THORACOTOMY

 

1. Indications:
• Cardiac arrest secondary to penetrating trauma
• Cardiac tamponade unresponsive to pericardiocentesis
  
   
2. The following can be performed during an open thoracotomy:
• Clamping of aorta
• Open cardiac massage
• Defibrillation
• Pericardiotomy
• Repair of cardiac defects
• Direct intracardiac infusion of crystalloid/blood products.
   
3. Tools:
• # 10 blade
• Mayo scissors
• Rib retractors
• ClampForceps
• Suction catheter
• Towels & sponges
   
4. How to open chest:
• Intubate, sedate, wide open IV, tube in every  orifice
• Incise from sternum to the L posterior axillary line at 4th-5th  IC space. 
• Injury to  L mammary artery is not infrequent. If so,clamp it.
• Separate the ribs and enter chest cavity with Mayo scissors
• Insert rib retractor and spread the ribs enough for two hand to fit inside
• Incise the pericardium horizontally avoiding injury of phrenic nerve located
  laterally and injury of coronary artery.
   
5. Open-chest maneuvers:

Pericardiotomy:

1. Blood is evacuated by incision of pericardium, avoiding injury to phrenic  nerve located laterally and injury to coronary arteries.

Cardiac Chamber Repair:

1. Clamp with your index and middle finger the Superior and Inferior Vena Cava.
   This stops the hemorrhage and creates a bloodless field. Clamp should  not be applied
    for more than 30-60 sec to avoid ventricular fibrillation.
    
2. Insert finger, Foley (inflate it) or try to repair the wound with mattress sutures
   (non-absorbable material).

Open Cardiac Massage and Defibrillation:

1. Place the heart between the palms of your two hands and compress
    
2. If ventricular fibrillation is witnessed, defibrillate with paddles at 20-40 W
    
3. Clamping of Descending Aorta:
    
• This is done in case of  hypotension  and cardiac arrest in order to increase
• and  improve coronary and cerebral blood flow and to fill the hypovolemic
• heart while injuries are being assessed and repaired.
   
4. To identify the descending aorta one must lift the lung out of the thoracic cavity.
    
5. Run  your hand inferiorly and posteriorly along the vertebral bodies until  you
   reach the diaphragm. At this level, the first structure anteriorly is the aorta
   (esophagus lies medial and anterior to the aorta). Identify by palpation and
   then place a clamp on it.

Direct intracardiac infusion of blood products/crystalloid:

1. This is good for rapid resuscitation and infusion of blood products.
    
2. Identify right atrial appendage. Grasp with clamp.
    
3. Place non-absorbable suture around appendage.
    
4. Incise myocardium.
    
5. Place large-bore foley catheter in right atrium.  Inflate balloon.  Secure purse-string.  Infuse directly into right atrium.

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