management algorithms are extrapolated from the adult literature and follow the
Advanced Trauma Life Support guidelines. Based on adult data, emergency
thoracotomy in the ED is indicated in children with cardiac arrest after a
penetrating injury and signs of life were previously present at either the scene
or on arrival.
The procedure is performed by first prepping and draping the left chest
in the usual sterile fashion. An incision is made at the 5thintercostal space from
the sternum to the mid-axillary line. Sharp dissection is carried through the
intercostal muscles into the thoracic cavity. A rib spreader is used to open the
wound for further exposure. The left lung is retracted anteriorly and superior,
and the pericardium is examined for pericardial tamponade. The pericardium is
incised with scissors anterior and parallel to the phrenic nerve. Manual cardiac
compression may be initiated directly on the heart. In the face of severe
hemorrhage, the aorta is identified just above the diaphragm. Placement of a
nasogastric tube may assist in identification of the esophagus. The aorta is then
cross-clamped with a large vascular clamp to stem ongoing bleeding during
resuscitation. If necessary, the left sided thoracotomy incision may be extended
through the sternum into the right chest to fully expose the heart and allow
evaluation for right thoracic injuries.
IV. SUMMARY