Name:
02 Resuscitative Thoracotomy
Description:
02 Resuscitative Thoracotomy
Thumbnail URL:
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Duration:
T00H05M47S
Embed URL:
https://stream.cadmore.media/player/5671131c-e26c-4f1b-bfb2-49d497f4ee85
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/5671131c-e26c-4f1b-bfb2-49d497f4ee85/4789148824001.mp4?sv=2019-02-02&sr=c&sig=oEczGrsjejCMHH9npm5qIig7ZFdSbB%2Fjj3RCYQBftys%3D&st=2024-12-21T13%3A59%3A25Z&se=2024-12-21T16%3A04%3A25Z&sp=r
Upload Date:
2022-03-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
In this video, we will discuss the proper technique in performing a resuscitative thoracotomy.
Segment:1 Objectives.
Although resuscitative thoracotomy is not itself a complicated procedure, the circumstances under which it is performed is often chaotic and possess a unique set of challenges.
Segment:2 Anatomy.
A thorough knowledge of this procedure will allow the surgeon to perform the resuscitative thoracotomy in a safe, rapid, and efficient manner, increasing the chance for recovery.
We will begin by discussing the relevant anatomy, the instruments and positioning necessary, the exposure and techniques, and, finally, tips and pitfalls for the resuscitative thoracotomy. Once the left anterolateral incision is made, and the left chest entered, you will encounter the two lobes of the left lung superiorly, the diaphragm inferiorly, and the heart anteriorly. Note that with excessive bagging of the patient, or if intern abdominal bleeding has occurred, the left diaphragm may occupy the majority of the left thoracic cavity.
On the pericardium, the phrenic nerve runs along its lateral surface. The aorta is located posterior to the heart, and just anterior to the vertebral bodies and covered by the mediastinum pleura. The patient should be positioned supine with the ipsilateral arm out to the side, or above the patient's head. Preparation is not necessary, though if time permits, splashing a betadine on the chest may be beneficial.
Instruments should include No. 10 blade, Mayo scissors, a vascular cross-clamp, and a Finochietto retractor. Always check ahead of time that the Finochietto retractor is set up properly. The skin incision is made boldly from the left lateral border of the sternum at the fourth intercostal space and continue laterally along the curvature of the rib towards the axilla. Carry this incision to the depth of the intercostal muscles.
Using the scissors, incise along the upper border of the rib, being careful not to injure the lung underneath.
Segment:3 Instruments and Positioning.
Place the Finochietto retractor so that the handle is positioned inferiorly to allow for extension of the thoracotomy incision to a clamshell incision, should the situation arise. However, when opening the retractor, be careful not to catch the axillary skin in the ratchets. Upon entry of the left chest, right mainstem intubation is helpful for exposure.
The lung is retracted superiorly to expose the heart and pericardium. At this point, note the location of the phrenic nerve. In the presence of tamponade, the pericardium will need to be entered using the scalpel. Once entered, the incision on the pericardium is extended superiorly and inferiorly using scissors, being careful to stay anterior to the phrenic nerve.
The heart is delivered from the pericardial sac into the field and can be examined for any injuries. Note the anatomy of the heart, including the coronary vessels, left ventricle, and the right ventricle. The optimal position of the aortic cross-clamp is just superior to the diaphragm. Staying just anterior to the vertebral body, the pleura should be opened, which can be done bluntly or with sharp dissection.
The aorta is identified and cross-clamp placed. Minimal dissection of the aorta will avoid avulsion of any intercostal vessels. NG tube placement can be helpful in discriminating between the non-pulsatile aorta and esophagus. Once the cross-clamp is placed on the aorta, open cardiac massage can be performed. Although this procedure only has a few steps,
Segment:4 Tips and Pitfalls.
situations when this procedure is performed is always rushed and done in less than ideal situations.
The surgeon must be prepared to account for them. Some tips and pitfalls to always remember is first to not make the incision too low. The ideal level is the fourth intercostal space, which is at the nipple line for men and the inframammary fold for women. Having the incision too high or too low will make exposure difficult. Next, when tamponade is present, opening the pericardium requires the use of the scalpel to enter initially, prior to extending the incision with scissors.
The pericardium is a very dense tissue, and can be very tense when there is tamponade. Using scissors would be a futile exercise. Cross-clamping of the aorta will also require a few points to remember. The cross-clamp should be placed on the aorta, near the diaphragm, where it is easiest to access. The mediastinal pleura will also need to be open, either sharply or bluntly before the cross-clamp can be placed.
And, lastly, do not skeletonize the aorta, as the intercostals can easily be avulsed and cause troublesome bleeding that is difficult to control. Thank you.
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