Resuscitative Thoracotomy

Quick Reference

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Quick Answer

Critical: Resuscitative thoracotomy (RT) is an emergency life-saving procedure performed in the ED for patients in traumatic cardiac arrest. Survival depends on mechanism (penetrating >> blunt), presence of signs of life, and time to intervention (below 15 minutes). Penetrating cardiac stab wounds have the highest survival (15-30%), while blunt trauma without signs of life has near-zero survival.

Emergency Department thoracotomy is indicated for penetrating thoracic trauma with witnessed arrest, allows release of pericardial tamponade, control of intrathoracic hemorrhage, aortic cross-clamping to redistribute blood flow, and direct cardiac massage. Success requires immediate recognition, rapid execution, and definitive surgical repair.

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ACEM Exam Focus

Primary Exam

• Anatomy: Intercostal spaces, neurovascular bundles (VAN superior to inferior), phrenic nerve course (anterior to hilum), cardiac anatomy, descending thoracic aorta landmarks
• Physiology: Cardiac tamponade physiology (Beck's triad, pulsus paradoxus), hemorrhagic shock, aortic occlusion effects on cerebral/cardiac perfusion
• Pharmacology: Resuscitation medications during traumatic arrest, tranexamic acid, massive transfusion protocols

Fellowship Written

• Indications and contraindications: EAST guidelines for patient selection based on mechanism, signs of life, CPR duration
• Technique: Left anterolateral thoracotomy, clamshell extension, pericardiotomy, aortic cross-clamping, cardiac repair
• Outcomes: Survival rates by mechanism (penetrating 11.2% vs blunt 1.6%), neurologically intact survival (3-5%)

Fellowship OSCE

• Resuscitation Station: This is a high-yield OSCE scenario - leading a resuscitation team for traumatic arrest, decision-making for thoracotomy, team leadership
• Key competencies: Rapid assessment, appropriate patient selection, closed-loop communication, delegation of tasks, execution under pressure
• Communication: Discussing futility, family communication in resuscitation, debriefing team after unsuccessful resuscitation

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Indications

Absolute Indications

Penetrating Thoracic Trauma with Signs of Life (SOL)

• Witnessed cardiac arrest in ED from penetrating chest trauma
• Loss of pulse during resuscitation of penetrating chest injury
• Pulseless with any sign of life: pupillary response, spontaneous ventilation, carotid pulse, measurable BP, extremity movement, cardiac electrical activity

Penetrating Cardiac Tamponade

• Beck's triad: hypotension, muffled heart sounds, elevated JVP
• Pulseless electrical activity (PEA) with suspected tamponade
• Rapidly deteriorating vital signs despite resuscitation

Relative Indications

Penetrating Extra-thoracic Trauma

• Abdominal or extremity penetrating trauma with witnessed arrest
• Primary goal: aortic cross-clamping to redistribute blood volume
• Lower success rate than thoracic injury (8-12%)

Blunt Trauma with Signs of Life

• Witnessed arrest in ED with clear signs of life on arrival
• Very limited time window (below 10 minutes pulseless)
• Survival rate 2-4.6% even with SOL
• Must have compelling indication (e.g., suspected tamponade from sternal fracture)

Massive Air Embolism

• Suspected venous air embolism from penetrating lung injury
• Allows hilar cross-clamping to prevent further embolization

When to Consider

RT should be considered immediately upon arrival of a patient in traumatic cardiac arrest. The decision must be made within 60-90 seconds of patient arrival. Delays significantly reduce already low survival rates.

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Contraindications

Absolute

Relative

Severe Traumatic Brain Injury

• GCS 3 with bilateral fixed dilated pupils
• May indicate irreversible neurological injury
• Consider in context of other injuries

Profound Hypothermia

• Core temperature below 28°C may mimic death
• "Not dead until warm and dead"
• Consider rewarming strategies before declaring futility

Pre-existing Terminal Illness

• Known metastatic cancer
• End-stage organ failure
• Advanced directives against resuscitation (if known)

Resource Limitations

• No surgical backup available (relative in metropolitan ED)
• Multiple casualties with limited resources (triage considerations)

Risk-Benefit Considerations

In penetrating trauma with signs of life, RT is almost always indicated even with relative contraindications, as this represents the only chance of survival. In blunt trauma, the threshold is much higher due to dismal outcomes. Always consider:

• Probability of meaningful survival
• Resource allocation in multi-casualty scenarios
• Provider safety (infectious disease risk)
• Ethical considerations and medical futility

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Anatomy

Surface Landmarks

Rib Counting Technique

1. Palpate sternal angle of Louis (T4-T5 junction)
2. Second rib articulates at angle of Louis
3. Count downward to identify 5th rib
4. Incision runs along superior border of 6th rib (in 5th ICS)

Deep Anatomy

Intercostal Neurovascular Bundle (VAN)

• Located in costal groove on inferior border of each rib
• Order from superior to inferior: Vein - Artery - Nerve
• To avoid injury: incise along superior border of the lower rib (6th rib for 5th ICS incision)
• Bleeding from intercostal vessels controlled with hemostats or figure-of-8 sutures

Pericardium

• Fibrous sac enclosing heart and proximal great vessels
• Anteriorly: lies just deep to sternum
• Laterally: reaches to left 5th-6th ICS
• Contains 15-50 mL of pericardial fluid normally
• Non-compliant: as little as 100-200 mL of acute blood accumulation causes tamponade

Phrenic Nerve

• Originates from C3-C5 nerve roots ("C3, 4, 5 keeps the diaphragm alive")
• Descends along lateral aspect of pericardium
• Right phrenic: passes anterior to right hilum along SVC and right atrium
• Left phrenic: passes anterior to left hilum along left ventricle
• Critical landmark: lies anterior to lung hilum (vagus nerve is posterior)

Heart Anatomy

• Right ventricle: most anterior cardiac chamber
• Left ventricle: most posterior, lateral, and inferior
• Right atrium: right lateral border
• Left atrium: most posterior chamber, not accessible via anterior thoracotomy
• Cardiac apex: typically 5th ICS, mid-clavicular line

Descending Thoracic Aorta

• Begins at aortic arch (T4 level)
• Descends in posterior mediastinum, left of vertebral column
• Crosses diaphragm at T12 to become abdominal aorta
• For cross-clamping: palpate against vertebral bodies just superior to diaphragm
• More easily accessible with clamshell approach

Anatomical Diagram

CROSS-SECTIONAL VIEW AT 5TH INTERCOSTAL SPACE
(Patient supine, view from head)

        Anterior
           |
    Sternum   5th Rib
        \     /
      [Chest Wall]
           |
    [Right Ventricle]  <-- Most anterior chamber
      /         \
[Left Ventricle] [Right Atrium]
     |              |
  (Apex)       (Lateral)
     |
[Descending Aorta] <-- Left of spine, posterior mediastinum
     |
  Vertebral
   Column


PHRENIC NERVE COURSE (Lateral view of left hemithorax)

Anterior ←                  → Posterior
              
    [Pericardium]
         |
    Phrenic Nerve ----→ (runs ANTERIOR to hilum)
         |
    [Left Hilum] 
    (Bronchus + Vessels)
         |
    Vagus Nerve ----→ (runs POSTERIOR to hilum)


AORTIC CROSS-CLAMP LOCATION

    Aortic Arch (T4)
         |
    [Lung Hilum] (T5-T7)
         |
    ←[CLAMP HERE]← Descending Aorta (T8-T10)
         |                (Just above diaphragm)
    Diaphragm (T12)
         |
    Abdominal Aorta

Danger Zones

Anatomical Variants

High-Riding Diaphragm

• More common in short stature, obesity, pregnancy
• May need to incise one space higher (4th ICS) for adequate exposure
• Identify by percussion or prior imaging if available

Pectus Deformities

• Pectus excavatum: sternum depressed, more difficult to perform clamshell
• Pectus carinatum: sternum prominent, easier access but different landmarks

Dextrocardia

• Rare (below 0.01%) but critical to recognize
• Heart positioned in right hemithorax
• May need right-sided thoracotomy instead

Previous Cardiac Surgery

• Median sternotomy scar indicates previous cardiac surgery
• Pericardium may be adherent or absent
• High risk of injury to grafts or prior repairs
• Clamshell approach may be safer than re-sternotomy

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Equipment

Essential Equipment

Optional Equipment

Equipment Sizing

Adult

Paediatric

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Preparation

Patient Preparation

Consent

• In true emergency, implied consent under doctrine of necessity
• No time for formal written consent in cardiac arrest
• Document rationale for procedure in medical record
• If family present, brief verbal explanation: "Your relative is in cardiac arrest from their injuries. We need to open the chest to try to save their life."

Positioning

• Supine position on trauma bay bed
• Arms abducted 90° or tucked if rapid access needed
• Left arm secured above head to expose left hemithorax
• Bed elevated to comfortable working height for operator
• Ensure C-spine immobilization maintained if not cleared

Monitoring

• Continuous cardiac monitoring (already in place for arrest)
• End-tidal CO2 monitoring if intubated (target greater than 10 mmHg during CPR)
• Arterial line if time permits (usually placed after ROSC)

Pre-procedure Checks

• Confirm cardiac arrest (no palpable pulse, no cardiac output)
• Verify indication and absence of contraindications
• Check CPR duration (below 15 min penetrating, below 10 min blunt)
• Activate massive transfusion protocol
• Alert operating theatre and surgical team for definitive repair

Operator Preparation

Personal Protective Equipment (PPE)

1. Universal precautions: double glove (consider cut-resistant inner glove)
2. Fluid-resistant gown
3. Face shield or goggles (high risk of blood splash)
4. Consider waterproof shoe covers
5. Ensure all skin covered (high infectious disease risk)

Hand Hygiene

• Alcohol gel if available (30 seconds)
• No time for formal surgical scrub in true emergency
• Consider chlorhexidine wipes if immediately available

Equipment Check

• Thoracotomy tray open and accessible
• Suction functioning and available
• Internal defibrillator paddles sterile and ready
• Backup equipment identified (second clamp, additional sutures)

Assistance Arranged

• Minimum 2 assistants: one for suction/retraction, one for ongoing CPR/drugs
• Scrub nurse or technician if available
• Designate team leader (usually EM consultant or senior registrar)
• Assign roles: airway, compressions, drugs, scribe

Backup Plan Identified

• Thoracic or cardiothoracic surgeon contact number called
• Operating theatre notified
• Blood products available (O-negative or type-specific)
• ICU bed requested
• Plan for failure: when to cease resuscitation

Site Preparation

Sterile Technique

• Ideally full aseptic technique, but often impossible in true arrest
• Pragmatic approach: chlorhexidine or povidone-iodine splash to chest (10-15 seconds)
• If patient has ROSC before incision, can pause for better prep
• Never delay procedure for sterile prep in pulseless patient

Skin Preparation

• Splash 2% chlorhexidine-alcohol or 10% povidone-iodine over left hemithorax
• Cover area from sternum to posterior axillary line, nipple to costal margin
• If time permits (patient not yet arrested), more thorough prep
• Remove any clothing, ECG electrodes in field

Draping

• In true emergency: no draping, proceed immediately
• If time permits: sterile towels to define field
• Full draping reserved for non-arrest thoracotomy (e.g., OR procedure)

Positioning

Patient Position

• Supine, head at 0° (no need for lateral positioning as in elective thoracotomy)
• Allows access to both hemithoraces if clamshell needed
• Allows ongoing CPR and airway management

Operator Position

• Stand on patient's left side (for left anterolateral thoracotomy)
• Comfortable height (bed raised or operator on step stool)
• Primary surgeon opposite assistant for retraction

Assistant Position

• First assistant: opposite side of bed for retraction and suction
• Airway provider: at head of bed
• CPR provider: opposite side, pauses compressions once chest open

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Procedure Steps

Step-by-Step Technique

Step 1: Incision

Identify Landmarks

• 5th intercostal space: sub-nipple in males, inframammary fold in females
• Incision from lateral sternal border to mid-axillary line
• Follows curve of rib

Skin Incision

• Use #10 scalpel blade
• Single, deep, decisive stroke through skin and subcutaneous tissue
• Approximately 15-20 cm long
• Err on the side of a larger incision (better exposure)

Muscle Division

• Incise through pectoralis major medially
• Divide serratus anterior laterally
• Can use scalpel or heavy Mayo scissors
• Aim for single continuous incision through all layers

Key Point: Speed is essential - entire incision should take below 30 seconds

Common Error: Hesitant, shallow incisions requiring multiple passes. Make one bold, deep incision.

Step 2: Enter Pleural Space

Identify Intercostal Muscles

• Expose intercostal muscles between ribs 5 and 6
• External, internal, and innermost intercostal muscle layers

Incise Intercostal Muscles

• Use Mayo scissors or scalpel
• Cut along superior border of 6th rib (avoids neurovascular bundle on inferior border of 5th rib)
• Plunge through to pleural cavity
• May hear rush of air (pneumothorax already present in trauma)

Digital Examination

• Insert finger through pleural opening
• Sweep medially and laterally to ensure no lung adherent to chest wall
• Feel for blood, clot, or cardiac activity

Extend Incision

• Use heavy Mayo scissors to extend pleural opening full length of skin incision
• Stay close to superior border of 6th rib throughout

Key Point: Entering too posterior risks injury to scapula; too anterior risks internal mammary artery injury

Common Error: Cutting on inferior border of 5th rib, injuring intercostal vessels and causing chest wall bleeding

Step 3: Insert Rib Spreader

Position Finochietto Retractor

• Insert blades between ribs 5 and 6
• Handle directed toward axilla (laterally)
• Ensure blades positioned deep to ribs, not superficial

Open Retractor

• Turn handle to spread ribs apart
• Open forcefully and widely (6-8 cm separation)
• Rib fractures are expected and acceptable
• Adequate exposure is priority

Optimize Exposure

• May need to divide costal cartilages if exposure inadequate
• Adjust retractor position if needed

Key Point: Don't be timid with rib spreading - fractures heal, inadequate exposure is fatal

Common Error: Inadequate spreading due to fear of rib fracture, resulting in poor visualization

Step 4: Evacuate Blood and Clot

Immediate Suction

• Use Yankauer suction or manual scooping
• Remove blood and clot from pericardium and pleural space
• May be 1-2 liters of blood
• Allows visualization of anatomy

Assess Bleeding Source

• Pericardial blood suggests cardiac injury
• Free pleural blood suggests lung or vessel injury
• Pulsatile bleeding requires immediate control

Key Point: Blood often wells up continuously - have assistant provide ongoing suction

Step 5: Pericardiotomy

Identify Phrenic Nerve

• White/yellow cord-like structure on lateral pericardium
• Runs vertically, anterior to hilum
• Often has accompanying pericardiophrenic vessels
• MUST identify before cutting pericardium

Grasp Pericardium

• Use tissue forceps to tent pericardium anteriorly
• Avoid area near phrenic nerve (laterally)
• Start incision anteriorly, 2-3 cm from phrenic nerve

Incise Pericardium

• Make small incision with scalpel or scissors
• Extend cranially and caudally with scissors
• Create longitudinal opening from apex to great vessels
• Stay at least 2 cm anterior to phrenic nerve

Evacuate Pericardial Blood

• Remove 200-500 mL of clotted and liquid blood
• Allows heart to fill and contract
• May see immediate improvement in cardiac activity

Key Point: Relief of tamponade may be all that is needed for ROSC in cardiac stab wounds

Common Error: Cutting pericardium without identifying phrenic nerve first, resulting in nerve transection

Step 6: Assess and Control Cardiac Injury

Inspect Heart

• Examine all visible cardiac surfaces
• Right ventricle: most anterior, most commonly injured
• Left ventricle: lateral and inferior
• Atria: superior, difficult to access
• Rotate heart with hand to inspect posterior surface

Identify Cardiac Wounds

• May be obvious laceration with active bleeding
• Or small puncture with sealed clot
• Beware multiple wounds (especially with gunshot)

Temporary Control

• Digital occlusion: place finger directly over hole
• Foley catheter balloon: insert catheter into wound, inflate balloon (20-30 mL), pull back gently to tamponade
• Skin stapler: rapid temporary closure for linear lacerations
• Pledgeted sutures: definitive control

Definitive Repair

• Use 2-0 or 3-0 Prolene (non-absorbable monofilament)
• Place horizontal mattress sutures with Teflon felt pledgets
• Sutures parallel to coronary arteries (avoid injury)
• Tie gently to avoid tearing through friable myocardium
• May need multiple sutures for large wounds

Coronary Artery Injury

• If coronary artery involved, do NOT ligate
• Repair around vessel or accept ongoing bleeding
• Ligation causes massive MI and death
• Consider operative bypass if patient stabilizes

Key Point: Simple finger pressure may be all that's needed initially - don't rush to suture

Common Error: Tying sutures too tightly, causing myocardium to tear and worsening bleeding

Step 7: Direct Cardiac Massage

Technique for Internal Cardiac Compression

• Two-handed technique: one hand on each side of heart
• Right hand on right ventricle (anterior)
• Left hand on left ventricle (posterior/lateral)
• Compress antero-posteriorly at 100-120/min
• Aim for 1/3 compression of cardiac diameter

One-Handed Technique

• If two hands don't fit (small chest)
• Cup heart in palm
• Compress against posterior chest wall
• Thumb anteriorly, fingers posteriorly

Monitor Effectiveness

• Palpate aortic pulsation
• Check carotid pulse (assistant)
• Watch for pupillary response
• Monitor end-tidal CO2 (should increase to greater than 20 mmHg with effective internal massage)

Internal vs External CPR

• Internal massage is 3-5 times more effective than external CPR
• Generates higher coronary perfusion pressure
• Should achieve ROSC faster if viable rhythm present

Key Point: Internal massage should feel like squeezing a water balloon, not crushing a rock

Common Error: Compressing too superficially, generating inadequate pressure

Step 8: Aortic Cross-Clamping

Indications for Cross-Clamp

• Intra-abdominal hemorrhage suspected
• Penetrating injury below diaphragm
• Ongoing hemorrhage despite cardiac repair
• Need to redistribute blood volume to heart/brain

Locate Descending Aorta

• Palpate along posterior mediastinum
• Identify pulsatile (or non-pulsatile) tubular structure
• Left of vertebral column
• Just superior to diaphragm for optimal position

Apply Vascular Clamp

• Use Satinsky or DeBakey clamp
• Gently dissect around aorta with finger
• Pass one blade of clamp posterior to aorta
• Close clamp with aorta in jaws
• Ensure esophagus NOT included in clamp (palpate nasogastric tube)

Confirm Position

• No pulsation distal to clamp
• Femoral pulses absent
• Cardiac filling improves
• Mean arterial pressure increases in upper body

Clamshell Thoracotomy for Better Access

• If aorta difficult to reach with left anterolateral approach
• Extend incision across sternum to right 5th ICS
• Divide sternum with Gigli saw, bone cutter, or heavy Mayo scissors
• Provides excellent exposure to entire heart and proximal aorta

Key Point: Cross-clamp is a temporizing measure, not definitive treatment

Common Error: Including esophagus in clamp (identified by NG tube), causing esophageal injury

Step 9: Internal Defibrillation

Indications

• Ventricular fibrillation (VF) on monitor
• Pulseless ventricular tachycardia (VT)
• VF/VT refractory to external defibrillation

Technique

• Use sterile internal defibrillator paddles
• Place one paddle on right ventricle (anterior)
• Place other paddle on left ventricle (lateral/posterior)
• Ensure paddles contact myocardium directly (not pericardium)
• "SHOCK ADVISED - STAND CLEAR"
• Ensure no team members touching patient or bed
• Deliver shock

Energy Levels

• Adult: start at 10-20 joules internal
• If unsuccessful, escalate to 30-50 joules
• Maximum 50 joules internal (avoid myocardial damage)
• Internal defibrillation requires much lower energy than external (external 150-360J)

Post-Shock Assessment

• Check rhythm immediately
• Resume internal compressions for 2 minutes
• Reassess rhythm
• Repeat shock if VF/VT persists

Key Point: Internal defibrillation is often successful when external has failed due to direct myocardial contact

Common Error: Using external defibrillation energy levels (200-360J) internally, causing myocardial burn injury

Step 10: Hilar Cross-Clamping

Indications

• Massive pulmonary hemorrhage
• Suspected air embolism from penetrating lung injury
• Exsanguinating bleeding from hilar vessels

Identify Hilum

• Locate where bronchus and vessels enter lung
• At level of 5th-6th thoracic vertebra
• Palpable as firm, tubular structures

Technique

• Bluntly dissect around hilum with finger
• Pass vascular clamp around entire hilar bundle
• Close clamp to occlude all hilar structures
• This stops both bleeding AND air embolism

Temporary Measure

• Allows transport to OR for definitive repair
• Pneumonectomy may be required
• Maximum clamp time: 20-30 minutes before irreversible lung ischemia

Key Point: Hilar clamping is a damage control maneuver, not definitive treatment

Common Error: Delaying hilar clamp in setting of massive air embolism, allowing further embolization

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Alternative Techniques

Clamshell Thoracotomy

When to Use

• Bilateral chest injuries requiring access to both hemithoraces
• Need better access to proximal great vessels or aortic arch
• Inability to adequately visualize heart or aorta with left anterolateral approach
• Suspected right-sided cardiac injury

Advantages

• Excellent exposure to entire mediastinum
• Easy aortic access
• Can repair bilateral injuries
• Allows bimanual cardiac massage

Disadvantages

• More time-consuming (additional 60-90 seconds)
• Higher morbidity (sternal division)
• More difficult to close
• Chest wall instability post-procedure

Technique

1. Perform left anterolateral thoracotomy as described above
2. Extend incision across sternum at 5th ICS level
3. Continue incision to right mid-axillary line (mirror image)
4. Divide sternum transversely with Gigli saw, heavy scissors, or bone cutter
5. Place rib retractor in right hemithorax
6. Lift sternum anteriorly for full exposure
7. Ensure bilateral internal mammary arteries ligated or cauterized if divided

Key Point: Clamshell is the preferred approach for bilateral injuries or difficult anatomy

Right Anterolateral Thoracotomy

When to Use

• Known isolated right-sided cardiac injury
• Right ventricular injury suspected
• Right pulmonary hilum injury

Technique

• Mirror image of left anterolateral approach
• Incision in right 5th ICS
• Otherwise identical technique

Limitations

• Poor access to left ventricle
• Difficult aortic access
• Less commonly performed (less operator familiarity)

Median Sternotomy

When to Use

• Elective or semi-elective cardiac surgery
• Pre-hospital thoracotomy (if trained provider, rare)
• NOT recommended for ED thoracotomy (takes too long)

Technique

• Vertical midline incision from sternal notch to xiphoid
• Divide sternum longitudinally with saw
• Place sternal retractor

Advantages

• Better access to right atrium, SVC, ascending aorta, aortic arch
• Easier to close than clamshell
• Familiar to cardiothoracic surgeons

Disadvantages

• Takes 3-5 minutes (too slow for arrest)
• Poor access to posterior cardiac structures
• Difficult to perform in supine trauma patient
• Requires special equipment (sternal saw)

Key Point: Reserve median sternotomy for OR, not for ED resuscitation

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Paediatric Considerations

Age-Specific Modifications

Paediatric-Specific Indications

Even Lower Survival in Children

• Overall paediatric survival ~4-6% (slightly lower than adults)
• Penetrating trauma survival ~7-10%
• Blunt trauma survival below 1%

Different Injury Patterns

• Blunt trauma more common than penetrating in children
• Higher proportion of thoracic vascular injuries (relative to cardiac)
• More likely to have concomitant severe TBI

Threshold for RT in Children

• Many centres have lower threshold for blunt trauma in children
• Rationale: better neurological reserve, better healing
• However, evidence does NOT support improved outcomes
• EAST guidelines apply equally to paediatric population

Equipment Sizing

Paediatric-Specific Equipment

• Neonatal: #15 blade scalpel, mosquito hemostats, 4-0 or 5-0 Prolene, paediatric bulldog clamps
• Infant/toddler: #10 or #15 blade, small hemostats, 3-0 or 4-0 Prolene, paediatric vascular clamps
• School-age: #10 blade, standard hemostats, 3-0 Prolene, small Satinsky clamp
• Adolescent: Adult equipment

Technique Modifications

Rib Spreading

• Neonatal ribs very pliable, may not require spreader
• Gently retract with fingers or small retractor
• Avoid excessive force (risk of rib fracture and chest wall instability)

Cardiac Repair

• Paediatric myocardium is thinner and more friable
• Use pledgets for ALL cardiac sutures (mandatory, not optional)
• Consider skin stapler for linear lacerations
• Smaller suture bites (2-3 mm)

Aortic Cross-Clamping

• Paediatric aorta is smaller and more delicate
• Use bulldog clamps or small vascular clamps
• Easy to occlude completely with manual pressure if clamp unavailable
• Shorter safe occlusion time (30 minutes maximum)

Internal Defibrillation

• Neonates/infants: 2-5 joules internal
• Children: 5-10 joules internal
• Adolescents: 10-20 joules internal
• Start low, escalate by 5-10 joule increments

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Complications

Immediate Complications

Delayed Complications

Provider Risks

Complication Prevention

Technical Strategies

• Identify phrenic nerve before pericardiotomy (prevents nerve injury)
• Incise along superior border of lower rib (prevents intercostal vessel injury)
• Use pledgets for all cardiac sutures (prevents myocardial tearing)
• Avoid cautery near phrenic nerve (prevents thermal injury)
• Monitor aortic clamp time (prevents visceral ischemia)

Systemic Strategies

• Massive transfusion protocol (prevents coagulopathy)
• Damage control surgery (prevents prolonged OR time)
• Early antibiotics (prevents infection)
• Correct hypothermia (prevents coagulopathy)
• Tight glucose control (prevents hyperglycemia-associated complications)

Provider Protection

• Double glove (inner glove can be cut-resistant)
• Face shield or goggles (prevents splash exposure)
• Water-resistant gown and shoe covers
• Sharps awareness (account for all sharps before procedure start)
• Safe sharps disposal (sharps container at bedside)

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Troubleshooting

Rescue Techniques

If Thoracotomy Fails

• ECMO/ECPR: if available and patient meets criteria (witnessed arrest, below 60 years, penetrating trauma, below 30 min CPR)
• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): alternative to aortic cross-clamp if thoracotomy unsuccessful or unavailable
• Damage control to OR: if ROSC achieved but ongoing bleeding, abbreviated procedure and immediate transfer to OR
• Consider organ donation: discuss with transplant team if patient declared dead but organs potentially viable

Declaring Death

• If no ROSC after 30-45 minutes of resuscitation including thoracotomy, death is almost certain
• Exceptions: severe hypothermia, toxic ingestion (continue resuscitation until rewarmed or toxin metabolized)
• Discuss with team before ceasing
• Document interventions and rationale for terminating resuscitation
• Support family appropriately

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Post-Procedure Care

Immediate Care

Post-ROSC Checklist

1. Airway: Confirm endotracheal tube position, secure tube
2. Breathing: Ventilate to SpO2 94-98%, PaCO2 35-45 mmHg (avoid hyperoxia and hypocapnia)
3. Circulation: Target MAP greater than 65 mmHg, start vasopressors if needed (noradrenaline first-line)
4. Rhythm: Treat arrhythmias, consider anti-arrhythmics (amiodarone) if VF recurs
5. Temperature: Prevent hyperthermia (target 36-37°C), consider targeted temperature management
6. Glucose: Monitor and correct (target 6-10 mmol/L)
7. Coagulopathy: Send coagulation studies, continue massive transfusion protocol, replace factors

Temporary Wound Management

• If patient going directly to OR: leave chest open (damage control), cover with sterile drape or plastic adhesive drape
• If patient stabilized in ED: suture skin only (ribs left separated), place chest tube(s), sterile dressing
• Definitive closure in OR after hemorrhage controlled

Transfer to OR

• All patients who achieve ROSC require immediate OR exploration
• Alert surgical team during resuscitation (don't wait for ROSC)
• Transfer with ongoing resuscitation (maintain CPR if needed)
• Blood products accompany patient
• Ventilator or bag-valve-mask for transport
• Minimum 2 providers during transport (airway + circulation)

Monitoring

Imaging Confirmation

Immediate (in OR or ED if stable)

• Chest X-ray: assess tube placement, pneumothorax, hemothorax, mediastinal width
• FAST or formal echocardiography: assess cardiac function, pericardial fluid, ventricular wall motion
• CT chest/abdomen/pelvis: only if hemodynamically stable, identify injuries missed on initial assessment

Post-Operative

• Daily CXR: monitor for pneumothorax, effusion, infiltrate
• Echocardiography: assess ventricular function, valvular function, pericardial effusion (day 1-3)

Documentation

Mandatory Documentation Elements

• Indication: mechanism of injury, time of arrest, CPR duration, signs of life, rationale for RT
• Consent: implied consent documented, family notified if present
• Procedure details: time of incision, approach (left anterolateral vs clamshell), findings (injuries identified), interventions (pericardiotomy, cardiac repair, aortic clamp, hilar clamp, defibrillation), complications, estimated blood loss
• Outcomes: ROSC achieved (time), rhythm after intervention, hemodynamic parameters post-ROSC, disposition (OR, ICU, deceased)
• Team members: names and roles of all participants
• Specimens: send any tissue removed to pathology
• Communication: family notification, surgical team notification, ICU notification

Medicolegal Considerations

• RT has high medicolegal risk due to invasiveness and low survival
• Thorough documentation is protective
• Document rationale clearly (indicated per EAST guidelines)
• Document any deviation from standard technique and rationale
• If patient dies despite RT, document that family informed and supported

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OSCE Practice

OSCE Station 1: Resuscitative Thoracotomy Decision-Making

Format: Communication and clinical decision-making Time: 11 minutes Setting: Simulated trauma bay with mannequin

Candidate Instructions:

You are the Emergency Medicine registrar on duty. Paramedics are 2 minutes away with a 28-year-old male who was stabbed in the left chest. He had a palpable radial pulse at the scene but has now lost cardiac output. CPR is in progress. Time from loss of output to ED arrival will be approximately 5 minutes. Your consultant asks you to prepare for a possible resuscitative thoracotomy and lead the resuscitation. The examiner will ask you questions about your approach.

Resources Available:

• Trauma team (nurse, registrar, anaesthetist)
• Thoracotomy tray
• Blood products available

Marking Criteria:

Viva Questions During Station:

1. "What are your indications for performing RT in this patient?"
2. "Describe the anatomical landmarks for your incision."
3. "How will you identify and avoid the phrenic nerve?"
4. "What are the survival statistics for this injury pattern?"
5. "At what point would you cease resuscitation?"

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OSCE Station 2: Anatomical Viva - Thoracotomy Anatomy

Format: Anatomical knowledge assessment using prosection or model Time: 11 minutes Setting: Anatomy station with thoracic prosection or high-fidelity model

Candidate Instructions:

You are shown a thoracic prosection demonstrating the left hemithorax. Please identify the structures indicated and answer the examiner's questions about the anatomy relevant to resuscitative thoracotomy.

Structures to Identify:

1. 5th intercostal space
2. Intercostal neurovascular bundle
3. Phrenic nerve
4. Cardiac chambers (RV, LV, RA, LA)
5. Descending thoracic aorta
6. Lung hilum
7. Internal mammary artery

Marking Criteria:

Viva Questions:

1. "Where would you make your skin incision for a left anterolateral thoracotomy?"
2. "Why do we incise along the superior border of the lower rib?"
3. "Show me where the phrenic nerve runs and explain how to avoid it."
4. "Which cardiac chamber is most commonly injured in penetrating trauma and why?"
5. "Describe the surface anatomy landmarks for locating the descending aorta."

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OSCE Station 3: Technical Skills - Simulated Thoracotomy

Format: Procedural skills on high-fidelity simulator or cadaver Time: 11 minutes Setting: Simulation lab with thoracic trainer

Candidate Instructions:

A 32-year-old male has been stabbed in the left chest and is in cardiac arrest. CPR has been ongoing for 8 minutes. You have decided to perform a resuscitative thoracotomy. Please perform the procedure on this simulator, talking through your steps.

Simulator Setup:

• High-fidelity thoracic trainer with skin, ribs, pericardium, heart
• Sterile thoracotomy tray
• Simulated blood in pericardium

Expected Actions:

1. Don PPE (gloves, gown, face shield)
2. Identify landmarks (5th ICS)
3. Make incision from sternal border to mid-axillary line
4. Divide intercostal muscles along superior border of 6th rib
5. Insert and open rib spreader
6. Identify phrenic nerve
7. Perform pericardiotomy 2 cm anterior to phrenic nerve
8. Evacuate pericardial blood
9. Identify cardiac injury (simulated laceration)
10. Control bleeding with finger pressure
11. Demonstrate suture placement (pledgeted horizontal mattress)
12. Demonstrate internal cardiac massage technique

Marking Criteria:

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Viva Questions

Viva Scenario 1: Penetrating Cardiac Arrest

Stem: "You are the Emergency Medicine consultant in a metropolitan trauma centre. Paramedics bring in a 25-year-old male who was stabbed in the left anterior chest 15 minutes ago. He had a palpable radial pulse at the scene but arrested 5 minutes prior to arrival. High-quality CPR has been ongoing. The rhythm on the monitor is PEA with a rate of 40."

Opening Question: "What are your immediate priorities?"

Model Answer: This patient has a penetrating thoracic injury with witnessed cardiac arrest and PEA rhythm within 15 minutes of arrest - he is a candidate for immediate resuscitative thoracotomy. My priorities are:

1. Confirm indication: Penetrating thoracic trauma, witnessed arrest, CPR below 15 minutes, signs of life (PEA rhythm) - meets EAST guideline criteria for RT
2. Rapid assessment: Confirm cardiac arrest (no palpable pulse), ensure high-quality CPR ongoing
3. Team activation: Activate trauma team, alert surgical consultant, activate massive transfusion protocol
4. Preparation: Don PPE (double gloves, gown, face shield), open thoracotomy tray, ensure equipment ready
5. Decision: Proceed immediately with left anterolateral thoracotomy - time is critical
6. Simultaneous interventions: Ensure ongoing CPR, ventilation, IV access, blood products en route

Follow-up Q1: "Describe your technique for the thoracotomy."

Model Answer:

1. Incision: Left 5th intercostal space (sub-nipple level), from lateral sternal border to mid-axillary line, deep single stroke through skin and muscle
2. Entry: Incise intercostal muscles along superior border of 6th rib (avoids neurovascular bundle), enter pleural space
3. Exposure: Insert Finochietto rib retractor, spread ribs widely (accept rib fractures)
4. Pericardiotomy: Identify phrenic nerve on lateral pericardium (anterior to hilum), incise pericardium 2 cm anterior to nerve from apex to great vessels
5. Assessment: Evacuate pericardial blood, identify cardiac injury
6. Intervention: Control bleeding (digital pressure, Foley balloon, pledgeted sutures), perform internal cardiac massage, consider aortic cross-clamp if needed
7. Reassess: Check rhythm, feel for cardiac output, assess response to interventions

Follow-up Q2: "You open the pericardium and find 300 mL of clotted blood. There's a 2 cm laceration on the right ventricle with active bleeding. What do you do?"

Model Answer:

1. Immediate control: Place my finger directly over the laceration to stop bleeding
2. Assessment: Check cardiac rhythm and activity - evacuation of tamponade may be sufficient for ROSC
3. Temporary measure: If unable to suture immediately, insert Foley catheter into wound, inflate balloon with 20-30 mL, pull back gently to tamponade
4. Definitive repair: Place 2-0 or 3-0 Prolene horizontal mattress sutures with Teflon felt pledgets, parallel to coronary arteries, tie gently to avoid tearing
5. Reassess: Continue internal cardiac massage, check for ROSC, look for other injuries
6. Disposition: If ROSC achieved, rapid transfer to OR for formal exploration and definitive repair

Follow-up Q3: "Despite cardiac repair and internal massage, there is no ROSC after 10 minutes. What do you do?"

Model Answer:

1. Reassess reversible causes (4Hs/4Ts):

   • Hypovolemia: Likely - ensure massive transfusion ongoing, consider aortic cross-clamp if not already done
   • Hypoxia: Check ventilation, ETT position, SpO2
   • Tension pneumothorax: Already relieved by thoracotomy
   • Tamponade: Already relieved by pericardiotomy
   • Thrombosis (PE): Unlikely in penetrating trauma

2. Additional interventions:

   • Aortic cross-clamping if not yet done (redistributes blood volume)
   • Internal defibrillation if VF/VT develops
   • Check for additional injuries (posterior cardiac wound, great vessel injury)
   • Ensure adequate blood product resuscitation

3. Futility assessment: If no response after 30-45 minutes total resuscitation time, despite all interventions, survival is near zero

4. Decision: Discuss with team, consider ceasing resuscitation if:

   • No cardiac electrical activity (asystole)
   • Heart completely non-contractile
   • No reversible causes remaining
   • Total CPR time greater than 45 minutes

5. Communication: Inform family, support team, debrief, complete documentation

Follow-up Q4: "What are the expected survival rates for this patient?"

Model Answer: Based on published literature and EAST guidelines:

• Overall survival for penetrating thoracic trauma with SOL: 15-21%

• Survival for penetrating cardiac injury specifically: 10-30% (higher for stab wounds, lower for GSW)

• Neurologically intact survival: 3-5% overall, but majority of survivors have good neurological function

• Factors favoring survival:

  • Stab wound (vs gunshot)
  • Single cardiac wound (vs multiple or great vessel injury)
  • Witnessed arrest with short CPR duration (below 10 min)
  • PEA rhythm (vs asystole)
  • Rapid intervention (time to thoracotomy below 5 min)

• This patient's profile: Stab wound, cardiac injury, witnessed arrest, PEA rhythm, CPR ~10 min - survival probability approximately 15-20%

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Viva Scenario 2: Blunt Trauma Decision-Making

Stem: "A 45-year-old male is brought in after a high-speed MVC. He was initially conscious at the scene but deteriorated during transport. He arrives in PEA with agonal respirations. CPR has been ongoing for 7 minutes. There is no obvious external injury."

Opening Question: "Do you perform a resuscitative thoracotomy? Justify your answer."

Model Answer:

This is a challenging decision requiring careful consideration of EAST guidelines:

Factors FAVORING thoracotomy:

• Witnessed arrest (deterioration during transport)
• PEA rhythm (sign of life)
• CPR duration below 10 minutes (within time window)
• Agonal respirations suggest very recent arrest

Factors AGAINST thoracotomy:

• Blunt mechanism (survival 2-4.6% with SOL, below 1% without)
• No obvious thoracic injury
• High likelihood of non-survivable multi-system trauma or TBI

Decision Framework: Per EAST guidelines, this patient meets criteria for a conditional recommendation for RT (blunt trauma with signs of life). The decision depends on:

1. Was there truly a witnessed arrest in the ED? If he arrests in front of the team with clear preceding signs of life - YES, perform RT
2. Is there suspicion of a reversible thoracic cause? (tamponade, tension pneumothorax, massive hemothorax) - if yes, RT may be beneficial
3. Pupillary exam: If both pupils fixed and dilated - suggests severe TBI, RT likely futile
4. Resource considerations: Is surgical backup immediately available?

My approach:

• Brief FAST exam (10-15 seconds max): If pericardial fluid present - PERFORM RT immediately (tamponade is reversible)
• If FAST negative and pupils fixed/dilated: Do NOT perform RT (futile)
• If FAST negative but reactive pupils and witnessed ED arrest: CONSIDER RT, but inform team of poor prognosis (below 5% survival)
• Continue medical resuscitation while making decision (CPR, intubation, transfusion)

Key Point: In blunt trauma, the threshold is much higher than penetrating. Without clear indication (e.g., tamponade), the evidence supports withholding RT in most blunt arrest patients.

Follow-up Q1: "The FAST shows pericardial fluid. You perform a thoracotomy and evacuate 400 mL of blood from the pericardium. The heart starts to contract weakly. What injuries are you considering?"

Model Answer:

Blunt cardiac injuries causing tamponade:

1. Cardiac chamber rupture: Most commonly right atrium or right ventricle (most anterior), usually from high-speed deceleration
2. Aortic injury: Traumatic aortic transection (descending aorta at ligamentum arteriosum), presents with hemopericardium if ruptures into pericardium
3. Coronary artery injury: Rare, usually LAD, from shearing forces
4. Myocardial contusion with delayed rupture: Can occur hours after injury
5. Valvular injury: Papillary muscle rupture, chordae tendineae rupture, valve leaflet tear

Most likely in blunt trauma: Right atrial or ventricular rupture from sudden deceleration

Assessment:

• Inspect all visible cardiac surfaces
• Rotate heart to visualize posterior surface
• Look for lacerations, contusions, hematomas
• Assess great vessels (ascending aorta, pulmonary artery)

Management:

• Repair if technically feasible (same technique as penetrating - pledgeted sutures)
• Beware: blunt cardiac rupture often has irregular, stellate wounds (harder to repair than clean lacerations)
• May require mesh/patch repair
• High likelihood of concomitant myocardial dysfunction (contusion)
• Immediate OR for definitive repair if ROSC achieved

Follow-up Q2: "What are the contraindications to RT in blunt trauma?"

Model Answer:

Absolute Contraindications:

1. Asystole without preceding shockable rhythm: Survival essentially 0%
2. No signs of life at any point during assessment/transport: Survival below 0.7%
3. Prolonged CPR (greater than 10 minutes pulseless): Neurologically intact survival essentially zero
4. Obviously non-survivable injuries: Major cranial destruction, decapitation, incineration
5. Pre-existing terminal illness with DNR: If known

Relative Contraindications:

1. Severe traumatic brain injury: Bilateral fixed dilated pupils, GCS 3
2. Multi-system trauma with hemorrhagic shock: If thoracic tamponade not suspected, aortic cross-clamp unlikely to help
3. Elderly with significant comorbidities: Functional outcome likely very poor even if survive
4. Resource limitations: If no surgical backup available, RT may achieve ROSC but patient dies anyway

Key Evidence:

• EAST guidelines meta-analysis: Blunt trauma without SOL had 0.7% survival, 0% neurologically intact survival
• Strong recommendation AGAINST RT in blunt trauma without SOL
• Even with SOL, survival only 2-4.6%

Clinical Application: In blunt trauma, I would only perform RT if:

• Clear witnessed arrest in ED with preceding SOL
• Suspected reversible thoracic cause (positive FAST, massive hemothorax)
• No evidence of severe TBI
• CPR below 10 minutes
• Surgical backup available

Otherwise, medical resuscitation continues but RT withheld.

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Viva Scenario 3: Aortic Cross-Clamping

Stem: "You are called to resus for a 30-year-old male with multiple stab wounds to the abdomen. He is in hemorrhagic shock (BP 60/40, HR 140) and deteriorating. As you're assessing him, he loses his pulse. You perform a resuscitative thoracotomy."

Opening Question: "Do you cross-clamp the aorta? Why or why not?"

Model Answer:

YES, I would cross-clamp the descending aorta. Rationale:

Indications for Aortic Cross-Clamp:

1. Intra-abdominal hemorrhage: This patient has abdominal stab wounds - likely source of exsanguination is below the diaphragm
2. Preferential blood flow: Clamping the descending aorta redistributes available blood volume to coronary and cerebral circulation
3. Hemorrhage control: Limits ongoing blood loss into abdomen
4. Temporizing measure: Buys time to get to OR for definitive hemorrhage control

Physiological Effects:

• Increases afterload above clamp (improves coronary and cerebral perfusion pressure)
• Stops exsanguination below clamp
• Allows resuscitation to "catch up" with blood loss

Technique:

1. Locate aorta: Palpate in posterior mediastinum, left of vertebral column, just superior to diaphragm
2. Blunt dissection: Use finger to create space around aorta
3. Apply clamp: Satinsky or DeBakey clamp across full diameter of aorta
4. Confirm position: Ensure esophagus (NG tube) not included in clamp
5. Note time: Start clock - maximum safe time 30-45 minutes

Expected Outcome:

• Immediate improvement in upper body blood pressure
• Allows heart to fill and potentially achieve ROSC
• MUST proceed to OR immediately for definitive hemorrhage control

Follow-up Q1: "How do you locate the descending aorta and apply the clamp?"

Model Answer:

Anatomical Landmarks:

• Descending aorta lies in posterior mediastinum
• Left of vertebral column (not midline)
• Just superior to diaphragm for optimal clamping position (below gives subdiaphragmatic blood flow)
• Can be palpated against vertebral bodies

Technique:

1. Ensure adequate exposure: May need clamshell thoracotomy for optimal access (better than left anterolateral alone)

2. Retract lung: Push left lung anteriorly and superiorly to expose posterior mediastinum

3. Palpate aorta:

   • Identify pulsatile (or non-pulsatile in arrest) tubular structure
   • Distinguish from esophagus by palpating NG tube (esophagus is softer, has NG tube)
   • Aorta is firm, non-compressible

4. Blunt dissection:

   • Use index finger to create space posterior to aorta
   • Sweep finger around aorta to separate from surrounding tissue
   • Do NOT use sharp dissection (risk of injury)

5. Apply clamp:

   • Pass one blade of Satinsky clamp posterior to aorta
   • Close clamp with aorta centered in jaws
   • Clamp perpendicular to aorta (not oblique)
   • Check for NG tube: Ensure esophagus NOT included in clamp

6. Confirm occlusion:

   • Palpate aorta distal to clamp - no pulsation
   • Check femoral pulses - should be absent
   • Upper body BP should improve

7. Document time: Note time of clamping (crucial for ischemia monitoring)

If Unable to Locate Aorta: Perform clamshell thoracotomy for better exposure

Follow-up Q2: "What are the complications of aortic cross-clamping?"

Model Answer:

Immediate Complications:

1. Esophageal injury (1-3%):

   • Mechanism: Including esophagus in clamp
   • Prevention: Palpate NG tube, ensure only aorta clamped
   • Consequence: Esophageal perforation → mediastinitis, sepsis
   • Management: Surgical repair, broad-spectrum antibiotics

2. Aortic injury (below 1%):

   • Mechanism: Crushing or tearing aortic wall with clamp
   • Prevention: Gentle handling, appropriate clamp size, perpendicular orientation
   • Consequence: Aortic rupture, massive hemorrhage
   • Management: Direct repair, graft if needed

3. Spinal cord ischemia (with prolonged clamping):

   • Mechanism: Occlusion of intercostal arteries supplying anterior spinal artery
   • Prevention: Minimize clamp time (below 45 min)
   • Consequence: Paraplegia
   • Management: Prevention key; no treatment once established

Delayed Complications:

4. Visceral ischemia (related to clamp time):

   • Renal failure: Ischemic ATN, may require dialysis
   • Hepatic injury: Ischemic hepatitis, transaminitis
   • Intestinal ischemia: Bowel infarction if prolonged
   • Critical Threshold: greater than 45-60 minutes clamp time

5. Ischemia-Reperfusion Injury:

   • Mechanism: Sudden release of clamp → washout of acidotic, hyperkalemic blood from lower body
   • Consequence: Cardiovascular collapse, arrhythmia, cardiac arrest
   • Prevention: Gradual clamp release, bicarbonate administration, volume loading, vasopressor support

6. Lower Limb Ischemia:

   • Mechanism: Prolonged occlusion of lower body perfusion
   • Consequence: Compartment syndrome, rhabdomyolysis, limb loss
   • Prevention: Minimize clamp time

Time-Dependent Risk:

• below 30 minutes: Minimal risk
• 30-45 minutes: Acceptable risk (renal impairment possible)
• 45-60 minutes: High risk (renal failure, bowel ischemia likely)
• greater than 60 minutes: Very high risk (multi-organ failure, paraplegia)

Clinical Strategy:

• Apply clamp only when indicated (intra-abdominal hemorrhage)
• Document time immediately
• Communicate clamp time to OR team
• Remove clamp as soon as bleeding controlled in OR
• Monitor for reperfusion injury upon release

Follow-up Q3: "The patient achieves ROSC. What is your disposition and immediate management?"

Model Answer:

Immediate Post-ROSC Management:

1. Airway:

   • Confirm ETT position (may have dislodged during resuscitation)
   • Secure tube (trauma fixation)

2. Breathing:

   • Target SpO2 94-98% (avoid hyperoxia - worse neurological outcomes)
   • Target PaCO2 35-45 mmHg (avoid hypocapnia - cerebral vasoconstriction)
   • Adjust ventilator settings
   • Place chest tube (left hemithorax will have blood)

3. Circulation:

   • Target MAP greater than 65 mmHg
   • Continue massive transfusion protocol
   • Start vasopressor if needed (noradrenaline 0.05-0.2 mcg/kg/min)
   • Monitor hemoglobin, coagulation (ongoing bleeding likely)

4. Rhythm:

   • Monitor continuously
   • Treat arrhythmias (amiodarone if VT/VF recurs)

5. Temperature:

   • Prevent hyperthermia (target 36-37°C)
   • Active warming if hypothermic

6. Glucose:

   • Monitor q1h
   • Target 6-10 mmol/L

Disposition:

IMMEDIATE TRANSFER TO OR - Non-negotiable

Rationale:

• Definitive hemorrhage control required (laparotomy for abdominal stab wounds)
• Aortic clamp must be removed (time-dependent ischemic injury)
• Cardiac repair may need formal revision
• Chest closure required

Communication:

• Alert surgical team DURING resuscitation (don't wait for ROSC)
• Direct OR transfer (bypass CT scanner - patient unstable)
• Blood products accompany patient
• ICU bed arranged for post-op

Transfer Checklist:

• Airway secure (ETT)
• Ventilator or BVM for transport
• Arterial line transduced
• Multiple large-bore IV access
• Blood products (6 units PRBC, 4 FFP, 1 platelets minimum)
• Vasopressor infusion running
• Monitoring: ECG, SpO2, BP
• Minimum 2 providers (airway + circulation)
• Surgeon notified and ready in OR
• Aortic clamp time communicated to OR team

Damage Control Philosophy:

• Abbreviated laparotomy (pack bleeding, bowel stapler for injuries)
• 30-60 minute operation maximum
• Transfer to ICU for resuscitation
• Return to OR in 24-48 hours for definitive repair

Post-Operative ICU Management:

• Correct coagulopathy (lethal triad: hypothermia, acidosis, coagulopathy)
• Targeted temperature management (avoid hyperthermia)
• Prognostication delayed until at least 72 hours
• Monitor for visceral ischemia (renal failure, liver injury)
• Assess neurological function when sedation lifted

Prognosis:

• Survival for penetrating extra-thoracic trauma with RT: 8-12%
• If ROSC achieved and survives to OR, survival improves to ~30-40%
• Neurological outcome dependent on total down-time

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Viva Scenario 4: Remote/Rural Considerations

Stem: "You are working in a remote Northern Territory hospital. A 35-year-old Indigenous male arrives after an assault with a knife. He has a stab wound to the left chest and is in profound shock (BP 70/40, HR 130). There is no surgeon available locally. RFDS will take 90 minutes to arrive. As you assess him, he arrests."

Opening Question: "What is your approach?"

Model Answer:

This is a complex scenario involving resuscitative thoracotomy in a resource-limited setting with retrieval considerations.

Immediate Management:

1. Confirm cardiac arrest: No pulse, no cardiac output

2. Assess indication for RT:

   • Penetrating thoracic trauma: YES
   • Witnessed arrest: YES (arrested in front of team)
   • CPR duration: below 5 minutes
   • Signs of life preceding arrest: YES (was conscious)
   • INDICATION MET - proceed with RT

3. Resource assessment:

   • Is thoracotomy tray available? (Most remote hospitals have basic surgical instruments)
   • PPE available?
   • Blood products available? (May be limited - activate flying squad from Darwin if available)
   • Retrieval team ETA: 90 minutes (too long to wait)

4. Decision: Perform resuscitative thoracotomy NOW

   • Waiting for RFDS = certain death
   • RT is patient's only chance
   • Even without surgical backup, tamponade release may achieve ROSC

Technique Modifications in Remote Setting:

1. Equipment limitations:

   • If no rib spreader: Use hand retraction or improvise with two large retractors
   • If no vascular clamp: Can occlude aorta with hand or use large artery forceps
   • If no Prolene sutures: Use silk (non-ideal but acceptable)
   • If no pledgets: Use pieces of sterile glove or plastic

2. Limited blood products:

   • Use all available O-negative or type-specific blood
   • Consider whole blood from walking donor bank (if available and patient consents)
   • Aortic cross-clamp to minimize blood loss
   • Cell salvage if equipment available

3. Definitive care planning:

   • If ROSC achieved, patient will require retrieval to Darwin or Alice Springs
   • Stabilize for transfer: ongoing transfusion, vasopressors, ventilation
   • Leave chest open with sterile drape (damage control approach)
   • Coordination with RFDS (provide clinical summary, request surgical team on retrieval)

Communication:

1. RFDS:

   • Call immediately when patient arrives (don't wait for arrest)
   • Update after RT performed
   • Request surgical team if available
   • Arrange for blood products during retrieval

2. Tertiary centre:

   • Contact Royal Darwin Hospital or Alice Springs Hospital
   • Alert trauma team and cardiothoracic service
   • Discuss case, get advice

3. Family:

   • Indigenous cultural considerations: involve Aboriginal Liaison Officer if available
   • Extended family may be present - consider cultural protocols
   • Explain gravity of situation, procedures being performed
   • Discuss possibility of patient death despite interventions

Retrieval Considerations:

1. If ROSC achieved:

   • Stabilize for transport (may take 60-90 min)
   • Ensure adequate IV access (2 x large bore)
   • Adequate blood products for journey
   • Ventilator with oxygen for flight
   • Vasopressor infusions
   • Continuous monitoring
   • Accompany patient on retrieval (you know the injuries and what was done)

2. If no ROSC:

   • Cease resuscitation after appropriate time (30-45 min)
   • Support family
   • Forensic considerations (assault - police involvement)
   • Offer autopsy

Follow-up Q1: "What cultural considerations are important when managing Indigenous Australian patients in this context?"

Model Answer:

Cultural Safety Principles:

1. Family and Community:

   • Indigenous Australians have strong family and community connections
   • Extended family may include large kinship group
   • Multiple people may wish to be present or informed
   • Respect cultural protocols around who can speak for patient

2. Communication:

   • Use Aboriginal Liaison Officer if available
   • Consider need for interpreter (even if patient speaks English, family may prefer traditional language)
   • Avoid medical jargon
   • Allow time for family discussion and decision-making
   • Respect that some family members may not be able to hear patient's name or discuss them (cultural protocols)

3. Gender Considerations:

   • Some Indigenous cultures have restrictions on opposite-gender care
   • Male healthcare providers for male patients preferred if possible
   • Ask patient/family about preferences

4. End-of-Life:

   • Different cultural beliefs about death and dying
   • Some groups believe spirit remains near body
   • May have specific mortuary rituals
   • Coordinate with Aboriginal Liaison Officer and hospital chaplaincy

5. Trust and Historical Context:

   • Acknowledge historical trauma and mistrust of healthcare system
   • Build rapport, explain procedures clearly
   • Involve Indigenous healthcare workers if available
   • Respect traditional healing practices (not incompatible with Western medicine)

Practical Application in This Scenario:

• Immediate: Focus on lifesaving intervention (RT), but acknowledge family presence
• If ROSC achieved: Involve family in decision-making about retrieval and ongoing care
• If patient dies: Support family, offer culturally appropriate care for body, facilitate traditional rituals if requested
• Documentation: Record involvement of Aboriginal Liaison Officer, cultural considerations in care

Health Disparities:

• Indigenous Australians have higher rates of trauma, violence, and penetrating injury
• Poorer access to tertiary care (geography, socioeconomic factors)
• Higher post-trauma mortality
• Address with culturally safe care, advocacy for resources, trauma prevention programs

Follow-up Q2: "The patient achieves ROSC. You have no surgeon available. What is your management while waiting for RFDS retrieval?"

Model Answer:

Immediate Stabilization (First 15-30 minutes):

1. Airway/Breathing:

   • Confirm ETT position, secure tube
   • Ventilate to SpO2 94-98%, PaCO2 35-45 mmHg
   • Insert chest tube (left hemithorax) - large-bore (32-36 Fr)
   • Connect to underwater seal drainage
   • Document initial drainage volume

2. Circulation:

   • Blood pressure: Target MAP greater than 65 mmHg
     • Start noradrenaline infusion (0.05-0.2 mcg/kg/min) if needed
     • Titrate to maintain cerebral and coronary perfusion
   • Transfusion:
     • Use all available blood products (prioritize O-negative or type-specific)
     • Ratio 1:1:1 (PRBC:FFP:Platelets) if available
     • If limited products, give PRBC and FFP (1:1 ratio minimum)
     • Tranexamic acid 1g IV loading, then 1g over 8 hours (if within 3 hours of injury)
   • Access: Ensure 2 x large-bore IV (14-16G), consider femoral central line or IO
   • Monitoring: Arterial line if able (provides beat-to-beat BP and access for ABG)

3. Wound Management:

   • Chest:
     • Do NOT attempt formal closure (no surgical expertise)
     • Damage control approach: Suture skin only (leave ribs separated), or leave open with sterile drape
     • If chest left open: cover with sterile plastic adhesive drape (Ioban) or wet sterile towels
     • This allows ongoing cardiac visualization if re-arrest occurs
   • Cardiac repair:
     • If simple repair performed, hope it holds
     • May ooze - monitor chest tube output
   • Other wounds: Dress and bandage, definitive repair in Darwin/Alice Springs

4. Coagulopathy Correction:

   • Lethal triad: Hypothermia, acidosis, coagulopathy
   • Warming: Active warming (Bair Hugger, warm blankets, warm IV fluids)
   • Acidosis: Ensure adequate ventilation (clear CO2), consider bicarb if pH below 7.1
   • Coagulopathy: FFP, platelets, cryoprecipitate if available, TXA

5. Monitoring:

   • Continuous: ECG, SpO2, BP (arterial line if possible), ETCO2
   • Hourly: Vital signs, urine output (aim greater than 0.5 mL/kg/hr), GCS, chest tube output
   • Labs: ABG, Hb, coags, lactate (q1-2h if able)

Ongoing Management (30-90 minutes until RFDS arrival):

1. Hemodynamic Monitoring:

   • Watch for re-bleeding (chest tube output greater than 200 mL/hr)
   • If massive re-bleeding and re-arrest: re-open chest, finger pressure on cardiac wound, prepare for re-retrieval
   • Maintain MAP greater than 65 with fluids and vasopressors

2. Prevent Complications:

   • Arrhythmia: Monitor rhythm, have defibrillator ready, amiodarone available
   • Hypothermia: Continuous active warming (target 36-37°C)
   • Hypoglycemia: Check BSL, maintain 6-10 mmol/L
   • Seizures: If occur, treat with benzodiazepines (midazolam), consider TBI

3. Communication:

   • RFDS updates: Call q30 min with patient status
   • Tertiary centre: Discuss with retrieval consultant, get advice
   • Family: Regular updates, prepare for transfer

Preparation for Retrieval:

1. Clinical Summary:

   • Mechanism of injury (stab wound, location)
   • Vital signs on arrival, time to arrest, CPR duration
   • RT performed (time, findings, interventions, ROSC achieved)
   • Total blood products given
   • Current vitals and trends
   • Chest tube output
   • Complications

2. Equipment for Transfer:

   • Portable ventilator or BVM with oxygen
   • Battery backup for monitors and infusion pumps
   • Blood products (request more with RFDS if available)
   • Emergency drugs (adrenaline, amiodarone, atropine)
   • Chest drain with portable collection system

3. Accompanying Staff:

   • Ideally, you accompany patient (you know the case)
   • RFDS retrieval team (doctor + nurse)
   • Handover all findings, interventions, concerns

Prognosis:

• If ROSC achieved and maintained, survival is possible
• Major challenges: delayed definitive surgical care, limited resources, long retrieval time
• Neurological outcome dependent on total arrest time and post-ROSC care
• Realistic discussion with family about grave prognosis but possibility of survival

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SAQ Practice

Question 1: Indications and Contraindications (8 marks)

Stem: A 28-year-old male is brought to the Emergency Department following a stab wound to the left anterior chest. On arrival, he is in cardiac arrest. CPR has been ongoing for 10 minutes since loss of pulse at the scene.

a) List FOUR absolute indications for emergency department resuscitative thoracotomy (4 marks)

Model Answer:

1. Penetrating thoracic trauma with witnessed cardiac arrest or loss of vital signs (1 mark)
2. Penetrating thoracic trauma with pulseless electrical activity (PEA) and CPR duration below 15 minutes (1 mark)
3. Suspected pericardial tamponade from penetrating injury (Beck's triad: hypotension, muffled heart sounds, elevated JVP) (1 mark)
4. Penetrating extra-thoracic trauma with witnessed arrest and CPR duration below 10 minutes (for aortic cross-clamping) (1 mark)

Alternative acceptable answers: Massive air embolism from penetrating lung injury; Exsanguinating intrathoracic hemorrhage with loss of vital signs

b) List FOUR absolute contraindications to resuscitative thoracotomy (4 marks)

Model Answer:

1. Blunt trauma with cardiac arrest and no signs of life at any point (1 mark)
2. Prolonged CPR (greater than 15 minutes for penetrating trauma or greater than 10 minutes for blunt trauma) (1 mark)
3. Asystole in blunt trauma mechanism (1 mark)
4. Obviously non-survivable injuries (e.g., decapitation, massive cranial destruction) (1 mark)

Alternative acceptable answers: Pre-existing terminal illness with documented DNR; Profound hypothermia (relative contraindication, but may be listed as absolute in exam context)

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Question 2: Procedure Technique (10 marks)

Stem: You have decided to perform a left anterolateral resuscitative thoracotomy on a patient with a penetrating cardiac injury and cardiac arrest.

Describe the key steps of the procedure (10 marks)

Model Answer:

1. Incision (1 mark):

   • Left 5th intercostal space (sub-nipple in males, inframammary fold in females)
   • From lateral sternal border to mid-axillary line
   • Deep single stroke through skin, subcutaneous tissue, and muscle

2. Entry to pleural space (1 mark):

   • Incise intercostal muscles along superior border of 6th rib (avoiding neurovascular bundle)
   • Enter pleural cavity with scissors or scalpel

3. Rib spreading (1 mark):

   • Insert Finochietto rib retractor with handle toward axilla
   • Spread ribs widely (6-8 cm) - rib fractures acceptable

4. Evacuate blood (1 mark):

   • Remove blood and clot from pleural space with suction or manual scooping

5. Identify phrenic nerve (1 mark):

   • Locate phrenic nerve on lateral pericardium, running anterior to lung hilum
   • Must identify BEFORE cutting pericardium

6. Pericardiotomy (2 marks):

   • Incise pericardium longitudinally, at least 2 cm anterior to phrenic nerve
   • Extend from cardiac apex to great vessels
   • Evacuate pericardial blood (relieves tamponade)

7. Assess and control cardiac injury (2 marks):

   • Inspect heart, identify wounds
   • Temporary control: digital pressure or Foley catheter balloon tamponade
   • Definitive repair: 2-0 or 3-0 Prolene horizontal mattress sutures with Teflon pledgets

8. Internal cardiac massage (1 mark):

   • Two-handed technique compressing heart antero-posteriorly at 100-120/min
   • Monitor for return of spontaneous circulation

Half marks accepted for partial descriptions. Award full marks for comprehensive, well-structured answer demonstrating procedural understanding.

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Question 3: Aortic Cross-Clamping (6 marks)

Stem: During a resuscitative thoracotomy for multiple abdominal stab wounds, you decide to cross-clamp the descending aorta.

a) List THREE indications for aortic cross-clamping during resuscitative thoracotomy (3 marks)

Model Answer:

1. Suspected intra-abdominal hemorrhage (penetrating abdominal injury or blunt abdominal trauma) (1 mark)
2. Exsanguinating sub-diaphragmatic hemorrhage requiring temporary control (1 mark)
3. To redistribute available blood volume to coronary and cerebral circulation (increase afterload) (1 mark)

Alternative acceptable answers: Pelvic hemorrhage; Retroperitoneal hemorrhage

b) Describe THREE potential complications of aortic cross-clamping (3 marks)

Model Answer:

1. Visceral ischemia (1 mark): Renal failure, hepatic injury, intestinal ischemia if clamp time greater than 45-60 minutes
2. Spinal cord ischemia (1 mark): Paraplegia from prolonged occlusion of intercostal arteries supplying anterior spinal artery
3. Ischemia-reperfusion injury (1 mark): Cardiovascular collapse, arrhythmia, or cardiac arrest upon clamp release due to washout of acidotic, hyperkalemic blood from lower body

Alternative acceptable answers: Esophageal injury if esophagus included in clamp; Aortic injury from clamp application; Lower limb ischemia and compartment syndrome

Common Mistakes:

• Stating "hemorrhage" as a complication (hemorrhage is the indication, not a complication of clamping)
• Not specifying time-dependent nature of visceral and spinal cord ischemia
• Confusing immediate vs delayed complications

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Question 4: Survival and Prognostication (6 marks)

Stem: A trauma fellow asks you about the expected survival rates for resuscitative thoracotomy.

Provide survival statistics for the following scenarios (6 marks):

a) Penetrating thoracic trauma with signs of life (2 marks)

Model Answer:

• Overall survival: 15-21% (1 mark)
• Penetrating cardiac stab wounds specifically: 20-30% (highest survival group) (0.5 mark)
• Neurologically intact survival: 3-5% overall, but majority of survivors have good neurological function (80% of survivors are neurologically intact) (0.5 mark)

b) Blunt trauma with signs of life (2 marks)

Model Answer:

• Overall survival: 2-4.6% (1 mark)
• Neurologically intact survival: below 2% (1 mark)

c) Blunt trauma without signs of life (2 marks)

Model Answer:

• Overall survival: below 1% (0.5-0.7%) (1 mark)
• Neurologically intact survival: Essentially 0% (1 mark)
• Strong recommendation AGAINST resuscitative thoracotomy in this group per EAST guidelines (no additional mark, but demonstrates understanding)

Common Mistakes:

• Confusing survival rates between penetrating and blunt mechanisms
• Not distinguishing between overall survival and neurologically intact survival
• Providing overly optimistic survival estimates
• Not recognizing that blunt trauma without SOL is essentially futile

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Australian Context

ACEM Credentialing

Credential Level: Extended Skill

• Not a core ED procedure for all emergency physicians
• Requires specific training, competency assessment, and maintenance
• Typically performed by FACEM with trauma interest or trauma surgeons

Training Requirements (ACEM Standards):

1. Formal training in resuscitative thoracotomy technique
2. Supervised procedures (minimum 3-5 under direct supervision)
3. Cadaver or simulation training
4. Annual skills maintenance (simulation)
5. Participation in trauma team training
6. Understanding of EAST and ARC guidelines

Supervision Requirements:

• Junior registrars: must have consultant supervision
• Senior registrars: may perform independently if credentialed
• FACEM: independent practice if credentialed and current

Logbook Requirements:

• Document all resuscitative thoracotomies performed
• Include: indication, technique, findings, outcome
• Required for credential maintenance
• Audit outcomes annually

Hospital Credentialing:

• Major trauma centres: ED consultants may be credentialed
• Regional/rural hospitals: may not have credentialed providers (retrieval considerations)
• Private hospitals: rarely performed (trauma patients go to public trauma centres)

Australian Guidelines

ANZCOR Guideline 11.7: Resuscitative Thoracotomy

• Published 2023 (updated from 2016 version)
• Aligned with EAST practice management guidelines
• Key recommendations:
  • "Penetrating thoracic trauma with SOL: perform RT"
  • "Blunt trauma with SOL: conditional recommendation (consider RT)"
  • "Blunt trauma without SOL: strong recommendation AGAINST RT"
  • "Time windows: below 15 min penetrating, below 10 min blunt"
  • Procedure should be performed by trained personnel
  • Institutions should have protocols and equipment ready

National Trauma Registry (Australia and New Zealand):

• Collects data on all major trauma (ISS greater than 12)
• Includes resuscitative thoracotomy outcomes
• 2022 data: RT performed in 0.5% of major trauma cases
• Survival: 8% overall (12% penetrating, 3% blunt)

State Trauma Systems:

• NSW: Institute of Trauma and Injury Management (ITIM) guidelines
• Victoria: Victorian State Trauma System (VSTS) guidelines
• Queensland: Queensland Trauma Network guidelines
• All align with ANZCOR and EAST recommendations

Australian Trauma Statistics

Penetrating Trauma in Australia:

• Less common than blunt trauma (10-15% of major trauma vs 85-90% blunt)
• Urban centres: higher rates (assaults, stabbings)
• Rural/remote: lower rates, but longer transport times
• Indigenous Australians: 3-4x higher rates of penetrating trauma

Resuscitative Thoracotomy in Australian Context:

• Performed in major trauma centres (metropolitan and some regional)
• Less commonly performed than in USA (lower penetrating trauma rates)
• Outcomes similar to international literature when performed for appropriate indications

Retrieval Services:

• NSW: CareFlight, Westpac Rescue Helicopter, NSW ECLS
• Queensland: QFRS, RACQ LifeFlight
• Victoria: Air Ambulance Victoria (AV), ECMO retrieval (VECMOS)
• South Australia: MedSTAR
• Western Australia: RFDS, RAC Rescue
• Northern Territory: RFDS (extensive coverage)

Resource Considerations

Metropolitan vs Regional:

RFDS Considerations:

• Covers 7.69 million square kilometers
• Average response time: 60-120 minutes (highly variable by location)
• Can carry limited blood products (pre-arranged)
• May have surgical capability on retrieval team (varies)
• Coordination essential for remote RT (call early, provide updates)

Telemedicine Support:

• Available in many remote hospitals (video consult with tertiary centre)
• Can provide guidance during RT if needed
• Limited by connectivity (satellite can be slow/unreliable)
• Useful for post-ROSC management advice

Indigenous Health Considerations

Epidemiology:

• Aboriginal and Torres Strait Islander Australians: 3-4x higher trauma rates
• Higher rates of penetrating trauma (assault, domestic violence)
• Poorer outcomes (higher mortality, more complications)
• Barriers to care: geography, socioeconomic factors, cultural factors

Cultural Safety:

• Involve Aboriginal Liaison Officer
• Respect kinship and family structures
• Gender considerations in care delivery
• Traditional healing practices (complementary to Western medicine)
• Historical trauma and mistrust of healthcare system

Communication:

• May require interpreter even if patient speaks English
• Avoid medical jargon
• Allow time for family discussion
• Respect cultural protocols around discussing deceased

Post-Procedure Care:

• Cultural considerations in end-of-life care
• Support for family (extended kinship group)
• Mortuary practices and rituals
• Follow-up and rehabilitation (may need to return to remote community)

Māori Considerations (New Zealand):

• Whānau (extended family) involvement in decision-making
• Tikanga (cultural protocols) in healthcare
• Manaakitanga (hospitality, care) as core value
• Karakia (prayer) may be important
• Similar trauma disparities to Aboriginal Australians

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 11.7: Resuscitative Thoracotomy. 2023. Available from: https://www.resus.org.au
2. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(3):475-86. PMID: 26356870
3. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-63. PMID: 22353771
4. National Trauma Registry of Australia and New Zealand. Annual Report 2022. Melbourne: Alfred Health; 2023.

Landmark Studies

5. Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190(3):288-98. PMID: 10920271
6. Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006;1:4. PMID: 16418698
7. Sheppard FR, Cothren CC, Moore EE, et al. Emergency department resuscitative thoracotomy for penetrating injuries: a review of published literature. J Trauma. 2005;58(5):1027-31. PMID: 15920421
8. Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A. Emergency thoracotomy: "how to do it". Emerg Med J. 2005;22(1):22-24. PMID: 15611534

Outcomes and Survival

9. Moore EE, Knudson MM, Burlew CC, et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011;70(2):334-9. PMID: 21307732
10. Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results. J Trauma. 2011;70(5):E75-8. PMID: 21150512
11. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-63. PMID: 22353771
12. Powell DW, Moore EE, Cothren CC, et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg. 2004;199(2):211-5. PMID: 15275876
13. Branney SW, Moore EE, Feldhaus KM, Wolfe RE. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma. 1998;45(1):87-94. PMID: 9680017

Technique and Anatomy

14. Torloni MR, Vedmedovska N, Merialdi M, et al. Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis. Ultrasound Obstet Gynecol. 2009;33(5):599-608. PMID: 19291813
15. Wall MJ Jr, Villavicencio RT, Miller CC 3rd, et al. Pulmonary tractotomy as an abbreviated thoracotomy technique. J Trauma. 1998;45(6):1015-23. PMID: 9867041
16. Wall MJ Jr, Hirshberg A, LeMaire SA, Holcomb JB, Mattox KL. Thoracic aortic and thoracic vascular injuries. Surg Clin North Am. 2001;81(6):1375-93. PMID: 11766181
17. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma-a review. Injury. 2006;37(1):1-19. PMID: 16410079
18. Tisherman SA, Schmicker RH, Brasel KJ, et al. Detailed description of all deaths in both the shock and traumatic brain injury hypertonic saline trials of the Resuscitation Outcomes Consortium. Ann Surg. 2015;261(3):586-90. PMID: 25072443

Specific Procedures

19. Wall MJ Jr, Hirshberg A, Mattox KL. Pulmonary tractotomy with selective vascular ligation for penetrating injuries to the lung. Am J Surg. 1994;168(6):665-9. PMID: 7978015
20. Asensio JA, Berne JD, Demetriades D, et al. One hundred five penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma. 1998;44(6):1073-82. PMID: 9637165
21. Feliciano DV, Bitondo CG, Mattox KL, et al. A four-year experience with splenectomy versus splenorrhaphy. Ann Surg. 1985;201(5):568-75. PMID: 3994000
22. Ivatury RR, Rohman M, Steichen FM, Gunduz Y, Nallathambi MN, Stahl WM. Penetrating cardiac injuries: twenty-year experience. Am Surg. 1987;53(6):310-7. PMID: 3592070

Aortic Cross-Clamping

23. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-63. PMID: 22353771
24. Ledgerwood AM, Kazmers M, Lucas CE. The role of thoracic aortic occlusion for massive hemoperitoneum. J Trauma. 1976;16(8):610-5. PMID: 957137
25. Moore EE. Resuscitative thoracotomy redux. J Trauma Acute Care Surg. 2015;79(3):351-2. PMID: 26307867
26. Brenner M, Bulger EM, Perina DG, et al. Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Trauma Surg Acute Care Open. 2018;3(1):e000154. PMID: 29766137

Complications

27. Wall MJ Jr, Hirshberg A, Mattox KL. Pulmonary tractotomy with selective vascular ligation for penetrating injuries to the lung. Am J Surg. 1994;168(6):665-9. PMID: 7978015
28. Asensio JA, Arroyo H Jr, Veloz W, et al. Penetrating esophageal injuries: time interval of safety for preoperative evaluation--how long is safe? J Trauma. 2001;50(2):289-93. PMID: 11242295
29. Feliciano DV. Everything you wanted to know about emergency department thoracotomy. Surgeon. 2010;8(6):333-7. PMID: 20950771
30. Lockey DJ, Lyon RM, Davies GE. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation. 2013;84(6):738-42. PMID: 23200993

Paediatric

31. Powell RW, Gill EA, Jurkovich GJ, Ramenofsky ML. Resuscitative thoracotomy in children and adolescents. Am Surg. 1988;54(3):188-91. PMID: 3348522
32. Rothenberg SS, Moore EE, Moore FA, Baxter BT, Moore JB, Cleveland HC. Emergency Department thoracotomy in children--a critical analysis. J Trauma. 1989;29(10):1322-5. PMID: 2810409
33. Sheikh AA, Culbertson CB. Emergency department thoracotomy in children: rationale for selective application. J Trauma. 1993;34(3):323-8. PMID: 8483170

Australian Context

34. Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg. 2006;244(3):371-80. PMID: 16926563
35. Curtis K, Caldwell E, Delprado A, Munroe B. Traumatic injury in Australia and New Zealand. Australas Emerg Nurs J. 2012;15(1):45-54. PMID: 22373643
36. Cameron PA, Gabbe BJ, Cooper DJ, Walker T, Judson R, McNeil J. A statewide system of trauma care in Victoria: effect on patient survival. Med J Aust. 2008;189(10):546-50. PMID: 19012550
37. Beck B, Cameron P, Lowthian J, et al. Major trauma in older persons. BJS Open. 2018;2(5):310-318. PMID: 30263971

Indigenous Health

38. Möller H, Falster K, Ivers R, Jorm L. Inequalities in hospitalised injury between Aboriginal and non-Aboriginal Australians: a population-based record linkage study. BMJ Open. 2015;5(7):e006776. PMID: 26169810
39. Möller H, Falster K, Ivers R, Jorm LR. Disparities in unintentional injuries between Aboriginal and non-Aboriginal children: a systematic review. Inj Prev. 2015;21(e1):e144-52. PMID: 24944343
40. Randall DA, Lujic S, Leyland AH, Jorm LR. Statistical methods to enhance reporting of Aboriginal Australians in routine hospital records using data linkage affect estimates of health disparities. Aust N Z J Public Health. 2013;37(5):442-9. PMID: 24090327

Retrieval Medicine

41. Laan DV, Vu EN, Thiels CA, et al. Chest wall injuries after blunt trauma: A review. J Trauma Acute Care Surg. 2016;80(4):696-704. PMID: 26808039
42. Sherren PB, Reid C, Habig K, Burns BJ. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care. 2013;17(2):308. PMID: 23566599