Here we tackle the evolving SAQ type – you start with something that tests your ‘basic approach’ and then takes an abrupt turn for the worse and challenges you. We take the approach of an undifferentiated scenario that eventually makes it’s way to Thoracotomy in the ED.
Bonus question – Please outline 12 steps detailing your procedure for an ED Thoracotomy? (Answer below taken from LITFL post on this topic)
- Prepare thoracotomy tray and don personal protective equipment.
- Position patient supine with the side to be operated on elevated to 15° by a wedge and the arm abducted.
- Incise through skin and subcutaneous tissue in the 5th intercostal space, starting from the costochondral junction and continuing to the mid-axillary line following the upper border of the sixth rib. The infra-mammary fold may be used as a guide.
- Divide the muscle, periosteum and parietal pleura in one layer with scissors and blunt dissection.
- Chest wall bleeding is usually minimal although internal thoracic arteries need to be ligated later as significant haemorrhage will occur as circulation is restored.
- Insert a rib-spreading retractor with the handle towards the axilla. Further distraction may be obtained by dividing the sixth rib posteriorly.
- To extend the incision to the right side, use strong scissors, bone cutters or a Gigli saw to cut through the sternum and into the right fifth intercostal space, mirroring the incision above.
- A bulging pericardium is incised vertically anterior to the phrenic nerve. The lung may need to be retracted to identify the phrenic nerve.
- Place a finger over any cardiac defect. If experienced, consider placing a sterile Foley catheter through the cardiac wound, inflate the balloon, then apply gentle traction to close the hole. Fluid may be directly infused into the heart if other venous access is unavailable; otherwise keep the catheter clamped.
- Close myocardial defects with buttressed Vicryl sutures avoiding the coronary arteries. Further procedures are undertaken as necessary, depending on the operator’s skill level.
- Hilar clamping may be required in the case of significant lung laceration or air embolism from bronchial-vascular communication.
- Perform internal cardiac massage compressing the heart between two flat hands in a hinged clapping motion. Defibrillate using small internal paddles either side of the heart with energy settings of 15-30 J (or biphasic equivalent).