Resuscitative Thoracotomy SOP

Question 1

Outline the contents of the resuscitative thoracotomy SOP

Answer 1

Surgical intervention undertaken in a specific context often with complex decision making.

Covers:
- Indications
- Decision making
- Team approach and rolls
- Technique
- Post-procedure management
- Discontinuing resuscitation

Question 2

Outline the indications for resuscitative thoracotomy

Answer 2

Cardiac tamponade
- Penetrating thoracic/supraclavicular/epigastric trauma (potential tamponade)
- Blunt trauma (probable tamponade)
- Arrest or loss of signs of life within the last 15 mins

Traumatic arrest due to haemorrhage
- None compressible intrathoracic/sub diaphragmatic exsanguination
- PEA plus mechanical cardiac activity
- Arrest or loss of signs of life within the last 10 mins

Question 3

What factors affect the decision making around thoracotomy?

Answer 3

• Time critical both for intervention and since signs of life
• Mechanism, examination and USS may help
• Prolonged no flow or low flow times are highly likely to have poor neuro outcomes either way
• Aortic occlusion has a significant metabolic insult

Any doubt speak to TCC

Question 4

Describe the team approach to thoracotomy

Answer 4

Kit dump
360 access
PPE

Para - scene management, kit dump, sharps, IVA, airway interventions
Doctor - procedure

Question 5

Talk through the steps of a thoracotomy

Answer 5

1. 360 access, clear none essential personnel
2. Stop chest compressions
3. Clean the skin 2% Chlorhexidine, sterile gloves
4. x2 finger thoracostomies
5. Reassess
6. Single incision from one to the other down to intercostal muscles
7. Tough cuts to sternum
8. Clear fascia
9. Divide sternum
10. Open thorax, extend posteriorly if required
11. Forceps then mayo scissors to create hole at cephalad aspect
12. Inverted T incision through pericardium
13. Remove clot, inspect the heart anterior and posteriorly
14. Close the hole staples/sutures, avoiding coronaries
15. Compress aorta, clamp if able
16. Internal cardiac massage
17. Fill the patient if heart empty
18. Haemorrhage control of internal mammaries if req
19. Consider removing aortic compression

Question 6

Describe the aspects of post-procedure management following thoracotomy

Answer 6

• Don’t forget any kit, document if something remains with/in the patient
• Transport, usually by road, if sustained ROSC
• Continue aortic compression, go by road if needing to keep manual compression on
• Consider feet first
• If aortic compression not required close the chest - dressing/cling film
• Anaesthetise if required
• Give TXA (consider calcium, adrenaline, sodium bicarb, antibiotics)
• Temperature management
• MTC, TCC to liaise if helpful

Question 7

Discuss PLE in the context of a patient receiving thoracotomy

Answer 7

• Persistent asystole, no response to efforts
• Debrief
• Don’t forget your kit!