Emergent Thoracotomy (Trauma)
Patient phenotype
Penetrating chest trauma + signs of life lost in ED or shortly after. Massive hemothorax > 1500 mL. Pericardial tamponade. Cardiac wound. Often arrest or peri-arrest. Surviving rate < 10% overall, < 1% in blunt trauma.
Procedure
Left anterolateral thoracotomy (or clamshell if right-sided pathology). Cross-clamp descending aorta, open pericardium, repair cardiac/vessel wound, internal cardiac massage, defibrillation. Time-critical.
Anesthetic plan
GETA — already intubated in ED usually. Massive transfusion. Multiple drips. Crash induction if not yet intubated: ketamine + roc.
Setup
- ·MTP activated PRE-arrival
- ·2× 16-gauge PIVs OR central rapid infusion catheter
- ·A-line (often femoral — already in place from ED)
- ·Rapid infuser primed
- ·Cell saver
- ·TXA, calcium, bicarb available
- ·Defibrillator + internal paddles
- ·Forced air warmer + fluid warmer
Biggest concerns by phase
Time-critical — deploy faster than think
Indications: penetrating chest trauma + signs of life lost within 15 min OR refractory shock + suspected cardiac/aortic source. Don't wait for full setup. 'Get there with what you have.'
Crash induction in arrest or peri-arrest
If already arrested: skip induction, intubate. Peri-arrest: ketamine 0.5 mg/kg + roc 1.2 mg/kg. Etomidate alternative. Don't worsen hypotension.
Cross-clamping + reperfusion physiology
Aortic cross-clamp = profound LV afterload increase, may unmask LV failure. Unclamping → hyperkalemia, acidosis, hypotension (washout from ischemic lower body). Anticipate: bicarb, calcium, vasopressor, slow unclamp.
Massive transfusion management
1:1:1 ratio, calcium with every 4 units, TEG/ROTEM if available. TXA 1g if within 3h of injury. Watch ionized Ca, K (rises with old PRBC), acid-base.
Hypothermia in trauma + open chest
Aggressive warming: warm fluids, BAIR all surfaces, room temp up. Hypothermia → coagulopathy + arrhythmia.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
25-yo M, single GSW to L chest, brought to ED with weak pulse, BP 60/palp, intubated by EMS. ED team starts thoracotomy. You arrive. Plan?
What an examiner probes for
- ▹Activates MTP, gets large-bore access
- ▹Confirms ETT, ventilation
- ▹Anticipates cross-clamp physiology
- ▹Manages MTP + electrolytes
- ▹Plans transition to OR for definitive repair
Sources
- EAST Resuscitative Thoracotomy Guidelines 2015
- ATLS 10e
Anatomy reference
Sourced reference images. 4 matches for "thorax chest heart".
Browse the full image library →
