Emergency Thoracotomy

  1. Perform hand hygiene and apply gloves. Apply personal protective equipment to include an impermeable      gown face shield, and mask at a minimum.  
  2.   If time allows, cleanse the patient's chest with an antiseptic solution.
  3.   Ensure that the patient is being mechanically ventilated via an endotracheal tube.
  4.   Establish large-bore intravenous (IV) access, and request blood for transfusion immediately.
  5.   If time permits, insert a gastric tube.
  6.   For patients in cardiac arrest, continue external cardiac massage until the thoracic incision is made.
  7.   Attach the electrocardiograph leads to the patient's limbs.
  8.   Turn on full-strength suction, and attach it to a sterile Yankauer tip via the extension tubing.
  Assemble the internal paddles.
  a.  Open the paddles and maintain the packaging as a sterile field. Pick up the end of the cable without                 contaminating the field or have the physician hand off the connector end of the cable. Plug it into the defibrillator.
  b.  Pour saline on gauze dressings to use between the paddles and the myocardium.

  • Provide assistance as necessary while the physician assembles the rib spreaders.
  • The physician incises the skin and enters the chest via a left anterolateral incision or bilateral anterior incisions ("clamshell"). Ventilations should be interrupted until the incision is complete.
  • The physician inserts the rib spreaders and exposes the pleural cavity.
  • The physician inspects the heart for penetrating injury which can be occluded temporarily with direct pressure by placing a finger or gauze into the hole.
Alternatively, a large Foley catheter (e.g., 28 Fr) can be inserted, and the inflated balloon can be used to occlude the hole.
    i.    The nurse or physician inflates the balloon with 10 ml or less of sterile fluid.
    ii.   The nurse or physician clamps the catheter or infuse blood and IV fluid directly into the heart via the                      catheter.
 The physician then sutures the defect with a nonabsorbable suture and pledgets.
   The defect may also be stapled shut with a skin stapler for temporary control of hemorrhage.

  • The physician may perform cardiac massage with either one or two hands by compressing the heart against the sternum.
  • The physician retracts the lung and inspects the descending aorta. The physician may occlude the aorta by compressing it against the spine or by cross-clamping it.
  • Document the time at which the aorta is clamped.
  • The physician may control pulmonary injuries by clamping across the parenchyma proximal to the injury or across the hilum of the lung, or by wrapping the hilum with a Penrose drain and then providing traction to occlude the vessels and control hemorrhage.
  • Assist with internal defibrillation:
 Turn on the defibrillator (usual energy required is 30 to 50 Joules [J] for adults). Internal paddles are programmed to deliver no more than 50 J.
 The physician places the paddles on opposite sides of the myocardium. A saline-soaked gauze dressing is placed between the paddles and the myocardium. The physician should make sure all personnel clear the stretcher; state, "all clear," and discharge the current into the paddles. (NOTE: Some monitors or defibrillators require a second person to discharge the paddles from the defibrillator. In this instance, the physician holding the paddles should say, "all clear," before the paddles are discharged.)

 Monitor the electrocardiograph for improvement in rhythm, and repeat these steps as necessary.
  • If the patient appears to be salvageable, plan immediate transport to the operating room:
  a.  In anticipation of the transfer, notify the operating room.
  b.  Prepare the patient (e.g., move all IV fluids, the portable oxygen tank, the cardiac monitor, and so forth to the stretcher).
  c.  If necessary, have security personnel or other staff members clear the corridors and secure an elevator to expedite the transfer.

  • On rare occasions, a patient may regain consciousness during thoracotomy. In this event, chemical and physical restraints are required immediately to prevent the patient from causing further injury by pulling on clamps, tubes, and so forth. Analgesics and sedatives should also be provided.
If the patient expires:
  a.  Perform postmortem care with attention to preservation of evidence for forensic purposes.
  b.  Provide emotional support for loved ones and allow them to see the body if possible (after wounds are covered, etc.).
  • Discard supplies, remove personal protective equipment, and perform hand hygiene.
  • Document the procedure in the patient's record.
  • Debrief or defuse involved team members as indicated.
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