Thoracotomy

/ Mike Halperin EM-2

‘Make your intentions honorable.’ -John Hinds

The case below was presented in Trauma rounds, July 22nd, 2015, by Dr. Benjamin Chan (EM-4).

CRACKING THE CHEST: Where’s the Foley?

It could have potentially been a quiet night — a Tuesday, or maybe it was a Sunday overnight. My second Bronx summer as an emergency medicine resident had just started, and ‘graduated responsibility’ was on my mind. The 4th of July and its penchant for crazy firework trauma had come and gone relatively peacefully. The EMS notification phone, however, has a distinct ring-tone with the uncanny ability to pierce the quiet, penetrating the furthest reaches of the Jacobi ED. I was in one of those reaches, in the yellow zone, ultrasound probe in hand about to scan the gallbladder of a middle-aged woman with abdominal pain. I quickly apologized and stepped out.

As a first year, when the EMS notification phone rang, I heard it, but would invariably keep doing what I was doing until the call was made overhead for us to gather in the acute resuscitation bays. Sometimes the calls are for the team on the opposite side of the ED, in which case I could disregard and keep working. This year, however, I’ve started to migrate towards the trauma bays, peering over the shoulder of the nurse taking report from EMS. If the call is for the other team I can go back to Yellow and my search for gallstones. This year, as second years, our senior residents are assigning us the sickest trauma patients. I’ve stopped waiting for the overhead call. It was my turn, and I’ll take the extra time for preparation if I can get it.

“Young adult male — stab wound to the left chest.” The nurse states in a monotone voice while jotting details on a notepad, phone nestled in the shrug of her right shoulder. “Intubated in the field.” Next line. “Heart Rate 130s, blood pressure 70/palp.” The acute resuscitation bays sit a stone’s throw from the clerks’ desk, and I hustle over as the nurse who took the call hangs up and makes the announcement overhead. I grab a mask and secure it behind my ears, feeling my own heart rate thump in my chest. I take a few deep breaths, but my sympathetic nervous system has shifted into overdrive. Gown and gloves on. My senior resident and I are on the same page; I place a scalpel, bottle of betadine, 36 french chest tube, and the chest tube pack onto the tray situated on what will be the patients left side. I grab a #ten- and #eleven- blade scalpel. For a split second it registers that the two blades are very different. I’d never been told, nor thought to ask which is preferred for a chest tube. I’m sure, though, that both work, and this really isn’t the time. The previous year my attending had good-naturedly prodded me to try “not to look like a chump in front of the trauma surgeons,” so I’d been practicing my hand-ties at home. Pretending that a giant salad spoon was the chest tube, I’d been revisiting knots I hadn’t done since my surgical rotation in medical school. My chest wall still thumping away, I think I’m ready in the eventuality that this young man, still en route via ambulance, would need a chest tube. Lungs, heart, great vessels, and injury to any and all of them were the thoughts running through my head. I kept trying to take deep breaths.

A Level 1 trauma notification is called — there are different categories of trauma, 1 being the most acute and means a trauma attending and chief would be arriving to the bay soon — and an EM senior resident, who generally covers the airway on trauma cases, is assigning roles. We have a nurse, an EM attending, another 2nd year on vascular access, and myself, whose job, at least initially, will be to perform the primary survey. Looking out the trauma bay, we’re all gowned-up; EMS will be arriving from the right.

All of a sudden there’s a slight increase, audible, but not yet visible from our vantage point, in the level of commotion at the ambulance bay. Moments later I see a young man, on his back on the gurney, he looks sweaty. My eyes track to the EMS monitor, he’s got a pulse, and he’s moving (signs of life (Hunt, 2006)). There’s blood on his left chest. EMS is bagging him via their endotracheal tube placed in the field as he’s rolled into resuscitation bay 1. EMS reports that not much is known; “he was found down, penetrating trauma to left anterior chest, large-bore intravenous access obtained, intubated on the scene.”

I thrust my stethoscope onto the left chest; I think it sounds decreased. I move to the right chest for comparison, better. I go for the axilla, still trying to somehow ignore the ambient noise of the trauma bay — still decreased on the left. “Decreased breath sounds on the left!” I try not to yell.

EM and trauma attending, in unison command, “Chest tube on the left, now.” Betadine goes on first, sterile gown and gloves in quick succession. I choose the #ten blade scalpel and am just barely piercing the skin at the superior border of the rib sitting in the anterior axillary space just superior to the nipple line. “We lost pulses,” says a voice to my left with his hand on the femoral artery. “No pulse.” Without hesitation, the decision is made to scratch the chest tube and move to thoracotomy.

The decisiveness made an impression. There was no debate, we hadn’t yet checked a subxiphoid ultrasound image that might hint at reasons for cracking the chest (Inaba, 2015). Both our EM and Trauma attending knew the indications, literature, process, complications of the thoracotomy so well, that the decision to proceed was almost matter-of-fact. The procedure seemingly takes no time (initiated by the trauma chief resident, and completed by the trauma attending) as the incision for a left anterolateral thoracotomy (Flaris, 2015) is competed and the steel rib-spreaders open up the 5th intercostal space large enough to fit your head through; there sits a very large heart, no obvious bleeding.

I’m holding the patient’s left arm above his head, out of the way. Everyone has a role; I’ve become part of the thoracotomy team. The heart is fibrillating on the monitor, the heart is visibly fibrillating in his open chest. Tamponade physiology recognized, and the right hand of the trauma attending leans in, makes an incision in the pericardium and a torrent of blood shoots out. I put my right hand out and try to the block the arterial spray. It’s hot, and it’s all over our gowns. The trauma attending sees where the blood is coming from and asks for a Foley catheter, which our EM attending has, shockingly to me, in his hand, and smoothly passes it from his position at the foot of the bed over to the left side of the stretcher as soon as it’s requested. The Foley is placed into the cardiac wound and balloon inflated to stop the bleeding. The scariest moment for me, is when the trauma attending shouts for a stapler, which thankfully was in the second drawer that I frantically throw open. Cardiac message (using two-handed, hinged clapping motion) is initiated and the patient is shocked twice using the long black internal paddles, one placed on each side of the heart. Epinephrine is drawn up in a syringe and delivered directly to the heart. I’m trying to maneuver the overhead lights, but can’t swing it low enough to get the beam into the thorax. I break out my Maglite-style penlight and shine it into the open cavity, doubtful, but hopeful that it’s helping the trauma chief and attending see what they’re looking at. Foley inserted, incision stapled, normal sinus rhythm on the monitor, we move out of the ED, into an elevator being held open by a medical student, to the third floor, around the corner and into the operating room. Once in the OR, the patient is fully in the hands of the surgical team. I grab the portable monitor to scurry back down to the ED, “let me know how it goes.” I say as I back out of the OR. On the way downstairs I pass a surgical resident who asks, dubiously, how our patient is doing, probably knowing only that this patient had just had his chest opened in the ED. “Should I continue to try to clear an intensive care unit bed?” I think so.

Forty-five minutes later, a second level 1 trauma is called. Chest thumping, I’m trying to get those deep breaths going. Standing in the trauma bay, my senior resident is again assigning roles. I overhear the trauma attending on the phone with his chief resident who is still in the OR closing up the ED thoracotomy patient. “Please close faster,” he calmly requests. Six days later, the young man walked out of the hospital.

The foresight my attending had to have a Foley catheter in his hand and anticipate it’s utility in the event of a cardiac stab wound has left a huge impression. He was overseeing the most critical of resuscitations but at some point had looked 10 steps ahead and was prepared. In contrast, I became frantic, searching for a stapler. Terms like graduated responsibility, competency, and milestones are tossed around often in residency training circles. My definition of success in residency is when you learn to anticipate and act, rather than react and flounder.

Practically, it means proper preparation as a routine. It doesn’t always work out, but I try to show up to my shifts a little early. I use this time to swing by the resuscitation bays and ensure they’re stocked with the things we might need in a pinch. Sometimes, loading my pockets with saline flushes, IVs, a bottle of betadine and a scalpel. EMS pre-notification the prep work includes making sure the ultrasound machine is on and both the phased array and linear probes are attached and working prior to patient arrival. Setting up a chest tube tray even if there’s only a slight chance it will be needed. Trying to be like my attending that night and know what’s going to happen ahead of time.

 

THE PROCEDURE:

Who gets one? The Eastern Association for the Surgery of Trauma (EAST) provides 6 scenarios based on 72, largely retrospective, studies of over 10,000 patients who underwent ED thoracotomy (Seamon, 2015). The 6 scenarios are based on 6 distinct populations depending on presence or absence of signs of life, and whether the injury was penetrating (thoracic or extra-thoracic) or blunt.

  • Strongly recommended: Pulseless with ‘signs of life’ (defined as; pupillary response, spontaneous ventilation, carotid pulse, measurable or palpable blood pressure, extremity movement, or cardiac electrical activity) after penetrating thoracic injury.
  • Strongly favored: Pulseless without signs of life after penetrating thoracic injury.
  • Conditionally recommended: Pulseless with signs of life after penetrating extra-thoracic injury.
  • Conditionally recommended: Pulseless without signs of life after penetrating extra-thoracic injury.
  • Conditionally recommended: Pulseless with signs of life after blunt injury.
  • Conditionally not recommended: Pulseless without signs of life after blunt injury.

Keep in Mind:

  • Decide quickly, ACLS doesn’t work for traumatic arrest, don’t do 6 minutes of CPR then decide to crack chest. Open or call it.
  • Cut, following the curve of the rib (beneath nipple in male or along inframammary fold in female), so that it opens wide enough without revision.
  • Spread the intercostal space with rib spreaders.
  • Second team continuing the resuscitation. Obtain venous access. Right subclavian central line, intubation, calling for blood, transfusing. Consider chest tube for right chest.

Now what? Relief of Tamponade (Bokhari, 2004 & Bartlett, 1998):

  • If endotracheal tube wasn’t mainstemmed, left lung will be popping out at you. Push lung into chest, superiorly and laterally to expose the pericardial sac. Grab the heart and lift.
  • Pick up the pericardium. Make an incision, avoiding the phrenic nerve, which appears as a white or yellow strand. It sits laterally, so aim for most anterior aspect of heart (the apex, closest to ceiling). You’ll know that you are through pericardium when you can see heart, or blood starts spurting out. Pericardial fluid should normally be straw-colored, without any hint of red. If nothing comes out, there was no pericardial tamponade, and the patients chance of survival markedly declines (Cipolle, 2012).
  • If blood, extend the nick you’ve made in the pericardium, from the top to the bottom parallel to phrenic nerve (from the apex of the heart to the aorta).
  • Fully expose heart. Deliver the heart from the pericardium and inspect it for any injury. Inspect anteriorly and laterally, if you still can’t find where the blood is coming from gently lift up the heart and see if there’s anything posterior.
  • If you find a wound anteriorly, still check posterior; there could be a through-and-through injury. Don’t try and stitch the heart. Put your finger on the hole; digital occlusion of small cardiac wounds can provide excellent hemostasis. Don’t place your finger in the hole as this could increase the size of the wound. Another method of temporary hemostasis is to place a 14 or 16 foley in the hole, fill with saline until just bigger than hole.

Control Hemorrhage:

  • Cross clamp pulmonary hilum in cases of pulmonary hemorrhage. Alternatively, push lung down until you see heart. Find inferior pulmonary ligament and cut it. Take entire lung and twist it 180 degrees for vascular control.
  • Intercostal bleeds are a very survivable injury, bleeding will be coming from behind lung. Hold pressure.
  • Injuries to thoracic great vessels (pulmonary artery and vein, vena cava, aorta, innominate artery, subclavian artery and vein) are a cause of significant morbididy and mortality. Cross clamp to control hemorrhage.

The young man walked out of the hospital 6 days after arriving; back out into the Bronx summer. I wonder what he thinks, or knows, about all that has occurred. He’s taught me quite a bit.

References:

Bartlett, R. (1998). Resuscitative Thoracotomy. In J. Roberts & J. Hedges (Eds.) Clinical Procedures In Emergency Medicine (pp. 264-279), Philadelphia, PA: W.B. Saunders Company.

Bokhari, F. (2004). Emergency Department Thoracotomy. In E. Reichman & R. Simon (Eds.), Emergency Department Procedures (pp. 256-261). New York, NY: McGraw-Hill.

Cipolle M et al. Deadly dozen: dealing with the 12 types of thoracic injuries. JEMS. 2012 Sep. 37 (9):60-5.

Flaris, A et al. Clamshell Incision Versus Left Anterolateral Thoracotomy. Which is Faster When Performing a Resuscitative Thoracotomy? The Tortoise and the Hare Revisited. World Journal of Surgery. 2015 May; 39(5): 1306-1311.

Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma — a review. Injury. 2006 Jan;37(1):1-19. Epub 2005 Apr 20.

Inaba, K. et al. FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation. Ann Surg. 2015 Sept; 262(3): 512-18.

Seamon MJ et al. J Trauma Acute Care Surg. July 2015; 79: 159-173

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