ED Thoracotomy

ED Thoracotomy

The warm rays of the sun serenate me as I drive to work eager to begin another shift. I find a parking spot on the first floor of the garage don my N95 mask and walk towards the hospital. First, I must stop by at the neighboring building and have my temperature checked. Today it is 97.3. I am awarded the sticker for the day; my boarding pass into the hospital and proof I do not bear symptoms of the novel coronavirus.                                                                           

    

            The emergency department is alive with action and before long there is call for a possible surgical emergency. A middle age gentleman presents with severe abdominal pain. His blood pressure is dangerously low and heart rate through the roof. Large bore IVs are placed by the sharpshooting nurses and the patient is started on the appropriate medication. He manages to provide his name when suddenly his eyes roll backwards and his voice fades. Suddenly the room is filled with the sound of alarms. I check his neck and groin for a pulse and find none. His abdomen begins to rapidly enlarge. CPR is initiated and the massive blood transfusion protocol activated.  A that point it becomes clear he is having significantly bleeding in his belly. I call for betadine and a 15-blade scalpel. While splashing his left chest with the sterilizing liquid I ask someone to grab the thoracotomy kit. I identify the space in between the 4^th and 5^thribs and make a deep incision just lateral to the lateral edge of the pectoral muscle. I extend the incision 10-15 cm into the axilla (armpit area). The incision is deepened down to the ribs.                                  

            My mind races as my hands work. What will we find in the abdomen? How much blood has he lost? Has he had any previous surgeries? I hadn’t even had a chance to examine his body for previous surgical scars!! Simultaneously other members of the team work to place an arterial line in the right common femoral artery and a cordis (big IV) in the common femoral vein. 

The thoracotomy kit arrives and I grab the large Kelly poke between the ribs into the pleural space! Sweat drips down my brow as I take the 15-blade again and extend the pleural defect the length of the skin incision. I pause to draw a breath not realizing I had not taken one for some time. Next I grab the rib spreader, place it between the ribs and turn the handle, widening the space. With the defect large enough to fit my entire hand I reach inside the chest and feel for the aorta. I brush aside the left lung and feel behind the esophagus. My fingers slide around a firm tubular structure. Without turning my head, I grab an aortic clamp and guide it towards my fingers. Once the clamp is on the aorta the rest of the room returns to focus and I take stock of my surroundings. On the opposite side of the gurney a line of people drenched in sweat share the duties of delivering lifesaving chest compressions to the patient. Another MD stands at the foot of the bed carefully orchestrating the administration of medications to stimulate the return of heart function and limit the presumed bleeding. I hesitate a moment before finding my voice. “The Aorta is clamped; Let’s roll to the OR.” 

http://www.mactheknife.org/Photopages/PMS_thoracotomy/PMS_thoracotomy.html

By clamping the aorta in the chest, we are able to stop the bleeding in the abdomen and by time for a potential repair. Blood products and IV medications temporize the damage and give the body’s organs a chance to survive this encounter. Thoracotomy procedures are rare in the emergency department but are generally indicated when there is penetrating nonthoracic or blunt thoracic injuries with witnessed cardiac arrest either prehospital or in-hospital. Another possible strategy in the situation would have been a REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) via the common femoral artery. The catheter is floated up into the aorta and past the anticipated area of bleeding. The balloon is inflated and prevents distal flow of blood therefore quelling the hemorrhage. With both of these strategies the obvious drawback is lack of perfusion to distal organs. Therefore, once either is initiated the race is on to identify and repair cause of bleeding and restore normal blood flow.

As we rush to the operating room I try and gather my thoughts and temper my adrenaline. My pager goes off as we burst through the OR doors. I unclip it from my hip and hand it to the scrub tech. “Chest tube needed in the MICU, doctor”. I smile to myself. It’s going to be one of those nights.