Emergency Department Resuscitative Thoracotomy Flashcards
Define Cardiac Box
superior border being the sternal notch
inferiorly the xyphoid process
laterally the nipples
Indications for EDT
1-Blunt < 10 min Prehospital CPR
2-Penetrating Torso < 15 min Prehospital CPR
3-Penetrating Neck < 5 min Prehospital CPR
4-Penetrating Extremity < 5 min Prehospital CPR
or
Blunt/Penetrating : Active CPR and signs of life or
Shock with Sbp < 60
Purpose of ED thoracotomy performed for abdominal trauma
cross-clamping the descending aorta
ANTEROLATERAL THORACOTOMY site
at the anterolateral chest wall, on the male from the left parasternal main body on an imaginary line along the nipple
female on the inframammary fold in the direction of the rib in the 4th/ 5th intercostal space
ANTEROLATERAL THORACOTOMY Steps
1-Supine Position , Left arm raised above head
2-Clean chest cage with betadine, both sides
3-orogastric tube (to Differentiate aorta from esophagus)
4-skin, subcutaneous tissue exposing serratus anterior musculature
extends from the sternum below the nipple to the midaxillary line
5-transected as laterally as the latissimus dorsi allows
6-expose the underlying intercostal musculature
7-maintaining the incision on the superior aspect of the inferior rib to avoid damage to the intercostal neurovascular bundle
8-awareness, the internal mammary artery may be avoided when approaching the lateral sternum and, if transected, can be ligated
9-Posterolaterally, the chest wall is opened well beyond the medial border of the latissimus dorsi
10-Finochietto retractor (rib spreader) handle away from sternum
11-if thoracotomy extension needed, the incision is taken across the sternal body down to the bone and extended in the same fashion down the right hemithorax
How to open Pericardium
The pericardium should be opened routinely to rule out cardiac injury, cardiac tamponade, and facilitate open cardiac massage.
An incision on the pericardium should be made anterior to the phrenic nerve and extended parallel to the phrenic nerve as superiorly as possible and inferiorly to the cardiac apex
In the event of tamponade
First cardiac delivery then clot evacuation and methodical examination of the myocardium.
If cardiac injury with active extravasation > control with light digital pressure
temporary control of full thickness cardiac injuries > Foley catheter placement with balloon inflation
large staples, vascular clamps (may be effective on atrial injuries), or suture control
definitive cardiorrhaphy can be achieved in the operating room.
NONCARDIAC-RELATED THORACIC HEMORRHAGE
-Access to the posterior thorax > division of the inferior pulmonary ligament
-Identified by grasping the inferior lobe, slip finger posteriormedial , groove between lung and medial thoracic
-ETT advanced into the right main stem bronchus to collapse the left lung
Pulmonary parenchymal injury
controlled with direct finger occlusion or noncrushing vascular clamp placement until the patient is transported to the OR for formal resection and/ or repair
For uncontrollable vascular or larger parenchymal disruption, pulmonary hilar clamping or complete twisting of the lung about the pulmonary hilum once the inferior pulmonary ligament has been divided can be undertaken
Aortic Cross Clamping
-The aorta runs anterior to the vertebral bodies and directly next to the left of the esophagus in this location
-nasogastric / orogastric tube helps to localize the esophagus when attempting to isolate the aorta away from it.
-opening of mediastinal pleural overlying the aorta
-And posteriorly paravertebral facia
-Aorta elevated and cross clamped
other option:
-Pressure at the distal descending thoracic aorta against the vertebral body
post-clamp physiologic stress of reperfusion and reperfusion injury
Acidosis, hyperkalemia, and shock should be anticipated,
continual aortic clamp times (> 40 minutes) > Fatal
REBOA Placement for abdominal vs pelvic hemorrhage
zone 1for intraabdominal hemorrhage control
zone 3 for control of pelvic hemorrhage
