Resuscitative thoracotomy

Resuscitative Thoracotomy (RT) is a rarely performed procedure that has an extremely high mortality. The patient’s injuries, however, may be associated with 100% individual mortality if the procedure is not performed. It is a time critical procedure that will likely be performed for the first time in a high-pressure situation. With limited opportunities for training, simplifying both the indications as well as the procedural technicalities is important.

RT is a controversial procedure, and with the evidence base unlikely to ever be the most robust (limited scope for prospective data), the indications are constantly altering especially in blunt trauma. Current evidence indicates the greatest benefit will be for cohorts with short transfer times and cardiac tamponade, which is often diagnosed post thoracotomy. RT is a high-risk procedure, and the risk of transmission of BBVs (Blood Borne Virus) to Health Care Professionals must not be underestimated. While this is a time critical procedure, standard PPE must still be adhered to.

Signs of life are considered present if there are any of the following:

• Pupillary response
• Spontaneous ventilation
• Presence of a carotid pulse
• Measurable/palpable blood pressure
• Cardiac electrical activity compatible with an output
• Extremity Movement.

There should be a consultant within the trauma team (usually TTL, General Surgeon or Cardiothoracic) 24/7 who is trained and nominated to perform the resuscitative thoracotomy in the MTC before the patient arrives.

Patients presenting pulseless to the ED.

Absolute

With signs of life after penetrating thoracic trauma.

Relative

• With signs of life after blunt trauma
• Without signs of life after penetrating thoracic trauma
• With or without signs of life after extra-thoracic penetrating trauma.

Contra-indications

• Without signs of life after blunt trauma
• Confirmed CPR >15 mins.

• Release of cardiac tamponade
• Release of tension pneumothorax
• Control of haemorrhage
• Internal cardiac massage.

The figure below shows the equipment required for a resuscitative thoracotomy.

Ensure adequate PPE is always worn as this is a high-risk exposure prone procedure.

Intubation, IV access, volume resuscitation should be simultaneously achieved whilst undertaking RT.

1. Position the patient supine.
2. Rapid skin preparation (rather than full sterility) is appropriate. PPE is mandatory.
3. Bilateral thoracostomies in 3rd or 4th intercostal space mid-axillary line (STOP AT THIS POINT IF ROSC).
4. Connect the thoracostomies with a deep swallow shape skin incision following the infra-mammary crease (see diagram below).
5. Insert two fingers into a thoracostomy to hold the lung out the way while cutting through all layers of muscle and pleura toward the sternum with Tuff Cutts.
6. Perform this on both sides.
7. Cut through the sternum. If unable to cut with scissors use the Gigli Saw.
8. Open the clam shell using rib spreaders.
9. Extend the incisions posteriorly if exposure is inadequate.
10. Lift the pericardium with forceps and make a large longitudinal incision using scissors.
11. Evacuate all blood/clot present and inspect the heart for the site of bleeding.

• Use a two-handed technique.
• One flat hand applied to posterior surface of heart and one on anterior surface.
• Blood is milked from the apex upwards at a rate of 80bpm.
• Keep the heart horizontal during massage.

• An assistant can compress the aorta against the spinal column using a gloved hand, entering the hemithorax from the left of the patient.
• Only an experienced Surgeon should clamp the aorta.
• An NG tube may aid in identification the aorta from the oesophagus.

1. Apply direct compression initially– temporarily occlude wounds with your fingers +/- gauze swab
2. Suturing following compression – Ideally only utilized by experienced surgeons as challenging and can occlude coronary arteries.

If significant haemorrhage encountered despite above measures, consider:

1. Foley Catheter (only in LV (Left Ventricular) wounds >1cm where pressure does not work) – pass a Foley catheter, inflate no more than 10ml and gently pull back being careful not to cause further injury, ensuring the catheter is clamped.
2. Staples (on LV wounds only).
3. Caval occlusion.

• The patient may wake up so be prepared to provide immediate anaesthesia.
• Control bleeders from intercostal and mammary arteries with direct pressure or artery forceps.
• Move directly to theatre for definitive repair.