INTERPRETATION OFRESULTS
■ Air return (rush) confirms pneumothorax.
■ Blood return confirms hemothorax, as long as the blood is coming from
the pleural space.
■ An air leak is either due to significant air movement from the lung into the
pleural space or a leak in the tubing. Temporarily clamp the tube near to
the chest—if the leak persists, it is in the tubing not the patient.
Emergency Department Thoracotomy
INDICATIONS
■ Patients with penetrating chest or abdominal traumawho are pulseless
but have electrical cardiac activity may benefit.
■ Blunt trauma patients with vital signs in the field and organized electrical
activity in the ED may benefit from ED thoracotomy.
■ Goals are to relieve cardiac tamponade, cross-clamp descending aorta for
control of abdominal hemorrhage, control hemorrhage from heart or great
vessels, and provide effective cardiac compressions.
CONTRAINDICATIONS
■ Blunt trauma patients who require over 15 minutes of prehospital CPR
and any trauma patient who is apneic, pulseless, and in asystole are
unlikely to benefit from this intervention.
TECHNIQUE
■ Patient should be intubated and, if possible, analgesia and deep sedation
should be provided.
■ NGT should be placed to help differentiate esophagus from aorta.
■ Incision using No. 20 blade is made into the left chest between fourth and
fifth ribs: Just inferior to the nipple in men or along the inframammary
fold in women (see Figure 19.3A).
■ Incision extends from sternum to posterior axillary line cutting down
through pectoralis and serratus muscles.
■ Once the pleural space is entered, ventilations are temporarily stopped to
allow the lung to collapse away from chest wall.
■ Place chest wall retractor (rib spreader) to spread ribs. The crank should
be placed laterally, so that the incision can be extended across the sternum
into the right chest if necessary.
■ If exam suggests any possibility of tamponade, perform pericardiotomy:
Lift pericardial sac near diaphragm with forceps, make a small incision
with scissors, and extend the incision cephalad along anterior pericardium
parallel to the phrenic nerve(see Figure 19.3B).
■ Aortic cross-clamping used when SBP <70 mm Hg: Identify aorta which
lies anterior to vertebral column. Place a vascular clamp around the aorta
or occlude aorta with digital pressure (see Figure 19.3B).
■ Retract pericardium to examine heart for injury and repair with staples or
sutures (see Figure 19.3C).
COMPLICATIONS
■ Injury to intrathoracic structures (internal mammilary artery, phrenic nerve,
coronary arteries, aorta, esophagus)
■ Ischemia of spinal cord, liver, bowel, and kidneys with cross clamping
aorta or of cerebral hemorrhage or LVF if pressure elevation is excessive
PROCEDURES AND SKILLSDon’t clamp a chest tube
except to look for an air leak—
clamping a chest tube exposes
the patient to the risk of
tension pneumothorax.Typically, operative treatment
of bleeding is required in
patients with initial chest tube
blood loss of >1500 mL or
>200–300 mL/hour
thereafter.Don’t advance a chest tube
after it’s been placed—it’s
better to place another tube
than risk introducing bacteria
into the chest.