Thoracic Surgery

Basic surgical intervention in the thoracic cavity has the primary goal of alleviating any malady that mechanically affects the function of the heart and lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs, which can be secondary to underlying pathologies or, most commonly, trauma. Interventions such as tube thoracostomy and thoracentesis are performed to evacuate fluid, blood, or air that is occupying the thoracic cavity in order to restore thoracic negative pressure. When direct intervention to the heart and mediastinum Mediastinum The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels. Mediastinum and Great Vessels is required, an emergency thoracotomy is performed. Once the immediate mechanical problems are addressed, more advanced reparative surgery involving heart, lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs, or mediastinal structures can then be performed as necessary.

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Surgical Anatomy

It is important to review the anatomy of the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall in order to more easily avoid the important vascular and nervous components as well as to locate the appropriate entry points during surgical interventions.

Surface anatomy landmarks

  • Clavicle
  • Sternal angle (Lewis angle)
  • Midclavicular line
  • Anterior, middle, and posterior axillary lines
  • Lower border of the pectoralis major muscle/inframammary fold (5th intercostal space)
Surface anatomy landmarks of the thorax

Surface anatomy landmarks of the thorax to keep in mind for chest tube placement

Image by Lecturio.

Layers of the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall

  • Skin
  • Subcutaneous tissue
  • Intercostal muscles:
    • External intercostal muscle
    • Internal intercostal muscle
    • Innermost intercostal muscle
  • Parietal pleura Pleura The pleura is a serous membrane that lines the walls of the thoracic cavity and the surface of the lungs. This structure of mesodermal origin covers both lungs, the mediastinum, the thoracic surface of the diaphragm, and the inner part of the thoracic cage. The pleura is divided into a visceral pleura and parietal pleura. Pleura
Muscles of the thoracic wall

Muscles of the thoracic wall, showcasing the external and internal intercostal muscles

Image by BioDigital, edited by Lecturio

Neurovasculature of the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall

  • Blood supply:
    • Intercostal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: branches of the aorta and internal mammary artery that anastomose
    • Internal mammary artery
  • Venous drainage:
    • Intercostal veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Internal thoracic vein
  • Innervation:
    • Intercostal nerves
    • Long thoracic nerve
  • Intercostal neurovascular bundle:
    • Located in close vicinity to the inferior costal groove
    • The structures in the bundle are located from superior to inferior as follows, and can be recalled by the mnemonic VAN:
      • V: Intercostal vein
      • A: Intercostal artery
      • N: Intercostal nerve
Intercostal neurovascular bundle

The intercostal neurovascular bundle, right below the costal groove, is made up of an intercostal vein, artery, and nerve.

Image by Lecturio.

Chest Tube Placement (Tube Thoracostomy)

Definition

Chest tube placement, or tube thoracostomy, is an invasive procedure that consists of inserting a large-bore tube into the pleural cavity to provide continuous drainage of pleural fluid and/or air.

Indications

  • Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax
  • Pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion
  • Hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
  • Hemopneumothorax
  • Thoracic empyema
  • Chylothorax

Contraindications

There are no contraindications for the placement of a chest tube. However, insertion must be done with caution in the following cases:

  • Underlying coagulopathy or low platelet count
  • Antiplatelet therapy and anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants

Procedure

  1. Chest X-ray has to be carefully reviewed to determine the best approach and location.
  2. Patient can be placed in the supine or in the lateral decubitus position.
  3. The arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm is placed over or behind the head.
  4. The site of insertion is usually at the anterior axillary line in the 4th or 5th intercostal space, but can be adjusted:
    • Can be placed more posteriorly for pleural effusion
    • A more precise localization with radiologic guidance may be required for complex loculated air or fluid collections.
  5. A 2-cm incision is made in the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin.
  6. A Kelly clamp is used to make a tunnel through the incision and intercostal muscles into the pleural cavity.
  7. A finger is used to make sure the lung is away from the incision site.
  8. The chest tube is inserted starting from its perforated end in a superior–posterior–medial direction. This step can be aided with a Kelly clamp.
  9. The tube is connected to a drainage system (Pleur-Evac) and secured to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin with a purse-string suture.
  10. A chest X-ray is obtained to ensure adequate placement.
Steps of the hemostat technique for chest tube placement

Steps of the hemostat technique for chest tube placement

Image by Lecturio.

Complications

  • Injury to the lung parenchyma: can present as a persistent air leak
  • Perforation of the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm and/or abdominal viscera:
    • If the insertion site is too low
    • Can result in liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver (on the right) or spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen (on the left) injury with intra-abdominal hemorrhage
  • Perforation of the heart:
    • From left tube thoracostomy
    • Will get rapid blood return in tube
  • Injury to the intercostal vessels:
    • Can happen if the chest tube is inserted close to the lower costal margin, where intercostal vessels lie
    • Can present as intrathoracic and/or insertion site bleeding
  • Reexpansion pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema:
    • Rare
    • Can happen if a large pleural effusion (> 1.5 L) is evacuated too quickly
    • Presents as acute onset of respiratory distress/cough/frothy sputum

Thoracentesis

Definition

Thoracentesis is an invasive procedure that consists of inserting a catheter into the pleural space to evacuate pleural fluid for diagnostic and/or therapeutic reasons.

Indications

Thoracentesis may be required in any condition that presents with pleural effusions that compromise breathing, such as:

  • Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
  • Parapneumonic effusion
  • Empyema
  • Atelectasis Atelectasis Atelectasis is the partial or complete collapse of a part of the lung. Atelectasis is almost always a secondary phenomenon from conditions causing bronchial obstruction, external compression, surfactant deficiency, or scarring. Atelectasis
  • Malignancy
  • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism
  • Hepatic hydrothorax
  • Hypoalbuminemia
  • Pancreatitis
  • Uremia

Contraindications

There are no absolute contraindications to thoracentesis. However, caution is advised with the following:

  • Coagulopathy
  • Use of antiplatelet agents Antiplatelet agents Antiplatelet agents are medications that inhibit platelet aggregation, a critical step in the formation of the initial platelet plug. Abnormal, or inappropriate, platelet aggregation is a key step in the pathophysiology of arterial ischemic events. The primary categories of antiplatelet agents include aspirin, ADP inhibitors, phosphodiesterase/adenosine uptake inhibitors, and glycoprotein IIb/IIIa inhibitors. Antiplatelet Agents and anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants
  • Recent surgery on the ipsilateral thoracic cavity
  • Metastatic cancer

Factors predictive of difficult thoracentesis:

  • Use of positive-pressure ventilation (i.e., mechanical, continuous positive airway pressure (CPAP))
  • Chest wall cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis
  • Loculated pleural effusion

Procedure

Preoperative preparation:

  • Perform a full physical examination with special emphasis on chest percussion.
  • Preprocedure images need to be carefully reviewed:
    • Chest X-ray
    • Chest CT scan
  • Withhold anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants before the procedure.
  • Continuous monitoring:
    • HR
    • BP
    • Oxygen saturation

Technique:

  1. The patient should be sitting, leaning forward, and resting the elbows on a table. In patients who are not able to sit up, the head of the bed is elevated 30 degrees.
  2. Ultrasonography can be performed to guide the procedure.
  3. When ultrasonography is not available, one of the following sites is located and marked:
    • 3rd–5th intercostal space in the midaxillary line
    • 5th–7th intercostal space in the posterior scapular line
    • Dullness to percussion indicates a site of greater fluid accumulation, ideal for puncture.
  4. A 22-gauge needle is used to enter the pleural space while applying negative pressure.
    • Entrance is confirmed by the aspiration of free-flowing fluid.
    • Bubbles in the syringe may indicate lung puncture.
  5. A thoracentesis needle catheter is prepared, including a 3-way stopcock, syringe, and tube leading to a collection bag.
  6. The thoracentesis needle catheter is inserted into the superior margin of the lower rib while maintaining negative pressure.
  7. An initial 30–60 mL of fluid is collected for laboratory analysis (e.g., Gram stain, culture, chemistry, cell count).
  8. The remaining fluid is drained into the collecting bag until 1 of the following occurs:
    • Fluid stops draining spontaneously.
    • The patient starts coughing or reports chest discomfort.
    • A total of 1–1.5 L of fluid is drained.
  9. When drainage is complete, the patient is instructed to hold their breath and then exhale while the catheter is withdrawn.
  10. Sterile gauze and dressing are placed on the wound.
  11. Postprocedure chest X-ray is obtained to rule out pneumothorax.
Thoracentesis on a left hemithorax

Thoracentesis on a left hemithorax

Image: “Thoracentesis” by National Heart, Lung and Blood Institute. License: Public Domain

Complications

  • Reexpansion pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema
  • Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax
  • Hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
  • Hematoma at the injection site
  • Intra-abdominal puncture, with liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver or spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen injury
  • Soft tissue infection
  • Pleural infection and empyema

Pleural fluid analysis

  • Transudative effusions (caused by changes in hydrostatic or oncotic pressure or pleural permeability):
    • Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
    • Liver cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis
    • Severe hypoalbuminemia
    • Nephrotic syndrome Nephrotic syndrome Nephrotic syndrome is characterized by severe proteinuria, hypoalbuminemia, and peripheral edema. In contrast, the nephritic syndromes present with hematuria, variable loss of renal function, and hypertension, although there is sometimes overlap of > 1 glomerular disease in the same individual. Nephrotic Syndrome
  • Exudative effusions (altered formation and absorption of pleural fluid):
    • Malignancy
    • Infection (e.g., empyema due to bacterial pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia)
    • Trauma
    • Pulmonary infarction
    • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism
  • Light’s criteria (for diagnosis of exudative effusions):
    • Pleural fluid/serum protein ratio > 0.5
    • Pleural fluid/serum LDH ratio > 0.6
    • Pleural fluid LDH > 23 the normal upper limit for serum 
  • Other findings associated with exudative effusions:
    • Color/appearance: purulent, bloody, milky, black, presence of particles
    • LDH > 1000 IU/L
    • Glucose < 3.4 mmol/L
    • pH < 7.3
    • Amylase > 110 U/L
    • WBCs > 50,000
    • Triglycerides > 1.24 mmol/L (chylothorax)

Emergency Thoracotomy

Definition

Emergency, or resuscitative, thoracotomy is an invasive procedure that consists of making a large incision in the left hemithorax to attain access to the heart and other mediastinal structures, including the thoracic aorta, to control bleeding and quickly repair life-threatening injuries.

Therapeutic goals

  • Resuscitation of agonic patients with penetrating cardiothoracic injuries
  • Evacuation of cardiac tamponade Cardiac tamponade Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade (especially in penetrating trauma)
  • Direct cardiac massage
  • Direct repair of cardiac injuries
  • Control of massive intrathoracic hemorrhage
  • Clamping of the descending thoracic aorta for maintenance of perfusion to the heart and brain
  • Prevention of air embolism

Indications

  • Cardiac arrest Cardiac arrest Cardiac arrest is the sudden, complete cessation of cardiac output with hemodynamic collapse. Patients present as pulseless, unresponsive, and apneic. Rhythms associated with cardiac arrest are ventricular fibrillation/tachycardia, asystole, or pulseless electrical activity. Cardiac Arrest following penetrating or blunt chest trauma Blunt chest trauma Blunt chest trauma is a non-penetrating traumatic injury to the thoracic cavity. Thoracic traumatic injuries are classified according to the mechanism of injury as blunt or penetrating injuries. Different structures can be injured including the chest wall (ribs, sternum), lungs, heart, major blood vessels, and the esophagus. Blunt Chest Trauma with signs of life
  • Cardiac tamponade with profound shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock in a patient who is unresponsive to volume expansion and unlikely to survive until proper surgery can be performed
  • Blunt or penetrating trauma to the chest or abdomen with profound shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock in a patient who is unresponsive to volume expansion and unlikely to survive until proper surgery can be performed
  • Massive chest or abdominal bleeding with profound shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock (> 1500 mL of blood obtained via chest tube)

Contraindications

  • Traumatic cardiac arrest with no signs of life in the prehospital setting (e.g., asystole, prolonged lack of pulse)
  • Patient who is immediately responsive to volume expansion or decompression of tension pneumothorax
  • Penetrating or blunt thoracic injury with > 15 minutes of CPR and no signs of life

Procedure

Preoperative preparation:

  • Perform bedside FAST, if available:
    • Cardiac tamponade
    • Hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
    • Intra-abdominal hemorrhage
  • The patient should be intubated and ventilated.
  • The site of the incision is washed with a skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin-sterilizing solution and covered with sterile drapes.
  • Continuous monitoring:
    • HR
    • BP
    • Oxygen saturation
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG)

Technique:

The usual approach in an emergency is through left thoracotomy. Thoracotomy is a last-resort potentially lifesaving procedure that needs to be performed quickly.

  1. The 4th or 5th intercostal space is identified (reference point: the nipple in men, the inframammary fold in women).
  2. An incision is made going from the lateral border of the left sternocostal junction to the posterior axillary line (anterolateral thoracotomy), exposing the intercostal muscles.
    • The incision should follow the curvature of the ribs.
    • The inferior border of the superior rib should be avoided to prevent damaging the intercostal neurovascular bundle.
  3. The intercostal muscles are transected from the sternum to the posterior axillary line, to gain access to the pleural space. 
  4. The ribs are spread with the fingers in order to insert and be separated further by the rib spreader (Finochietto retractor).
  5. The left lung is displaced superiorly, and the pericardium is inspected for tamponade or lacerations.
  6. To relieve tamponade:
    • The pericardium is grasped using forceps and opened from the apex toward the base (pericardiotomy).
    • Clotted blood is manually removed and liquid blood is suctioned.
  7. To perform direct cardiac massage:
    • With the wrists together, the physician gently compresses the heart in a clapping motion from the apex toward the base.
    • If ventricular fibrillation Ventricular fibrillation Ventricular fibrillation (VF or V-fib) is a type of ventricular tachyarrhythmia (> 300/min) often preceded by ventricular tachycardia. In this arrhythmia, the ventricle beats rapidly and sporadically. The ventricular contraction is uncoordinated, leading to a decrease in cardiac output and immediate hemodynamic collapse. Ventricular Fibrillation is felt, defibrillation with internal paddles is performed.
  8. To control myocardial laceration: with surgical staples, mattress sutures, or a Foley catheter (a balloon is inflated within the cardiac cavity with normal saline)
  9. To clamp the aorta in cases of nonresponse to fluid resuscitation:
    1. The pleura Pleura The pleura is a serous membrane that lines the walls of the thoracic cavity and the surface of the lungs. This structure of mesodermal origin covers both lungs, the mediastinum, the thoracic surface of the diaphragm, and the inner part of the thoracic cage. The pleura is divided into a visceral pleura and parietal pleura. Pleura and fascia are dissected to expose the aorta.
    2. A nasogastric tube is inserted to identify the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus.
    3. A vascular clamp, aortic compression device, or the physician’s hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand is used to clamp/put pressure on the aorta against the spine.
  10. The rest of the cavity is checked for uncontrolled sources of bleeding and other life-threatening injuries.
  11. If the injury is located on the right hemithorax, the thoracotomy is expanded by transecting the sternum (clamshell thoracotomy).
  12. If resuscitation is successful, the patient is immediately transferred to the OR.
Types of thoracotomy

Types of thoracotomy incisions

Image by Lecturio.

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

  • It is still under debate whether one should close the chest completely or perform a temporary closure.
  • Transfer to the OR for definitive management.
  • After definitive management, transfer to the ICU for continued resuscitation.

Prognosis

  • The most important determinant of survival is the location and magnitude of the injuries.
  • Reported survival of up to 70% following emergency thoracotomy in penetrating trauma
  • The survival rate is much poorer for blunt trauma.
  • Survival is related to the length of CPR, with > 15 minutes equated with poor survival.
  • Direct cardiac massage may result in better cardiac output and cerebral perfusion.
  • A 5th of survivors suffer significant neurologic injury.

Clinical Relevance

Indicates for tube thoracostomy:

  • Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax: accumulation of air within the pleural space between the parietal and visceral pleura Pleura The pleura is a serous membrane that lines the walls of the thoracic cavity and the surface of the lungs. This structure of mesodermal origin covers both lungs, the mediastinum, the thoracic surface of the diaphragm, and the inner part of the thoracic cage. The pleura is divided into a visceral pleura and parietal pleura. Pleura, which can be open (with communication to the outside) or under tension (without an opening in the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall and ongoing air leak from the injured lung parenchyma)
  • Pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion: accumulation of fluid within the pleural space, which can be a transudate or an exudate according to Light’s criteria, depending on the result of the cytochemical analysis
  • Hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax: accumulation of blood within the pleural space due to profuse bleeding, usually seen in the context of trauma to the chest
  • Hemopneumothorax: accumulation of both blood and air within the pleural cavity, also frequently seen in the context of trauma to the chest: The clinician must be careful at the time of decompression, since the pressurized air may propel blood through the incision.
  • Thoracic empyema: accumulation of purulent material (pus) within the pleural cavity, seen in the context of infections of the lower respiratory tract (i.e., pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia)
  • Chylothorax: accumulation of chyle within the pleural cavity after injury to the thoracic duct

Indication for thoracentesis:

  • Pleural effusions: the accumulation of fluid within the pleural space, which, according to cytochemical analysis (Light’s criteria), can be classified as a transudate or exudate

Indication for emergency thoracotomy:

  • Cardiac tamponade: restriction in cardiac filling due to the excessive accumulation of fluid within the pericardial cavity that leads to decreased cardiac output and serious systemic consequences ( hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension and shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock)
  • Massive hemothorax: drainage of > 1500 mL of blood via tube thoracostomy or bleeding of > 200 mL per hour for at least 2 hours: Hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax itself is the accumulation of blood within the pleural space.
  • Massive hemorrhage with witnessed or impending cardiac arrest: The descending aorta can be clamped to control the hemorrhage and temporarily restore the circulation to the brain and heart. Survival in this situation is rare, and there is significant morbidity related to spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord and kidney ischemia.

References

  1. Adams, G. A., et al. (2020). Tubes and drains. In Adams, G. A., et al. (Eds.). On call surgery. Retrieved from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323528894000314
  2. Asfaw, S. H. (2021). Chest tube placement. In Delaney, C. P. (Ed.). Netter’s Surgical Anatomy and Approaches. Retrieved from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323673464000505
  3. Kalanjeri, S., Pastores, S. M. Thoracentesis. In Oropello, J. M., et al. (Eds.). Critical Care. McGraw-Hill. https://accessmedicine-mhmedical-com.ezproxy.unbosque.edu.co/content.aspx?bookid=1944&sectionid=143523214
  4. Paulsen, D.F. (Ed.). (2010). Respiratory System. In Histology & Cell Biology: Examination & Board Review, 5e. McGraw-Hill. https://accessmedicine-mhmedical-com.ezproxy.unbosque.edu.co/content.aspx?bookid=563&sectionid=42045312
  5. Morris, C. A., Wolf, A. S. (2018). Clinical procedure tutorial: thoracentesis. In Jameson, J., et al. (Eds.). Harrison’s Principles of Internal Medicine, 20th ed. McGraw-Hill. https://accessmedicine-mhmedical-com.ezproxy.unbosque.edu.co/content.aspx?bookid=2129&sectionid=193349886
  6. Lubbers, W. (2017). Emergency procedures. In Stone, C., Humphries, R. L. (Eds.). Current Diagnosis & Treatment: Emergency Medicine, 8th ed. McGraw-Hill. https://accessmedicine-mhmedical-com.ezproxy.unbosque.edu.co/content.aspx?bookid=2172&sectionid=165057582
  7. Eidt, J. F. (2020). Resuscitative thoracotomy: Technique. UpToDate. Retrieved January 8, 2021, from https://www.uptodate.com/contents/resuscitative-thoracotomy-technique
  8. Ali, J. (2014). Torso trauma. In Hall, J.B., et al. (Eds.). Principles of Critical Care, 4th ed. McGraw-Hill. https://accessmedicine-mhmedical-com.ezproxy.unbosque.edu.co/content.aspx?bookid=1340&sectionid=80027398
  9. Flannagan, M. (2021). Emergency thoracotomy for trauma. In Delaney, C.P. (Ed.). Netter’s surgical anatomy and approaches. Retrieved from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323673464000517
  10. Cothren, C. C., Moore, E. E. (2006). Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World Journal of Emergency Surgery 1(4). https://doi.org/10.1186/1749-7922-1-4

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