ED Thoracotomy/Emergency Resuscitative Thoracotomy (ERT)

EMERGENCY RESUSCITATIVE THORACOTOMY AND

TERMINATION OF RESUSCITATION ON THE BASIS OF PREHOSPITAL CRITERIA

Emergency resuscitative thoracotomy (ERT) has a poor salvage rate with a high risk of iatrogenic blood borne pathogen exposure and/or injury to health care providers.

Indications:

The American College of Surgeons (ACS) position in resuscitative thoracotomy, taught in Advanced Trauma Life Support (ATLS), is simple. For blunt trauma, ERT is not indicated. For penetrating trauma, ERT is appropriate when signs of life are present.

Signs of Life:

1.     Reactive pupils

2.     Spontaneous movement

3.     Organized ECG activity (VF, VT, PEA, etc)

4.     Cardiac activity on ultrasound

The Western Trauma Association (WTA) has promulgated a simpler and perhaps more pragmatic algorithm that is more liberal with ERT. If CPR has been performed fewer than 10 minutes for blunt trauma, ERT is appropriate. The same applies with up to 15 minutes of CPR for penetrating trauma.

http://westerntrauma.org/documents/PublishedAlgorithms/WTACriticalDecisionsResuscitativeThoracotomy.pdf

EAST updated its ERT recommendations in 2015 as follows:

1.     In patients who present pulseless to the Emergency Department with signs of life after penetrating thoracic injury, we strongly recommend resuscitative Emergency Department thoracotomy.

2.     In patients who present pulseless to the Emergency Department without signs of life after penetrating thoracic injury, we conditionally recommend resuscitative Emergency Department thoracotomy.

3.     In patients who present pulseless to the Emergency Department with signs of life after penetrating extra-thoracic injury, we conditionally recommend resuscitative Emergency Department thoracotomy.

4.     In patients who present pulseless to the Emergency Department without signs of life after penetrating extra-thoracic injury, we conditionally recommend resuscitative Emergency Department thoracotomy.

5.     In patients who present pulseless to the Emergency Department with signs of life after blunt injury, we conditionally recommend resuscitative Emergency Department thoracotomy.

6.     In patients who present pulseless to the Emergency Department without signs of life after blunt injury, we conditionally recommend against resuscitative Emergency Department thoracotomy

The performance of ERT is at the discretion of the Trauma Chief Resident, Fellow and Attending. If all the above-mentioned physical findings establishing absence of signs of life are verified, the patient may be pronounced DOA and no further resuscitation is required. The Trauma Service faculty and residents should ensure completion of the Trauma H&P in its entirety, completing under diagnosis “Patient pronounced DOA” and noting any injuries diagnosed by gross physical examination (e.g., femur fracture, penetrating head injury, etc.).

References: American College of Surgeons’ Committee on Trauma: Advanced Trauma Life Support, ed.9, Chicago, 2013, The American College of Surgeons.

Trauma Alert RED should be activated for ALL trauma codes.

EMERGENCY RESUSCITATIVE THORACOTOMY (ERT)-TECHNIQUE

The procedure is performed in conjunction with other resuscitative efforts and should not be employed in isolation. Under certain conditions, resuscitative efforts might best be accomplished in the Operating Room. An Emergency resuscitative thoracotomy should only be performed by general surgery PGY-3, or higher, level residents or attendings. If there is a delay in arrival of the surgery team, it is appropriate for the ERT to be initiated by the emergency department attending.

Procedure:

1.     Rapid bilateral antero-lateral Betadine or Chlorhexidine prep while thoracotomy tray opened. Thoracotomy trays are located in Trauma Bay Omni cells.

2.     Left antero-lateral thoracotomy incision located beneath nipple in males and in inferior breast fold in females. Incision extends from left sternal border to anterior border of latissimus dorsi and chest entered along the superior aspect of fourth or fifth rib. Care must be taken to avoid injury to heart and lung. A right antero- lateral thoracotomy may ALSO be preferred for primary right chest wounds.

3.     Insert rib spreader with handle located toward table laterally.

4.     Examine pericardium, if tense hemopericardium present (pericardium distended with maroon discoloration) then proceed to step 7.

5.     If systemic air embolism is suspected or massive hemorrhage from lung parenchyma or hilum is present, then place Satinsky clamp across hilum medially.

6.     Retract left lung with left hand. Locate aorta by running right hand medically along posterior chest wall. Aorta located along lateral aspect of vertebral bodies and will be postero-lateral to esophagus. Dissect around aorta inferior to pulmonary hilum and apply aortic cross-clamp.

7.     Enter pericardium by longitudinally incising pericardium anterior and parallel to phrenic nerve. This is best accomplished by grasping pericardium with forceps and cutting with Metzenbaum scissors. Pericardial incision is carried inferiorly to diaphragmatic reflection and superiorly to level of superior pulmonary hilum. Care must be taken to avoid injury to left atrial appendage and phrenic nerve. This is best accomplished by lifting tip of scissors laterally as incision is made.

8.     Manually lift heart from pericardial sac. If hemopericardium present, then examine for cardiac perforation. Teflon pledgetted 3-0 prolene suture on a taper needle is present in thoracotomy suture pack for repair of cardiovascular wounds. If hemopericardium is not present, then begin open cardiac compression. Aortic cross-clamping, if not previously performed, is indicated if no hemodynamic response is noted.

9.     Additional exposure may be accomplished by extending thoracotomy incision across sternum into contralateral chest cavity.

Powell DW, Moore EE et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg. 2004 Aug; 199(2):211-5.

Emergency Resuscitative Thoracotomy Tray

1            Finochetto

1            Pediatric Finochetto Medium

1            Tuffier Rib spreader

1            Medium weitlander retractor

2            army/navy retractor

1            str liston bone cutter

1            lebsche sternal chisel

1            mallet           

1            med Richardson

1            sm Richardson

2            9 ½ “ Debakey forceps

2            7 1/2 “ Debakey forceps

4            hemostats

2            8” Kelly

2            Vanderbilt

2            7” Tonsil

6            8” Tubing clamp

1            st Mayo

1            Curved Mayo

2            9” Metz

2            8” Crilewood Needle holder

1            lg towel clip

1            sm satinsky

1            Med Satinsky

1            lg satinsky

1            sm rummel

1            peds yankauer suction

1            wire cutter

(Suture is not kept with tray.  Each surgeon must request suture or pledgets from the supply tech in the room.)