trauma, ERT is not indicated. For penetrating trauma, ERT is appropriate when signs of life are present.
Signs of Life:
1. Reactive
pupils
2. Spontaneous
movement
3. Organized
ECG activity (VF, VT, PEA, etc)
4. Cardiac
activity on ultrasound
The Western Trauma Association (WTA)
has promulgated a simpler and perhaps more pragmatic algorithm that is more
liberal with ERT. If CPR has been performed fewer than 10 minutes for blunt
trauma, ERT is appropriate. The same applies with up to 15 minutes of CPR for
penetrating trauma.
EAST updated its ERT recommendations in 2015 as follows:
1. In patients who present pulseless to the Emergency Department with signs of life after penetrating thoracic injury, we strongly recommend resuscitative Emergency Department thoracotomy.
2. In patients who present pulseless to the Emergency Department without signs of life after penetrating thoracic injury, we conditionally recommend resuscitative Emergency Department thoracotomy.
3. In patients who present pulseless to the Emergency Department with signs of life after penetrating extra-thoracic injury, we conditionally recommend resuscitative Emergency Department thoracotomy.
4. In patients who present pulseless to the Emergency Department without signs of life after penetrating extra-thoracic injury, we conditionally recommend resuscitative Emergency Department thoracotomy.
5. In patients who present pulseless to the Emergency Department with signs of life after blunt injury, we conditionally recommend resuscitative Emergency Department thoracotomy.
6. In
patients who present pulseless to the Emergency Department without
signs of life after blunt injury, we conditionally
recommend against resuscitative Emergency Department
thoracotomy
The performance of ERT is at the discretion of the trauma Attending. If all the above-mentioned physical findings establishing absence of signs of life are verified, the patient may be pronounced DOA and no further resuscitation is required. The Trauma Service faculty and residents should ensure completion of the Trauma H&P in its entirety, completing under diagnosis “Patient pronounced DOA” and noting any injuries diagnosed by gross physical examination (e.g., femur fracture, penetrating head injury, etc.).
References: American College of
Surgeons’ Committee on Trauma: Advanced Trauma Life Support, ed.9,
Chicago, 2013, The American College of Surgeons.
EMERGENCY RESUSCITATIVE THORACOTOMY (ERT)-TECHNIQUE
The procedure is performed in
conjunction with other resuscitative efforts and should not be employed in
isolation. Under certain conditions, resuscitative efforts might best be
accomplished in the Operating Room. An Emergency resuscitative thoracotomy should
only be performed by general surgery PGY-3, or higher, level residents or
attendings. If there is a delay in arrival of the surgery team, it is
appropriate for the ERT to be initiated by the emergency department attending.
Procedure:
1. Rapid
bilateral antero-lateral Betadine or Chlorhexidine prep while thoracotomy tray
opened. Thoracotomy trays are in Trauma Bay.
2. Left
antero-lateral thoracotomy incision located beneath nipple in males and in
inferior breast fold in females. Incision extends from left sternal border to
anterior border of latissimus dorsi and chest entered along the superior aspect
of fourth or fifth rib. Care must be taken to avoid injury to heart and lung. A
right antero- lateral thoracotomy may ALSO be preferred for
primary right chest wounds.
3. Insert
rib spreader with handle located toward table laterally.
4. Examine
pericardium, if tense hemopericardium present (pericardium distended with
maroon discoloration) then proceed to step 7.
5. If
systemic air embolism is suspected or massive hemorrhage from lung parenchyma
or hilum is present, then place Satinsky clamp across hilum medially.
6. Retract
left lung with left hand. Locate aorta by running right hand medically along
posterior chest wall. Aorta located along lateral aspect of vertebral bodies
and will be postero-lateral to esophagus. Dissect around aorta inferior to
pulmonary hilum and apply aortic cross-clamp.
7. Enter
pericardium by longitudinally incising pericardium anterior and parallel to
phrenic nerve. This is best accomplished by grasping pericardium with forceps
and cutting with Metzenbaum scissors. Pericardial incision is carried
inferiorly to diaphragmatic reflection and superiorly to level of superior
pulmonary hilum. Care must be taken to avoid injury to left atrial appendage
and phrenic nerve. This is best accomplished by lifting tip of scissors
laterally as incision is made.
8. Manually
lift heart from pericardial sac. If hemopericardium present, then examine for
cardiac perforation. 3-0 prolene suture is ideally used for repair of
cardiovascular wounds. If hemopericardium is not present, then begin open
cardiac compression. Aortic cross-clamping, if not previously performed, is
indicated if no hemodynamic response is noted.
9. Additional exposure may be accomplished by extending thoracotomy incision across sternum into contralateral chest cavity.
Powell DW, Moore EE et al. Is
emergency department resuscitative thoracotomy futile care for the critically
injured patient requiring prehospital cardiopulmonary resuscitation? J
Am Coll Surg. 2004 Aug; 199(2):211-5.
Emergency Resuscitative Thoracotomy
Tray
1 Finochetto
1 Pediatric
Finochetto Medium
1 Tuffier
Rib spreader
1 Medium
weitlander retractor
2 army/navy
retractor
1 str
liston bone cutter
1 lebsche
sternal chisel
1 mallet
1 med
Richardson
1 sm
Richardson
2 9
½ “ Debakey forceps
2 7
1/2 “ Debakey forceps
4 hemostats
2 8”
Kelly
2 Vanderbilt
2 7”
Tonsil
6 8”
Tubing clamp
1 st
Mayo
1 Curved
Mayo
2 9”
Metz
2 8”
Crilewood Needle holder
1 lg
towel clip
1 sm
satinsky
1 Med
Satinsky
1 lg
satinsky
1 sm
rummel
1 peds
yankauer suction
1 wire
cutter
(Suture is not kept with
tray. Each surgeon must request suture from the supply tech in the
room.)