Allow temporary descending aorta occlusion to limit abdominal haemorrhage
WEST guideline
Indication
Penetrating trauma <15 CPR
Blunt trauma <10 minutes of CPR
Penetrating neck or extremities with <5 minutes CPR
Profound refractory shock - CPR with SBP <60 or signs of life
Against
Inverse of above
EAST guideline
Signs of life defined as any of the following
Pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, or cardiac electrical activity.
Recommendations
Strong
Pulseless with SOL after penetrating thoracic injury
Conditional
Pulseless with SOL after blunt injury
Pulseless with SOL after penetrating extra-thoracic injury
Pulseless without SOL after penetrating extra-thoracic injury
Pulseless without SOL after penetrating thoracic injury
Against
Pulseless without SOL after blunt injury
End Points of Emergency Department Thoracotomy
Unrepairable cardiac or great vessel damage occurred
Massive head injuries identified (probably shouldn’t start if identified prior)
No ROSC after 15 minutes
Surgical Procedures
Steps
Incision in 5th intercostal space
Lateral border of the sternum to the table
#10 blade
Divide the pleura
Damage control
Stop massive bleeding with pressure
Hilar twist/clamp
Open pericardium
Cross clamp aorta
Open CPR
Pericardial Tamponade
Pericardial incision 1cm anterior to phrenic nerve, cranial to caudal
Assess whole heart and source control
Close pericardium over a drain
Cardiac Injury
Digital pressure or large balloon foley on gentle traction
3.0 or 4.0 prolene
Mattress sutures under coronaries
Can use a foley catheter and gentle traction
Pulmonary Haemorrhage
Clamp hilum for proximal control
Oversew, segmental or lobar resection
In air embolism → Clamp hilum, needle aspirate LV apex
Pulmonary Tractotomy
Stapler fired down tract
Non anatomical lung preservation
For injuries crossing multiple segments
Damage control
To perform hilar clamping or the “pulmonary hilar twist”
Mobilize the injured lung hilum by first dividing the inferior pulmonary ligament to the level of the inferior pulmonary vein
Control the hilum of the lung with a large vascular clamp (eg, Crawford or Satinsky) or by using a Rommel tourniquet and snares
For the pulmonary twist maneuver, rotate the lower lobe anteriorly up over the upper lobe twisting the lung clockwise 180°, which compresses the main pulmonary artery and vein against the bronchus
Place lараrotοmу packs at the base and apex of the lung to prevent the lung from untwisting.
Left anterolateral thoracotomy with cross-clamping of the descending thoracic aorta and open cardiac massage to control massive intra-abdominal bleeding, page 1
Steps
Retract the left lung superiorly.
Divide the inferior pulmonary ligament.
Palpate the orogastric or nasogastric tube (if present) to differentiate the esophagus from the empty descending aorta.
Perform the periaortic dissection at the level of an intervertebral space in a plane perpendicular to the aorta to avoid injսrу to intercostal vessels, which branch from the aorta at the level of the mid-vertebral body (figure below)
Incise the parietal pleura overlying the aorta and separate the tissues between the aorta and esophagus, as well as the prevertebral fascia to create sufficient space to place the aortic clamp without avulsing the intercostal arteries from the posterior surface of the aorta.
The aorta should be cross-clamped at the most distal location that is practical to preserve spinal cord blood supply.
Benefits
Vital organ perfusion → Heart, Brain
Limit infra-diaphragmatic haemorrhage
How simplified
Left lung retracted anterosuperiorly
Dissect descending thoracic aorta off oesophagus and prevertebral fascia