ED Thoracotomy and VATS

Robert Southard, MD
Assistant Professor
Baylor College of Medicine
Disclosure
I have nothing to disclose
John Doe
The patient was an unknown man,
approximately 20 yo, who suffered stab
wounds to the chest and abdomen

Initially awake and moaning at the scene with
HR 120, lost pulses pulling into ambulance
bay

John Doe
Airway and IV access (16ga EJ ) obtained

Thoracotomy performed
Aorta crossclamped
Pericardium opened
Epinephrine given
Injury to posterior aspect of LV noted repair
attempted

John Doe
Additional access obtained in groin and
subclavian with cordis 7 units blood given

Pulses regained

To OR for further attempt at operative repair

He ultimately died
Emergency Department Thoracotomy
Incision
4
th
intercostal space
Immediately below nipple in male
Along inframammary fold in female

Sternal border to mid-axillary line along the
intercostal space (curving toward head)

Emergency Department Thoracotomy
Emergency Department Thoracotomy
Place rib spreader posteriorly (allows conversion to
clamshell)
Emergency Department Thoracotomy
Take down inferior pulmonary ligament
This ligament ends at the inferior pulmonary vein
Emergency Department Thoracotomy
Take down inferior pulmonary ligament

Open the pericardium
Allows access to heart for cardiac massage and repair
Releases tamponade

Emergency Department Thoracotomy
Open the pericardium
Avoid the phrenic nerve
Open cardiac massage
Repair cardiac injury
Cardioversion
Emergency Department Thoracotomy
Repair cardiac injury

Emergency Department Thoracotomy
Repair cardiac laceration avoid coronaries

Emergency Department Thoracotomy
Repair cardiac laceration
May be easier to repair in fibrillating/nonbeating
heart
Consider delayed cardioversion

Epinephrine
May be necessary
Makes repair significantly more difficult

Emergency Department Thoracotomy
What to do once you are in
Take down inferior pulmonary ligament

Open the pericardium

Clamp the pulmonary hilum
Significant lung injury with hemorrhage
Air embolism may result from bronchial communication
with vasculature under positive pressure ventilation
Emergency Department Thoracotomy
Clamp the pulmonary hilum
Emergency Department Thoracotomy
Twist the lung occludes pulmonary blood flow
Emergency Department Thoracotomy
Take down inferior pulmonary ligament

Open the pericardium

Clamp the pulmonary hilum

Clamp the aorta
Decreases circulating volume and provides control of
abdominal hemorrhage
Emergency Department Thoracotomy
Clamp the aorta
Identification
Usually decompressed in young volume depleted
patients
Pulseless floppy tube, like the esophagus

Find aorta by palpation
Slide hand laterally to medially along posterior chest wall
First tubular structure is aorta
NG/OG placement may facilitate
Emergency Department Thoracotomy
Clamp the aorta
Emergency Department Thoracotomy
Clamp should be removed once blood
volume restored

Risk of paraplegia

Intestinal ischemia > 30 min poorly tolerated
Emergency Department Thoracotomy
Take down inferior pulmonary ligament

Open the pericardium

Clamp the pulmonary hilum

Clamp the aorta
Terminology
ED Thoracotomy versus Resuscitative
Thoracotomy
Terminology
Where performed
Emergency Department

Operating Room

Prehospital


Terminology
Ideally everyone would suffer GSW or MVC
in an OR

Logistics and resources will dictate the best
place to perform thoracotomy at a given
institution and situation
Terminology
Why performed
Penetrating


Blunt


Cardiac
Terminology
Why performed
Penetrating
10% survival

Blunt
1.4% survival

Cardiac
16% survival
Terminology
What is being done
Resuscitative

Therapeutic


Terminology
What is being done
Resuscitative
Clamping aorta
Establishing central access
Cardioversion


Low rate of success
Terminology
What is being done
Therapeutic
Injury identified and repaired
Pulmonary injury clamping hilum
Relief of cardiac tamponade
Repair of cardiac injury


Reasonable likelihood of success
Terminology
What is being done
20 yo man with stab wound to chest

SW to chest
Patient in extremis
Emergent thoracotomy
performed
Terminology
What is being done
20 yo man with stab wound to chest

SW to chest
Patient in extremis
Emergent thoracotomy
performed
Injury to right atrium
Tamponade released
Atrium repaired
Terminology
What is being done
20 yo man with stab wound to chest

SW to chest
Patient in extremis
Emergent thoracotomy
performed
Injury to right atrium
Tamponade released
Atrium repaired
Patient survives
Wow!

Great save, Dr. DeBakey!

What a wise and
experienced surgeon!
Terminology
What is being done
20 yo man with stab wound to chest

SW to chest
Patient in extremis
Emergent thoracotomy
performed
Injury to right atrium
Tamponade released
Atrium repaired
Terminology
What is being done
20 yo man with stab wound to chest

SW to chest
Patient in extremis
Emergent thoracotomy
performed
Injury to left subclavian
artery
Impossible exposure
Terminology
What is being done
20 yo man with stab wound to chest

SW to chest
Patient in extremis
Emergent thoracotomy
performed
Injury to left subclavian
artery
Impossible exposure
Patient dies

Two staff members get
needle sticks
What a waste of resources!

Why do we even do these
things?

Terminology
What is being done
Diagnostic
Most often performed
Injuries are almost always unknown until thoracotomy
performed

If nothing to fix once the chest is exposed
OK to stop
Emergency Department Thoracotomy
How do you decide when to perform
emergent thoractomy?
Emergency Department Thoracotomy
Indications
Cardiac arrest due to trauma in a salvageable
patient
Emergency Department Thoracotomy
Contraindications
Prolonged CPR
> 15 min in penetrating trauma
> 10 min in any blunt trauma
Other nonsurvivable injuries
Head
Western Trauma Association
Algorithm
Traumatic Cardiac Arrest
What is the downside?
If no thoracotomy survival 0%


J ACS. 214(1): 18-25, J anuary 2012.
0 survivors
3 needle stick injuries
Traumatic Cardiac Arrest
Avoid this procedure if patient is not
salvageable




Western Trauma Association
Algorithm
Emergency Department Thoracotomy
Low Likelihood of Success
No signs of life 1% survival
Pupillary response
Respiratory effort
Motor activity
Organized cardiac activity

Blunt trauma 1% survival
Emergency Department Thoracotomy
Only a few therapeutic maneuvers
Clamp lung
Relieve tamponade
Repair heart
Clamp aorta

Use this procedure judiciously
Highly resource intensive
VATS
Retained hemothorax
Most hemothoraces can be treated with tube
thoracostomy

Failure to evacuate the pleural space
Empyema
Fibrothorax


Video-Assisted Thoracoscopic Surgery
Significant morbidity of thoracotomy led to
delays in evacuation
Multiple attempts at tube drainage

VATS has emerged as a minimally invasive
option for evacuating a retained hemothorax


VATS - Timing
Delays of >7 days before VATS
Increased incidence of empyema
Increased technical difficulty
The role of thoracoscopy in the management of retained thoracic collections after trauma. Heniford
BT, Carrillo EH, Spain DA, Sosa J L, Fulton RL, Richardson J D. Ann Thorac Surg 1997;63:94o-3.
VATS - Timing
J ournal of Trauma and Acute Care Surgery. 72(1):11-24, J anuary 2012.
No correlation between timing of VATS and need for additional procedures
VATS - Timing
J ournal of Trauma and Acute Care Surgery. 72(1):11-24, J anuary 2012.
Decision for thoracotomy not standardized

High failure rate 30%

Study not designed to answer this question
VATS - Timing
How early should VATS be performed for retained haemothorax in blunt
chest trauma?
Lin HL, Huang WY, Yang C, Chou SM, Chiang HI, Kuo LC, Lin TY, Chou YP. Injury. 2014
Sep;45(9):1359-64.
Group 1 within 3 days
Group 2 days 4-6
Group 3 after day 6
17 out of 29 study patients proceeded to OR without chest CT,
based on upright CXR alone

4 of these 17 (14%) were found to have minimal clot burden


Algorithm for Retained Hemothorax
Trauma Patient
Evidence of
Retained
Hemothorax on
CXR on HD2
Order Chest CT VATS
Continued
Observation
CT
positive
CT
negative
EAST Guidleines
Persistent retained hemothorax, seen on
plain lms, after placement of a thoracostomy
tube should be treated with early VATS, not a
second chest tube (Level 1)

VATS should be done in the rst 3 days to 7
days of hospitalization to decrease the risk of
infection and conversion to thoracotomy
(Level 2)