Resuscitative Procedures
Resuscitative Procedures
Prof. Miklosh Bala, Director of Trauma and Acute Care Surgery Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel.
- Overview of chest injuries
- Resuscitative procedures: Chest tube insertion, Thoracostomy
- Resuscitative Thoracotomy
1. Introduction
Chest trauma is the leading cause of death under 40. 75% of cases are represented by penetrating and blunt injuries. Patients are usually primarily treated by chest tube placement, while only 10–15% require operation.
Surgical timing is strongly influenced by the patient’s clinical condition. Immediate treatment may be thoracotomy in the emergency room. The site of injury together with the type of trauma dictates the choice of surgical technique and access route.
2. Initial Management and Primary/Secondary ATLS Survey
- Secure early IV access in severe injuries.
- Recognize that severe thoracic trauma patients are often polytrauma patients.
- Assess chest rise and asymmetry suggesting a flail segment.
- Palpate chest wall for symmetry, crepitus, and movable segments.
- Perform auscultation and regular monitoring of vital signs.
- Request ABG, complete blood count, platelets, electrolytes, cardiac markers, serum lactate, blood typing, and coagulation testing.
- Avoid hypovolemia and vascular collapse; appropriate volume resuscitation and acidosis treatment are very important.
- EFAST is a standard of care diagnostic procedure at bedside or pre-hospital. It identifies fluid in peritoneal, pericardial and pleural cavities, tamponade, and cardiac motion in traumatic arrest/PEA contexts.
- TTE (Transthoracic Echocardiography) is a useful noninvasive tool for wall motion abnormalities, valvular disruption, and pericardial effusions; it is the first choice for tamponade diagnosis.
- AP chest radiography is a primary diagnostic tool, but has limited sensitivity for some serious intrathoracic pathology.
- CT is considered for adults with suspected chest trauma without severe respiratory compromise who respond to resuscitation or are hemodynamically normal.
3. Pleural Injuries
A. Pneumothorax
- Occurs in 15%–40% of patients with chest trauma.
- Defined as air in the pleural space causing partial or entire collapse of the lung.
- Leading symptoms/signs: unilateral breath sound and tissue emphysema.
- May be caused by rib-fracture pleural laceration after blunt trauma, penetrating injury, or tracheobronchial injury.
B. Occult Pneumothorax
- Visible on CT but not on preceding plain chest X-ray.
- 50%–60% of traumatic pneumothoraces fall into this category.
- May be life-threatening if tension develops, especially if ventilation is required.
C. Tension Pneumothorax
- Suspected tension pneumothorax presenting with jugular distension, unilateral breath sounds, and tissue emphysema must be decompressed immediately by needle thoracostomy or a chest tube.
D. Hemothorax
- Found in about 20%–40% of patients with blunt thoracic trauma.
- Can arise from intercostal arteries, internal mammary arteries, lung parenchyma, the heart, the lung hila, and the great vessels.
- Detection threshold: at least 175 mL on chest radiography or 20 mL on ultrasonography.
- Any relevant hemothorax with a cut-off size of 3 cm should be drained by chest tube; for smaller hemothoraces, drainage should be considered if coexisting findings such as pneumothorax are present.
4. The Deadly Dozen
Lethal Six
- Acute airway obstruction
- Tension pneumothorax
- Pericardial tamponade
- Open pneumothorax
- Massive hemothorax
- Flail chest
Hidden Six
- Aortic rupture
- Myocardial contusion
- Tracheobronchial injuries
- Diaphragmatic rupture
- Esophageal rupture
- Pulmonary contusion
5. Symptomatic Simple and Tension Pneumothorax Management
Treatment by tube thoracostomy depends on the size and clinical effect of the pneumothorax. Clinical diagnosis of tension pneumothorax mandates emergent chest decompression, which may be achieved rapidly by either needle catheter thoracostomy or finger thoracostomy.
- Needle catheter thoracostomy uses a large-bore (≥14 gauge) over-the-needle catheter. Two optimal locations exist: the fifth intercostal space (approximately at the inframammary fold) between the mid and anterior axillary lines; and the second intercostal space at the midclavicular line. Variable chest wall thickness, catheter kinking, and technical/anatomic complications can limit success and duration of needle decompression.
- Finger thoracostomy uses a scalpel opening at the fifth intercostal space between the mid and anterior axillary lines, followed by finger entry into the pleural space to release air and fluid.
- Tension pneumothorax can recur after either finger or needle decompression because soft tissues may occlude the tract. Insertion of a tube thoracostomy follows emergent decompression.
Definitive treatment of any pneumothorax or hemothorax is tube thoracostomy. Larger operative exploration is rare and used to manage pulmonary injury or hemorrhage source. Multiple studies have confirmed that a 14 French thoracic catheter is equally effective as larger tubes for definitive treatment of pneumothorax with less pain.
Source PDF note: See movie.
6. Emergency Department Thoracotomy (EDT)
A. Overview
EDT, also known as resuscitative thoracotomy, can be used as an adjunct during the resuscitation of penetrating trauma patients who have sustained cardiac arrest. It should be performed liberally in specific penetrating trauma categories, particularly with suspected cardiac injury or cardiac tamponade.
B. Safety
Clear indications are required because resource utilization and provider safety are major concerns. Injuries from sharp instruments and the high rate of bloodborne pathogens in trauma patients make this a high-risk procedure for trained personnel only.
C. Indications
Both EAST and WTA produced recommendations based on mechanism, location, and signs of life. Per EAST guidelines, pulseless patients with thoracic penetrating trauma and signs of life should undergo thoracotomy.
- Signs of life list: pupillary response, spontaneous ventilation, carotid pulse, measurable blood pressure, extremity movement, or cardiac electrical activity.
- In patients with blunt injuries without any sign of life, thoracotomy was recommended against.
- For all other patients, conditional recommendations were given to proceed with EDT.
- Penetrating neck or extremity wounds with greater than 15 minutes of CPR also indicate non-salvageability.
Survival figures: overall survival 5–10%; blunt trauma usually <1%; penetrating trauma about 10%; stab wounds about 15%; gunshot wounds about 5%; isolated abdominal, thoracic, and cardiac injuries about 5%, 10%, and 20%, respectively.
D. Special Considerations
- Age over 60 is an independent predictor of mortality, with cited futility over 57 in the source text.
- Ages 15–18 should follow a similar algorithm to adults.
- Ages 0–14 with blunt thoracic injury have extremely low survival even with witnessed loss of pulses, so withholding EDT may be considered.
- In pregnancy, indications remain the same because the primary goal is maternal resuscitation.
E. Equipment
If personnel are available and capable, the necessary equipment should be readily accessible in the trauma resuscitation room. Equipment should be stored within a single operative tray and instruments should be loose within the tray for easy handling.
F. Technique
- Team Assembly: Team assembly and universal precautions before arrival.
- Evaluation: Evaluate location of penetrating wounds; right-sided thoracic wounds may prompt simultaneous right thoracotomy or clamshell approach.
- Concurrent Tasks: While EDT is being performed, the rest of the trauma team secures a definitive airway, establishes large-bore IV access for fluid and blood resuscitation, and places a right tube thoracostomy to evaluate the right chest.
- Preparation: Because EDT is life-saving and emergent, there is no time for sterile technique; splashing iodine onto the chest is not antimicrobial preparation.
- Positioning: Patient positioned supine with the left arm abducted for a left anterolateral thoracotomy.
- Incision: Make a generous curvilinear skin incision over the left chest from the left lateral edge of the sternum to the anterior edge of latissimus dorsi.
- Pleural Entry: Enter intercostal space with Mayo scissors just superior to a rib, spread widely, enlarge the pleural opening, and place a thoracic retractor.
- Pericardiotomy: Assistant retracts the left lung posteriorly to expose the anterior mediastinum and pericardium. Identify the phrenic nerve; incise the pericardium 1 cm anterior to it; confirm and evacuate tamponade; deliver the heart if needed.
- Cardiac Repair: Repair cardiac injury with simple interrupted sutures; use pledgets only if the tissue tears and reinforcement is needed.
- Aortic Cross-Clamping: Retract the lung anteriorly, evacuate significant hemothorax, identify the descending thoracic aorta posterior and medial in the left chest, incise the parietal pleura, and cross-clamp the aorta with a Debakey aortic aneurysm clamp or Satinsky clamp.
- Rationale for Clamping: Cross-clamping helps by improving cerebral perfusion during internal massage, improving coronary perfusion, and slowing intra-abdominal hemorrhage until definitive abdominal surgery. The cross-clamp should be placed as distally as possible and removed as soon as possible, preferably within 30 minutes.
- Cardiac Massage: Patients with asystole should receive internal cardiac massage using cupped hands and palms only, compressing from apex to base at 100 beats/min.
- Defibrillation: If ventricular fibrillation develops, use internal paddles at 10–15 J and continue ACLS protocols.
- Clamshell Extension: Extend to bilateral/clamshell thoracotomy when needed for right-sided injuries, right thoracostomy output, or better mediastinal exposure.
- Mammary Arteries: Transverse sternotomy divides internal mammary arteries, which should be ligated or clipped if circulation returns.
7. Steps of an Emergency Department Thoracotomy
- Entering the thoracic cavity
- Posterior retraction of the lung
- Exploration/repair of cardiac injuries
- Anterior retraction of lung
- Aortic cross-clamping
- Internal cardiac massage
8. Important Points
- An emergent thoracotomy tray with all necessary instruments and retractors needs to be prepared and quickly available in the emergency department.
- FAST exam may be applied to evaluate for tamponade.
- As you perform the EDT, the remainder of the trauma team should concomitantly secure a definitive airway with endotracheal intubation, establish large bore intravenous access for fluid and blood resuscitation, and place a right tube thoracostomy to better evaluate for hemorrhage in the right chest.
- In a female, retract the breast superiorly. The incision should follow the inframammary crease. In a male, the incision should be centered over the fourth or fifth intercostal space.
- Make the initial pericardiotomy with a small stab incision using a scalpel if a tense tamponade is encountered.
- Before cross-clamping the aorta, incise the parietal pleura that covers the descending thoracic aorta.
- During transverse sternotomy, ligate or clip both internal mammary arteries as they will bleed significantly during cardiac massage or if the patient regains a pulse.
- Removal of the aortic cross-clamp or replacement of the clamp below the renal vessel should be performed within 30 minutes to limit ischemia time.