TRM 04.02 EMERGENCY DEPARTMENT THORACOTOMY GUIDELINE

Trauma Service Guidelines Title: Emergency Department Thoracotomy Guideline Developed by: K. Gumm, R. Judson, M, Walsh, P. Antippa, B. Thomson, C. McGurgan, R. Whiting C. Norton, R. Segal, J. Tatoulis, Advisory Committee on Trauma Created: V1.0 September 2011 Revised by: K. Gumm R. Judson, B. Thomson, P. Antippa, J, McCormick, R. Shakerian, C. Mcgurgan, D. Camilleri, M. Walsh, A. Paspaliaris, G. Plunkett Advisory Committee on Trauma, Revised: V3.0 Nov 2018, V2.0 March 2015 See Also: TRM08.12 Traumatic Cardiac Arrest Guideline; TRM08.16 Trauma OPSTAT; TRM08.01 Massive Blood Transfusion Guideline

© Melbourne Health 2018“The information made available in these guidelines is produced for guidance purposes only and is designed as a general reference. The information made available does not, and does not purport to, contain all the information that the user may desire or require. Users should always exercise independent judgement and, when necessary, refer to other reference sources including obtaining professional assistance.

Trauma Service its officers, employees, agents and advisers:● are not, and will not be, responsible or liable for the accuracy or completeness of the information [on these web pages/in these guidelines];● expressly disclaim any and all liability arising from, or use of, such information;● except so far as liability under any statute cannot be excluded, accepts no responsibility arising from errors or omissions in such information;● accepts no liability for any loss or damage suffered by any person as a result of that person, or any other person, placing any reliance on the

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Table of Contents

Definitions: 1

RMH Experience 2

Aims of an Emergency Department Thoracotomy 2

Indications for Emergency Department Thoracotomy 2

Methods and Equipment 3

Emergency Department Thoracotomy Tray 7

Background

Thoracic trauma is one of the leading causes of death worldwide in all age groups, and accounts for 20-50% of all traumatic injuries. Most thoracic injuries can be managed conservatively but a small group will require a thoracotomy as part of their initial resuscitation. 1-5

Rapid response times and improved paramedical treatment at the scene have resulted in increasing numbers of patients arriving in the Emergency Department in extremis. Salvage of this group of patients requires immediate control of haemorrhage, and resuscitation. This is achieved by focusing on correction of reversible causes of shock, namely, haemorrhage, obstruction (due to tension pneumothorax or pericardial tamponade) and hypoxia. 1, 4, 6

Survival rates following Emergency Department Thoracotomy (EDT) for all patients with penetrating thoracic trauma are 9-12% and up to 38% in those with signs of life; whereas for all patients with blunt trauma survival rates are 1-2% and up to 5% in those with signs of life. 2-10

Definitions: Emergency Department Thoracotomy (EDT) 5, 7, 8

Occurring in the emergency department as an integral part of the initial resuscitation process immediately after presentation.

Urgent Thoracotomy 5, 7, 8

Thoracotomy performed in the operating theatre.

Signs of Life 1, 6, 9

Pupillary response to light Respiratory effort Cardiac activity/ contractility on eFAST Spontaneous movement Palpable pulse

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Aims of the Emergency Department Thoracotomy 10 1, 6, 10

Primary Aim

Alleviate cardiac tamponade which is causing refractory obstructive shock.

In the presence of senior surgical staff, secondary aims to consider are:

▪ Haemorrhage control

▪ Performing open cardiac massage

▪ Cross clamping the descending thoracic aorta to prevent exsanguination from catastrophic intra-abdominal bleeding.

Indications for Pericardial Decompression via Emergency Department Thoracotomy in either Blunt and/or Penetrating Trauma Profound refractory shock with SBP ＜70mmHg despite bilateral chest

decompression and aggressive 1:1:1 blood product resuscitation AND Cardiac Tamponade on eFAST AND Cardiac Activity on eFAST

OR

Witnessed cardiac arrest in ED or Pre-hospital Arrest (< 10 mins) in the in an undifferentiated trauma patient

AND Cardiac Tamponade on eFAST

The Massive Blood Transfusion Guideline should be activated and the MEP pack retrieved and a TRAUMA OPSTAT activated to notify theatre that an urgent surgical case may be on their way for definitive

management once the EDT is complete.

Contraindications for Pericardial Decompression via Emergency Department Thoracotomy: Pre-hospital CPR of > 10 minutes in the context of traumatic arrest Injuries that are not compatible with

life (including non-survivable head injuries)

No return of spontaneous circulation (ROSC) after 10 minutes in the context of traumatic arrest

Lack of training in the procedure

The patient’s age and pre-existing co-morbidities mean that successful resuscitation is highly unlikely

Urgent Thoracotomy

Time critical patients who are NOT in extremis and who do not meet the indications above are best managed in the operating room by the thoracic team. The patients can have safe rapid transport to theatre by the Trauma OPSTAT.

If the thoracic team is delayed and not immediately available in theatre at the time of the patient’s arrival, the thoracotomy should be commenced by the general surgeon.

The approach should be as outlined below using the left lateral thoracotomy (which can then be extended/ converted to clamshell).

Lateral decubitus positions (left or right) are not recommended in a critical trauma situation.

Methods and Equipment 1, 3,10, 14 The approach

The left anterolateral approach is frequently utilised (see Figure 1) for EDT due to the advantages of:

rapid access with simple instrumentation in the supine patient

easy extension to the contra lateral hemi-thorax (clamshell)

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The right anterolateral approach may be selected in cases where there is a penetrating injury is to the right side of the chest

How to 10,14, 19

Although surgical draping is not essential, large, waterproof, disposable sterilepaper drapes are included in the Emergency Department Thoracotomy (EDT) tray. The patient is positioned supine with both arms abducted at right angles, and the left side of the chest and hip partly elevated (folded towels, pillow or sandbags).

Rapidly prepping and draping of the entire area is required prior to the skin incision taking place.

The skin incision should be below the nipple, in the infra-mammary fold and should target the fifth intercostal space (see Figure 1), extending through the soft tissues of the chest wall following the curve of the rib. In women the breast should be retracted. If a finger thoracostomy has been performed, the incision should be extended as per the above description.

Entry into the pleural cavity should be on the superior margin of the sixth rib to avoid the intercostal neurovascular bundle. Muscle, periosteum and parietal pleura are divided in one layer with scissors and blunt dissection. Chest wall bleeding is generally minimal.

To spread the ribs once the incision is completed (see Figure 4) and the pleural cavity exposed, a suitable retractor (Finochietto comes assembled on the EDT) should be inserted with the handle pointing towards the axilla. The superior and inferior costal cartilages of the opened interspaces may be incised in order to achieve additional exposure. Figure 1 Resuscitative thoracotomy, general techniquefrom Jones & Rivers 2019, Chapter 18 Resuscitative Thoracotomy 5. [ Custalow CB: Color atlas of emergency department procedures, Philadelphia, 2005, Saunders] 11

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Procedures Pericardotomy to relieve cardiac tamponade

The pericardiotomy should be made with scissors at least 1cm anterior to, and parallel to the phrenic nerve.

Any blood and clot should be evacuated.

In the beating heart, digital pressure on bleeding sites should be maintained until the patient is resuscitated.

If the heart is fibrillating, suture control of the bleeding points should be performed before defibrillation.

The pericardium may appear normal despite the presence of tamponade. It must ALWAYS be opened.10

Repair of the heart/ Haemorrhage control

Use Satinsky clamp for atrial wounds

A skin-stapling device can be useful for temporary control of bleeding from the myocardium.

Close pericardium with interrupted sutures

Internal (open) Cardiac Massage

Cardiac massage should begin immediately if there is true cardiac arrest.

This can be done using two hands with a hinged clapping motion i.e. 2 cupped hands, opposed at the wrist and avoiding thumb pressure

Internal cardiac should not be the only indication for EDT as external compressions have been shown to be equally effective

Internal defibrillation for ventricular fibrillation (VF) requires energies of 15 to 30 joules

Post Procedure CareOnce cardiac output has returned the patient requires rapid transport to the operating theatre for definitive care. Hypotensive resuscitation principles (aiming for systolic ~ 90mmHg) should be employed to maintain perfusion, but minimise haemorrhage (see TRM 08.01 Massive Blood Transfusion in Trauma Guidelines ).

Cessation of Resuscitation

Cessation of resuscitation requires careful consideration and the EDT should not be performed where:

Injuries incompatible with life

Pulseless electrical activity (PEA)

Asystolic arrest

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Emergency Department Thoracotomy Tray

There are two trays available; one with 2 assembled Finochietto retractors, and one with instruments

Other equipment on EDT trolley

Sutures 13 5 x 3/0 Prolene round needle3x 2/0 Ticron5x 1 Prolene

Pledgets 1 Packet Teflon felt pledgets (867701)

Staplers 1 Skin stapler

Scalpels 1 Box disposable sterile No 23 scalpel blades

Suction 2 Disposable suction tubing and Yankeur suckers

Defibrillator paddles 1 Internal defibrillator paddles

Tegaderm™ 1 Large Tegaderm™

Drapes 1 Large disposable drape (3M 6617) keep

Skin prep 1 “Red” Chlorhexidine 2% in 70% alcohol or Povidone Iodine

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Perform an Emergency Department Thoracotomy

Return of SOL URGENT THEATRE

Patient arrives Commence Primary Survey

Continue primary & secondary survey

Are there any indications for

Emergency Department

Thoracotomy?

Indications for EDT BP < 70mmhg despite resus

Cardiac tamponade on eFAST < 10mins prehospital CPR

Survivable injuries

Patient Requires Urgent Thoracotomy?

Emergency Department Thoracotomy

If patient is expected with penetrating/ blunt chest trauma in extremis notify cardiothoracic teamRetrieve the MEP pack

TRAUMA OPSTAT

No

Cessation of treatmentInjuries incompatible

with life Pulseless electrical activity

Asystolic arrest

Downgrade Trauma OPSTAT

Notify theatre # 6312

No Yes

Yes

Notify Cardiothoracics

Yes

Signs of Life Pupil response

Respiratory effortCardiac activity

Spontaneous Movement Palpable pulse

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References

1. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery. 2015;79(1):159-173.

2. Menaker J, Scalea T. Emergency Department Thoracotomy In: Cameron J, Cameron A, eds. Current Surgical Therapy 12th ed: Elsevier; 2017: 1141-1145

3. Raja A. Thoracic Trauma In: Walls R, Hockberger R, Gausche-Hill M, eds. Rosen's Emergency Medicine; concepts and clinical practice 9th ed: Elsevier; 2018: 282-403.e282.

4. Camilleri D, Gumm K, Liersch KW, M , et al. TRM08.12 Traumatic Cardiac Arrest Guideline Melbourne: The Royal Melbourne Hospital; May 2018

5. Jones R, Rivers E. Resuscitative Thoracotomy. In: Roberts I, Hedges J, eds. Roberts and Hedges Clinical Procedures in Emergency Medicine and Acute Care Elsevier; 2019: 338-352. e332.

6. ANZCOR. Management of Cardiac Arrest due to Trauma; ANZCOR Guideline 11.10.1: Australian and New Zealand Council of Resusitaiton April 2016.

7. Boddart G, Hornez E, De Lesquen H, et al. Resuscitation thoracotomy. Journal of Viseral Surgery. Decemember 2017;154:S35-S41.

8. Lesquen H, Beranger F, Natale C, Boddaert B, Acaro J. Resuscitation thoracotomy-technical aspects. Journal of Viseral Surgery. 2017;154:S61-S67

9. Moore H, Moore E, Burlew C, et al. Establishing Benchmarks for Resuscitation of Traumatic Circulatory Arrest: Success-to-Rescue and Survival among 1,708 Patients. Journal of the American College of Surgeons. 2016 223(1):42-50.

10. Fitzgerald M, NewtonBrown E, Tan G, Martin K. Emergency & Trauma Centre Resuscitative Thoracotomy and Pericardial Decompression Handbook. 3rd ed. The Alfred 2015

11. Custalow C. Resuscitative thoracotomy, general technique. In: 18.4 F, ed. Color atlas of emergency department procedures. Philadelphia Saunders 2005.