Criteria:
1) Follow your ATLS protocol first!
– This means this patient should be intubated, have had bilateral chest tubes/thoracostomies, and adequate/appropriate volume resuscitation first
– If the patient still remains hypotensive and there is still active bleeding and they fit the EAST criteria, may proceed with thoracotomy
2) Tool kit (simplified ED)
A. Finochietto Retractor (crank handle must be opposite side of spreader handle, bar always down toward the bed)
B. Always carry a 10 blade!
C. Lebsche knife and mallet used to cut across sternum if needed (or a really thick pair of scissors)
3) Step by Step Procedure (please watch this video: EMCrit demonstration) https://www.youtube.com/watch?v=7CfSToBqgAY
A) Most literature support a “Clamshell” approach as it gives you access to right and left side of thorax to stop potential bleeding. Ideally the patient should have had bilateral chest tubes prior to your decision to do a thoracotomy (and you’ll want to stand next to the left side of the patient). You’ll want to take your 10 blade and cut across from the incision holes of the right chest tube and cut across to the incision hole of the left chest tube (starting from the 4th or 5th ICS mid-axilla and follow along the sternum (just underneath the nipple line for males and (underneath mammary fold for females)). Once you cut all the way toward the left side, you should be cutting toward the patient’s left shoulder blade to give you enough room to explore.
B) Sometimes by the simple act of cutting, the patient will have return of circulation, and you can stop there. If however there is no return of circulation or if you see active bleeding, continue with your resuscitation. Use your rib spreaders and start on left side (watch video link to see how it’s done), and place bar side down toward patient’s bed. Whoever intubated needs to make sure they passed and NG tube. This will help distinguish the esophagus from the aorta (more on this later).
C) Expose the heart and check for damages to the pericardium (blood/air filled, lacerations, etc). However the pericardium should always be exposed because even a small amount blood within pericardium can cause tamponade. After this, you’ll want to perform internal cardiac compressions (cardiac massage), and try to “milk” the blood from the apex of heart toward base.
D) Cross-Clamp the aorta (with a Statinsky or DeBakey clamp) should be done to redirect blood for cerebral perfusion. Generally, the esophagus lies to the right and anterior to aorta especially as you head down toward the diaphragm. The esophagus is also slightly translucent and can see the NG tube that is passed. In order to clamp the aorta you need to dissect away at the inferior pulmonary ligament. If this is difficult to do/identify, have someone to compress the distal/thoracic aorta against the vertebral column with their hand.
E) Use internal paddles if the patient’s heart warrants defibrillating. Use same shock/protocol as normal ACLS. Check with your institution if you even have internal paddles
The point is, this is a last ditch effort that warrants an attempt if patient meets criteria, especially if penetrating.
Sources:
Weingart S. The abbreviated ED thoracotomy tray. EMCritt RACC blog 2015
