ED Thoracotomy

West trauma guidelines
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-repair heart with 3-0 nonabsorbable running suture

Technique

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If hypotension persists following thoracotomy and pericardotomy, the descending thoracic aorta should be occluded to maximize coronary perfusion and to decrease the required effective circulating volume to facilitate resuscitation. Typically, the thoracic aorta is cross-clamped inferior to the left pulmonary hilum; alternatively, it can be clamped above the lung in the more proximal descending aorta. Blunt dissection with one’s thumb and fingertips can be performed to isolate the descending aorta. If the aorta cannot be easily isolated from the surrounding tissue, digitally occlude the aorta against the spine to effect aortic occlusion.

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After performing the thoracotomy and pericardotomy, the patient’s intrinsic cardiac activity is evaluated; patients in asystole without cardiac tamponade are declared dead.

Bimanual internal massage of the heart is initiated; this should be performed with a hinged clapping motion of the hands, with the wrists apposed, sequentially closing from palms to fingers. The ventricular compression proceeds from the cardiac apex to the base of the heart. Intracardiac injection of epinephrine may be administered into the left ventricle, using a specialized syringe, which resembles a spinal needle. Typically, the heart is lifted up slightly to expose the posterior left ventricle, and care is taken to avoid the circumflex coronary during injection. The heart is vigorously massaged to enhance coronary perfusion. After allowing time for vasopressors to circulate, the heart is defibrillated (30 J) using internal paddles. Following several minutes of such treatment, as well as generalized resuscitation, salvageability is reassessed; we define this as the patient’s ability to generate a systolic blood pressure of greater than 70 mm Hg with an aortic cross-clamp if necessary.

FYI
-Air embolism (West guidelines*): Treatment for bronchovenous air embolism demands immediate pulmonary hilar cross-clamping to prevent further propagation of pulmonary venous air. Placing the patient in the Trendelenburg’s position traps air in the apex of the left ventricle; then with an open pericardium, needle aspiration is performed to remove intracardiac air. In addition, aspiration of the aortic root may be required to alleviate any accumulated air. Vigorous cardiac massage may promote dissolution of air already present in the coronary arteries, and direct needle aspiration of the right coronary artery with a tuberculin syringe may be lifesaving. The production of air emboli is enhanced by the underlying physiology–there is relatively low intrinsic pulmonary venous pressure caused by associated hypovolemia and relatively high bronchoalveolar pressure from assisted positive-pressure ventilation. This combination increases the gradient for air transfer across bronchovenous channels. Although more often observed in penetrating trauma, a similar process may occur in patients with blunt lacerations of the lung parenchyma.

Sources:

*http://www.trauma.org/index.php/main/article/361/

*http://westerntrauma.org/documents/PublishedAlgorithms/WTACriticalDecisionsResuscitativeThoracotomy.pdf

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