Makindo Medical Notes

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina |Adult Resus:Basic Life Support |Adult Resus: Advanced Life Support |Resus:Acute Haemorrhage

Introduction

• 🫀 Resuscitative thoracotomy is a last-resort, life-saving procedure in catastrophic trauma, performed to restore circulation and control exsanguination.
• It should only be undertaken by trained and credentialed professionals (Emergency Physicians, trauma surgeons, cardiothoracic surgeons) in centres equipped for definitive care.
• ⚡ While ideally performed in theatre, if a patient loses cardiac output it must be carried out immediately in the Emergency Department.

Indications

🎯 Primary goals: relieve tamponade, decompress tension, control haemorrhage, restore circulation.

• 💨 Decompression of tension pneumothorax
• ❤️ Relief of pericardial tamponade
• 🪡 Repair of penetrating cardiac wounds
• 🩸 Control of intrathoracic haemorrhage
• ✋ Open cardiac massage
• 🔑 RCEM: within the scope of practice for trained Emergency Physicians in extremis.

✅ Absolute Indications: - Penetrating chest trauma with witnessed loss of output in ED. - Tamponade with cardiac arrest. - Exsanguinating thoracic haemorrhage.

❌ Contraindications: - No cardiac output for >10 mins without ROSC. - Asystole without pericardial tamponade. - Blunt trauma with cardiac arrest (unless tamponade strongly suspected).

Acute Management Protocol

1. 📞 Call cardiothoracic support – notify consultant + SpR immediately.
2. 🧰 Prepare thoracotomy kit – sterile instruments, suction, lighting, cardiac sutures.
3. 🔍 Indications check – penetrating thoracic/upper abdominal trauma with arrest, or need for aortic cross-clamp in exsanguination.
4. ✂️ Bilateral thoracostomies – 5th intercostal space, mid-axillary line; decompress air/fluid before proceeding.
5. 🔪 Clamshell incision – join thoracostomies across sternum (Tuff Cut scissors / Gigli saw).
6. 🫀 Cardiac/pericardial management:
   • Open pericardium longitudinally; evacuate blood/clot.
   • Direct pressure or 4-0 Prolene sutures for cardiac wounds.
   • Pack/Foley catheter for temporary tamponade.
7. ⛓️ Control bleeding – clamp hilum/aorta if required.
8. 🤲 Open cardiac massage if no spontaneous output.

Relevant Anatomy

• ❤️ Heart + great vessels (aorta, pulmonary arteries, SVC/IVC)
• 🫁 Lungs & pleura (managing haemothorax/pneumothorax)
• 🪶 Diaphragm (injuries may extend to abdomen)

Surgical Approaches

• 🟧 Clamshell incision – gold standard ED approach; excellent bilateral access.
• 🟥 Left anterolateral thoracotomy – faster, for left-sided/cardiac access.
• ⬜ Median sternotomy – ideal in controlled theatre settings.

Post-Procedure Considerations

• 🩺 Stabilisation – haemostasis, volume resuscitation, secure airway/ventilation.
• 📉 Monitoring – haemodynamics, arrhythmias, re-bleeding.
• 📝 Documentation – timings, interventions, findings, patient response.
• 🚑 Transfer – to operating theatre or ICU for definitive management.

Outcomes

• 🔪 Penetrating cardiac trauma – survival up to 15–20% if performed promptly.
• 🚗 Blunt trauma – survival extremely poor (<2%).
• ⏱️ Outcome depends on time to thoracotomy, mechanism of injury, and availability of definitive surgical repair.

References

• Royal College of Emergency Medicine (RCEM) Guidelines
• NEJM Review: Resuscitative Thoracotomy
• Advanced Trauma Life Support (ATLS®) 10th Edition