o Pulseless electrical activity is established. o Systolic blood pressure is 4}mmHg after 20 minutes. o Asystolic arrest has occurred (Boffard, 2003). How we do it.
Trauma2005:7:105-108
Emergency Department Thoracotomy (EDT) D Doll, F Bonanno, MD Smith and E Degiannis
Key words: cardiac tamponade; Emergency Department; thoracic
trauma;
thoracotamy
Introduction Emergency Department Thoracotomy
thoracotomy done
in the Emergency
(EDT)
on a patient presenting moribund. The aims of EDT are the resuscitation of patients with penetrating cardiothoracic injuries by evacuating the hemopericardium and repair of the cardiac injury, control of thoracic haemorrhage, prevention and treatment of air embolism, preservation and redistribution of the rernaining blood volume with improvement of coro nary /carotid arterial flow, reduction of subdiaphragmatic blood loss, increase of the left ventricular stroke work index and increase in myocardial contractility and sometimes the performance any
of the abovementioned.
Clinical indications for EDT in penetrating trauma Patients presenting in the Emergency Department All critically injured patients who present in extremis
to the Emergency
Department
with
Nonintubated patients who underwent CPR for less that five minutes before arrival in the Emergency Department (Copass et al., 1984; Mattox, 1989).
o
Intubated patients who underwent CPR for less that 10 minutes before arrival in the Emergency
is
Department
of open cardiac massage in combination with
o
penetrating
trauma and signs of life (pupillary response to light, respiratory effort, response to pain or cardiac activity on electrocardiogram) should undergo EDT. Even in the absence of the above signs of life, two subgroups of patients with penetrating trauma should undergo EDT
Department (Copas
s et' a1.,
1984;Mattox, 1989).
these categories EDT should be done even in the absence of cardiac electrical activity.
In both
Patients treated in the Emergency Department In penetrating chest trauma, witnessed cardiac arrest in the Emergency Department is considered a clear indication for EDT. Persistent postinjury hypotension (i.e., systolic blood pressure less than 60mmHg) not
responding to copious fluid resuscitation also constitutes a clear indication for EDT, particularly if cardiac tamponade, intrathoracic haemorrhage or air embolism cannot be excluded. Refractory moderate postinjury hypotension (i.e., systolic blood pressure of less than 80 mmHg) suspected to be due to intrathoracic haemorrhage or intraabdominal haemorrhage is a relative indication for EDT. The patients age and comorbidity as well as logistic issues have to be taken into consideration (Biffl et al., 2000; Velmahos et al., 1995).
Clinical indications for EDT in blunt trauma
uni-
Emergency Department Thoracotomy in blunt trauma Trauma Directorate Chris Hani Baragwanath Hospital, versity of the Witwatersrand Medical School, Johännesburg, should be performed rarely, if ever, in patients with South Africa. cardiopulmon ary arrest because of a very low survival Address for correspondence: E Degiannis, Department of Surgery, Medical School, University of the Witwatersrand, 7 Yorck Road, Parktown, 2193 Johannesburg, South Africa. E-mail: degiannis@yebo .co.za
O
2005 Edward
Arnold (Publishers) Ltd
rate and poor neurological outcome. We, as well as other trauma surgeons, caution against this indication as our results have been dismal. On the other hand some authorities perform EDT for blunt trauffi&, but 1
0.
1
I9I I 1460408605ta334oa
106 D Doll et al. they limit this strictly to those patients who arrive with witnessed cardiopulmon ary arrest (Asensio and Tsai, 2003).
vital signs present or When to stop EDT?
Emergency Department Thoracotomy is a 'team It should not be prolonged unduly, but should have specific endpoints. If an injury is repaired and the patient responds, he or she should be moved to the operation room for the definitive repair or closure. Emergency Department Thoracotomy should be terminated if: event'.
o o
Irreparable cardiac damage has occurred.
The patient is identified as having massive head injuries.
o o
Pulseless electrical activity is established.
Systolic blood pressure
is 4}mmHg after 20
minutes.
o
Asystolic arrest has occurred (Boffard, 2003).
How we do it The doctor who will undertake EDT must be able to
perform a thoracotomy fast, be able to open the pericardium and to suture the heart, to clamp the hilum of the lung and clamp the descending aorta. The instruments available in the Emergency Department are limited making surgical expertise of vital importance. The patient undergoes immediate endotracheal intubation coupled with reliable venous access and aggressive fluid replacement. A left antero-lateral thoracotomy with the patient in supine position is performed and although elevation of the left arm increases the extent of the operative field, abduction of the arm is sufficient for satisfactory intraoperative exposure in most cases. The skin incision extends from the lateral border of the left sternocostal junction inferior to the nipple, to
the mid axillary line laterally, usually in the fifth intercostal space. If injury of the left subclavian artery is suspected the third intercostal space is a preferable alternative. In females a submammary incision is performed. The muscles are divided at the same line as the skin incision usually with coagulation electrocautery, but rapid incision with a scalpel is acceptable. Care is taken not to injure the lungs on opening the pleura. A rib spreader is introduced and opened up Trauma 2005: 7: 105-108
rapidly. This almost invariably leads to fracture of ribs. Caution must be taken by the surgeon and his assistants not to injure themselves, on the rib fragments, while inserting their hands in the thoracic cavity. To avoid injury, it is advisable to cover the edges of the incision with abdominal swabs. If better access to the thoracic cavity is required, the costal cartilages of the corresponding ribs can be divided. At the end of the operation it is important to look for the intercostal artery corresponding to the divided cartilages and ligate them if severed. The surgeon should initially look at the pericardium to exclude cardiac tamponade. Besides seeing a hole in
the pericardium, this is evident by the white-bluish colour of the pericardium produced by the underlying intrapericardial clot. As the pericardium is very tense it is difficult to open it by using mosquitoes, therefore the pericardium is carefully nicked with the scalpel blade at an area anterior to the phrenic nerve and the incision is extended vertically superiorly and inferiorly with
scissors, always paying attention to the phrenic nerve. If the heart is beatirg, repair is delayed until initial resuscitation measures have been completed. If it is not beating, suturing precedes resusucitation.
The injury
to the heart is
repaired
with
3-0
nonabsorbable suture, interrupted figure of eight or mattress sutures, depending on the preference of the individual surgeon and the possibility of coronary vessels being included in the stitches. In certain cases, if controlling of the haemorrhage from the cardiac injury makes suturing difficult, insertion if a Foley's catheter and inflating the balloon with water can control the bleeding. If the laceration is too long, the assistant's finger can be placed horizontally on the whole length of the laceration to control the
bleeding. This
is followed by careful insertion of
stitches under the assistant's finger while there is simultaneous retraction of the finger distally to the initial stitches. In situations in which the bleeding is torrential, compression of the right atrium or occlusion of IVC and probably also SVC can allow vital time for the surgeon to occlude the gap in the myocardium. It is always important to look for and identify the through and through injury to the heart which may result in a simultaneous posterior wound. This necessitates elevation of the heart with associated kinking and inflow
reduction. This can cause bradycardia and cardiac arrest. Bathing of the heart in hot saline usually helps reversion back to normal rhythm. Closure of the pericardium leaving only a 2 cm defect distally is desirable but not obligatory, as aggressive fluid
Emergency Department Thoracotomy 107 resuscitation or ischemic reaction of the heart can produce cardiac enlargement due to distension of the heart chambers or swelling of the heart muscle. In penetrating injuries of the lungs that are bleeding profusely: if they are at the periphery a large Satinsky clamp including copious parenchyma of the lung will control the bleeding. Tractotomy has no place in the EDT scenario. Bleeding from a large vessel near the hilum or uncontrollable bleeding from the parenchyma can be best dealt by clamping of the hilum. This
is achieved by initially retracting the lung anteriorly and inserting the left hand round the lower pole of the lung (sometimes tearing the low pulmonary ligament), and controlling the hilum between the index and the third finger of the left hand. A large Satinsky is then taken with the right hand and the hilum is clamped from the opposite direction (the clamp is inserted from right to the left and the hilum is clamped just medially to the fingers of the surgeon.). If a Satinsky clamp is not available in desperate situations control of the hemorrhage can be achieved by a 180 degree twist of the lungat its hilum. If bleeding from the subclavian vessels is encountered, clamping of the left subclavian artery can reduce
but not cornpletely control the bleeding from
the severed vessel. Probably the best way of controlling the haemorrhage is by placing an abdominal swab at the site of the injury and applying manual compression as the patient is transported to theatre. Bleeding from other major mediastinal vessels is very difficult to control through a left thoracotomy. Side occlusion of bleeding vessels can control the bleeding in accessible vessels.
The rationale for clamping the descending thoracic aorta in EDT is preservation and redistribution of the remaining blood volume, improvement of coronary I carotid arterial flow, reduction of subdiaphragm atic blood loss, increase of the left ventricular stroke work index and increase in myocardial contractility. There
are also adverse effects from thoracic aortic cross clamping; these are decreased blood flow to the abdominal viscera to approximately I0%, decreased renal perfusion to approximately I0% and decreased blood flow to the spinal cord again to approximately I0%. This also induces anaerobic metabolism, hypoxia/ lactic acidosis and it imposes a tremendous afterload
onto the left ventricle. We do not know the safe duration of cross clamping nor the incidence of reperfusion injury. Although thoracic aortic occlusion has been tolerated for as long as 75 minutes without spinal cord sequelae, clinical experience with elective thoracic
aortic procedures indicates that 30 minutes is generally the threshold for reversible normothermic ischemia. The resulting hypoxia induces the elaboration, expres-
sion and activation of inflammatory cell adhesion mechanisms and mediators that have been linked to organ dysfunction and multiple organ failure (Biffl et al., 2000). Although mentioning the suggested routine use of thoracic aortic clamping in patients with
massive intra-abdominal haemorrhage makes sense physiologically, its association with a significant improvement in the overall survival of these patients has yet to be clearly established. For clamping the descending aorta the left lung is elevated medially, and the pleura superficial to the aorta is cut with scissors in a plane transverse to the aorta, and a long vascular clamp is inserted. In desperate situations, compression of the descending aortawith the fist against the verteb-
ral column can be helpful when followed by clamping. Application of the vascular clamp without opening of the preaortic pleura is not advisable as it easily slips. The surgeon must be careful not to include the oesophagus in clamping the aorta. Major air embolism can be a subtle clinical entity following thoracic trauma probably more common than recognized. The typical scenario for its occurrence involves a patient sustaining a penetrating chest wound who develops precipitous shock after endotracheal intubation and positive end expiratory pressure ventilation (PEEP). The shock results from global myocardial ischemia produced by coronary air emboli arising from traumatic alveolo-venous communication. A similar process may occur in patients with blunt lacerations of the lung parenchyma. Pulmonary hilum cross
clamping is of paramount importance to prevent further pulmonary venous air embolism. Air should be aspirated from the left ventricle with the patient in Trendelenburg position. In addition vigorous cardiac massage may assist movement of air out of the coronary arteries. Venting of air from the root of the aorta prevents further egress into the coronary and other major arteries (Biffl et al., 2000). Cardiac massage where required in EDT should be done with both hands, one anteriorly and one posteriorly to the heart after opening the pericardium. Cardiac massage with one hand compressing the heart against the vertebral column is less efficient and can cause severe injury to the left ventricle. Defibrillation with internal paddles may be needed, delivering between 10 and 50 joules.
Intracardial epinephrine can also be administered either in the left or the right ventricle or systemically (Biffl et al., 2000). Trauma 2005:7: 105-108
108 D Doll et al. In penetrating injury of the right side of the
chest,
right sided EDT should be performed. If there is suspicion of further injuries extending into the left chest or aortic clamping is required a separate left thoracotomy or a clamshell incision can be performed. If the resuscitive thoracotomy is successful, attention should turn rapidly to the control of chest wall bleeding. These patients have systemic acidosis, are frequently hypothermic and often receive massive transfusions resulting in significant coagulopathy. Divided muscles and tissues of the chest wall can bleed significantly when systemic perfusion is restored. Early attention to the haemostasis of these tissues will prevent continued blood loss while other injuries are treated. If the patient is successfully resuscitated, immediate transport to the operation theatre is mandatory.
Stab wounds are associated with a better prognosis after EDT when compared to gunshot wounds.
Conclusion In conclusion the results of EDT are best if it is directed towards the treatment of cardiac tamponade. EDT achieves also a significant salvage rate among patients
without vital signs on admission and who have cardiac injury, especially if the prehospital CPR is of short duration and the patients are intubated in the field. The results of EDT are dismal for penetrating abdominal trauma. Most authorities would not recommend EDT in the presence of blunt trauma.
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tomy. In. Definitive surgical trauma care,
Results of EDT are based on the site of injury. In penetrating thoracic injuries the presence of cardiac tamponade appears to be a favourable condition for improved survival (Velmahos et al., 1994; Ivatury,
incentive for EDT in these circumstances is the potential of temporary control of hemorrhage from the pulmonary hilum or major vessels in the thorax prior to transfer of the patient to the operation theatre. Despite these theoretical advantages significant success has not been realised in patients with noncardiac injuries. Thoracotomy in the Emergency Department has been recommended for subdiaphragmatic injuries, for restoration of cardiac rhythm by open massage and clamping of the thoracic aorta. Only a very small proportion 2003).
of
An additional
patients with extra-thoracic injuries survive
(approximately
course
manual, Melbourne and Sydney, 2003.
Results
5
%).
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