Review Note
Last Update: 02/20/2025 02:50 AM
Current Deck: ACG Part 2::Thoracic SSU
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Commit #286287
SS_TS 1.13 Discuss the anaesthetic management of the following procedures :
- Thoracospy and throactomy for :
Bleeding
- Thoracospy and throactomy for :
Bleeding
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Commit #286287- Resuscitative thoracotomy (RT) is an immediate thoracotomy carried out on patients who are in a ‘peri-arrest’ state or in established cardiac arrest, usually after trauma. To have a reasonable chance of survival, the procedure must be performed rapidly, and for this reason, it is frequently conducted outside the operating theatre.
Indication for RT:
- Ideally performed by cardiothoracic surgeon in operating room however usually performed during arrest or peri-arrest for penetrating trauma so mostly performed by non-surgerons, out of theatre
- Penetrating chest trauma who is either in a peri-arrest state (who would not tolerate transfer to an operating theatre) or who has been in established cardiac arrest for a short period of time
- Wounds to epigastrium, which may breach the thoracic cavity, and axillary and posterior thoracic wounds
- Patients who have signs of life after blunt trauma
- When: RT performed Before 15 min of cardiopulmonary resuscitation (CPR) in penetrating trauma and 10 min following blunt trauma otherwise is unlikely to be successful
- Signs of life include pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable arterial pressure, extremity movement, or cardiac electrical activity
Anaesthesia considerations:
- Usually team member or leader of trauma/arrest call
- If performed during an arrest no anaesthetic agent required for thoracotomy
- If periarrest RSI + ETT as for ruptured AAA - often small dose fentanyl, ketamine + roc
- As patient wakes/acheives ROSC may require anaesthetic agent
- Ketamine with an initial dose of approximately 1 mg kg1 is often given i.v.; lower doses may be indicated if there is severe cardiovascular compromise
- When ROSC occurs anaesthetic goals:
- Correction of hypovolaemia with blood products and treatment with tranexamic acid 2g
- Vasopressors as needed
- A balanced transfusion protocol of packed red blood cells to fresh frozen plasma in a ratio of 1:1 with additional cryoprecipitate and platelets is usually indicated as part of local major haemorrhage protocols.
- Pointof-care coagulation testing can be used to guide product use.
- Patients requiring massive transfusion often require correction of electrolyte imbalances (e.g. hyperkalaemia and hypocalcaemia).
- The use of a warmed rapid infuser is essential as these patients are often profoundly hypothermic
- Disposition: Will often require definitive surgery so often straight to theatre, ICU will need to be involved post-op
- Management of postoperative traumatic injury and postcardiac arrest brain injury, combined with the response to systemic ischaemia and reperfusion.
- Myocardial dysfunction may result from cardiac hypoperfusion, direct cardiac injury or coronary artery injury (either from penetrating trauma or cardiac repair).
Post-RT/other:
- OT/ICU
- Hot debrief - explanation and reassurance to all staff of why the intervention was carried out and also identify opportunities for improvement
- Penetrating trauma often results in criminal investigation, and although treatment is the priority, the operating team should be aware of forensic considerations, including preservation of clothing, possessions and other evidence. Meticulous documentation is necessary, and statements for the police and (in England and Wales) the coroner are often required.
- Resuscitative thoracotomy should always be subject to trauma network governance process. A standard operating procedure should be produced and appropriate training and standardised equipment in place. The standard operating procedure and equipment should be developed by a group, which includes representatives from all relevant groups, including cardiothoracic surgery.
- The risks to providers include sharps injuries from fractured ribs, needles, surgical instruments, and blood splash contamination. The use of adequate personal protective equipment and keen awareness of sharps are mandatory. Risks can be reduced by having only the operator’s hands in the operating field whenever possible.
https://www.bjaed.org/action/showPdf?pii=S2058-5349%2820%2930046-9