Penetrating Chest Trauma

    Traumatic arrest with witnessed signs of life* in the field

    Persistent hypotension (systolic blood pressure (SBP) <60 mm Hg) despite resuscitative efforts

 Blunt Trauma

    Traumatic arrest that occurs in the emergency department (ED)

    Persistent hypotension (SBP <60 mm Hg) despite resuscitative efforts

 Pulmonary Trauma

    Chest tube drainage >1,500 mL

    Persistent hypotension or cardiac arrest with known lung laceration

 Air Embolism

    Persistent signs of hypovolemic shock

    Hemoptysis and cardiac arrest after intubation and ventilation

 Nontraumatic Hypothermic Cardiac Arrest

    In settings where cardiopulmonary bypass is not immediately available

 Goals

    Relief of cardiac tamponade

    Support of cardiac function with open massage, cross-clamping the aorta, and/or internal cardiac defibrillation

    Control of hemorrhage

    Diagnosis and management of air embolism

    Mediastinal irrigation and rewarming (for hypothermic cardiac arrest)

CONTRAINDICATIONS

 No signs of life and prehospital cardiopulmonary resuscitation (CPR) performed:

    >15 minutes after penetrating trauma

    >10 minutes after blunt trauma

 Multisystem blunt trauma

 Severe head injury

 Asystole as an initial rhythm without tamponade

 Inability to provide definitive care after procedure

RISKS/CONSENT ISSUES

 This is an emergent procedure and does not require written consent

LANDMARKS (FIGURE 15.1)

 Left-sided supine anterolateral approach over the 5th rib, in the fourth intercostal space

    In males incise below the nipple

    In females below the inframammary fold

TECHNIQUE

 Patient Preparation

    Patient should be intubated and a nasogastric tube should be placed (this should not delay the procedure!)

    Place towels under the left chest and place left arm above the head

    Sterilize the incision area with copious povidone–iodine solution

 Incision

    Using a no. 20 blade, incise from the sternal border to the posterior axillary line

    During the primary incision, cut firmly through subcutaneous tissue to the intercostal muscle

 Dissection and Rib Spreading

    Using scissors, cut the intercostal muscles above the 5th rib to avoid the neurovascular bundle

    Temporarily stop ventilation just before exposing the pleura to avoid lacerating the lung

    Insert rib spreader with the ratchet placed toward the axilla and handlebar down

    Use a Gigli saw, Lebsche knife, or trauma shears to cut the sternum for right-sided exposure

 Pericardiotomy

    Hold the pericardium with forceps, and use scissors to cut from the cardiac apex to the aortic root (FIGURE 15.2)

    The incision should be made anterior and lateral, avoiding the left phrenic nerve

    Evacuate blood and clots from the pericardium

    Deliver the heart from the pericardium if cardiac repair is required

Related posts:

Delayed Sequence Intubation Reduction of Nursemaid’s Elbow (Radial Head Subluxation) No Desat: Maximally Aggressive Preoxygenation Elbow Arthrocentesis Episiotomy Gastroesophageal Balloon Tamponade and the Sengstaken–Blakemore Tube