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Procedural Skills (SLO6)
Question 83 of 127
You are participating in a trauma simulation in which the patient requires resuscitative thoracotomy. Which of the following muscles is divided during resuscitative thoracotomy?
Answer:
The major muscles that are divided during resuscitative thoracotomy include the pectoralis major, pectoralis minor and the serratus anterior.Resuscitative Thoracotomy
Procedural Skills (SLO6)
Last Updated: 2nd March 2021
Resuscitative thoracotomy is a temporising measure that allows direct control of haemorrhage from exsanguinating thoracic injures or decompression of cardiac tamponade and allows control of the aorta to limit bleeding from infradiaphragmatic injuries to facilitate resuscitation.
Indications
- Penetrating thoracic trauma
- Signs of life present/witnessed
- Cardiac arrest < 15 minutes
- Decompensating tamponade
- Persistent hypotension
- Blunt thoracic trauma
- Signs of life present/witnessed
- Cardiac arrest < 10 minutes
- Massive haemothorax
- Decompensating tamponade
- Persistent hypotension
Procedure
- Position the patient in the supine position if not already so. Intubation, ventilation, intravenous access, etc. should be performed by other members of the trauma team and not delay the thoracotomy.
- Time should not be wasted on full asepsis (that is, fully preparing the skin and surgically draping the patient) but a rapid application of skin preparation is appropriate.
- Using a scalpel and blunt forceps make bilateral 4 cm thoracostomies (breaching the intercostal muscles and parietal pleura) in the 5th intercostal space in the mid-axillary line—the same technique and landmarks as for conventional chest drains. Note: The procedure is stopped at this point if tension pneumothorax is decompressed and cardiac output returns.
- Connect the thoracostomies with a deep skin incision following the 5th intercostal space.
- Insert two fingers into a thoracostomy to hold the lung out of the way while cutting through all layers of the intercostal muscles and pleura towards the sternum using heavy scissors. Perform this on left and right sides leaving only a sternal bridge between the two anterolateral thoracotomies.
- Cut through the sternum or xiphoid using the heavy scissors. If unable to cut through bone with scissors, use the Gigli saw (serrated wire).
- Open the “clam shell” using one or two large self retaining retractors/rib spreaders from the full thoracotomy set. If this is not available, the incision can be held open manually by one or two gloved assistants. The retractor should be opened to its full extent to provide adequate exposure of the chest cavity with access to all areas. If exposure is inadequate the incisions need to be extended posteriorly.
- Lift (“tent”) the pericardium with clamp/forceps and make a large midline longitudinal incision using scissors. This approach minimises the risk of damage to the phrenic nerves, which run in the lateral walls of the pericardial sac. Making the incision too short will prevent full access to the heart.
- Evacuate all blood and clot present, then inspect the heart rapidly but systematically for the site of bleeding. One of three scenarios are now likely:
- The heart will begin to beat spontaneously with a return of cardiac output. In this situation any cardiac wounds should be closed as described below.
- The heart begins to beat slowly with a considerably reduced cardiac output. In this situation wounds should be closed quickly, then attempt to improve cardiac output with supplementary internal cardiac massage and inotropic support.
- The heart remains in asystole. In this case wounds should be quickly closed and then attempts made to restart the heart. Simply flicking the heart may produce a return of contractions.
- Control any bleeding:
- Holes less than 1 cm can usually be occluded temporarily using a finger or gauze swab. If this is successful no other method should be attempted.
- For larger defects, a Foley urinary catheter can be passed through the hole then inflated and gently pulled back. This technique reduces the volume of the ventricular cavity (with subsequent reduction in stroke volume) therefore only a small volume (<10 ml) should be used in the balloon. Ensure that the catheter is clamped to prevent blood loss from it. If a catheter is used in this way, a “giving set” can be attached to permit rapid volume infusion directly into the heart.
- If bleeding cannot be controlled with finger/gauze/Foley catheter, it may be necessary to close the defect with large sutures, but it should be emphasised this is a last resort as there is a risk of occluding coronary arteries. If sutures are used the minimum required to achieve haemostasis facilitated by finger/gauze/Foley catheter should be used. Non-absorbable size 0/0 or 1/0 monofilament or braided are appropriate; take 1–2 cm “bites”.
- If massage is required, it must be of optimal quality.
- If defibrillation is required use internal paddles with an initial energy level of 10 joules. If these are not available, close the clam shell and defibrillate using conventional external pads.
- If the procedure is successful the patient may begin to wake up so be prepared to provide immediate anaesthesia.
- Restoration of circulation will be associated with bleeding, particularly from the internal mammary and intercostal vessels. Large bleeders may be controlled with artery forceps.
- Once perfusion has been restored the patient should be moved to theatre (optimally a cardiothoracic facility although this will depend on local expertise) for definitive repair.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
