ED Thoracotomy

Source: Cameron

Discussion revolves around definition of Presence of Vital Signs vs. Signs of Life.
- vital signs include blood pressure, palpable pulse and spontaneous respirations
- signs of life include electrical cardiac activity, respiratory effort, pupillary reactivity.

Indications for EDT
1) salvagable post injury cardiac arrest
2) hypotension from
- cardiac tamponade
- intrathoracic hemorrhage
- air embolism
- active intra-abdominal hemorrhage

Relative indications:
1) refractory moderate hypotension from the same reasons as 2) above.

Incision:
- start just lateral to the sternum just inferior to the nipple.
- curvilinear incision following inferior border of pec major
- continue all the way down to the lattisimus dorsi
- using mayo scissors cut intercostal muscles just above the rib

Things you can do after chest accessed
1) pericardiotomy
- open longitudinally, parallel to phrenic nerve
- extend up to root of aorta and down to the apex
2) Aortic cross-clamping
- divide pulmonary ligmament with straight scissors
- bluntly dissect away mediastinal pleura from aorta and esophagus
- dissect away esophagus and prevertebral fascia to the point where you can encircle the aorta.
- with aorta encircled with left hand apply a curves aortic clamp with the right hand.
- be judicious about aortic cross clamping. It increases cardiac work and will result in post-clamp shock when reperfusion occurs.
3) Open cardiac massage
- begin bimanual cardiac massage if arrest has occured
4) control non cardiac hemorrhage
- great vessel damage is almost impossible to repair in ED. Apply pressure and get to the OR
- pulmonary hemorrhage can be controlled with Duvall clamp or vascular clamp
- last resort is to clamp or occlude inflow at the hilum. Which will require division of the pulmonary ligament. Similar to aortic clamping will result in increase in cardiac afterload and may supress cardiac index.

Risks assoated with EDT.
- HIV. Trauma pt 4%. EDT pt 14%
- acutely injured pt. HIV 4% HepB 20% HepC 14%

Sent from iPhone