What are the steps to perform a thoracotomy in an emergency situation?

Step-by-Step Instructions for Emergency Finger Thoracotomy

Emergency finger thoracotomy is a potentially life-saving procedure that should be performed immediately for patients with penetrating thoracic trauma who are in cardiac arrest or have impending cardiac arrest, as it offers survival rates of 7-21% when performed correctly and promptly. 1

Indications

• Penetrating thoracic trauma with:
  • Cardiac arrest (duration less than 15 minutes)
  • Impending cardiac arrest
  • Pericardial tamponade
  • Massive hemothorax with shock
  • Tension pneumothorax not responding to needle decompression

Required Equipment

• Sterile gloves
• Antiseptic solution
• Scalpel (#10 blade)
• Kelly clamps or large forceps
• Chest tube (if available)
• Rib spreader (if available)

Anatomical Landmarks

• For left-sided approach (preferred): 4th or 5th intercostal space, mid-axillary to anterior axillary line
• For right-sided approach: Same location on right side (less common)

Procedure Steps

1. Position the patient supine with arm abducted to 90 degrees

2. Identify the correct intercostal space (4th or 5th) at the mid-axillary to anterior axillary line

   • The 4th intercostal space is typically at nipple level
   • The 5th intercostal space is just below nipple level

3. Prepare the area with antiseptic solution if time permits

4. Make a 5-7 cm incision along the upper border of the lower rib of the chosen intercostal space

   • This avoids the neurovascular bundle which runs along the lower edge of each rib

5. Bluntly dissect through subcutaneous tissue using Kelly clamps

6. Penetrate the intercostal muscles with the tip of the scalpel or Kelly clamp

7. Extend the opening by spreading the Kelly clamps or forceps

8. Insert your finger into the pleural space

   • Feel for adhesions or obstructions
   • Listen for air escape (pneumothorax) or observe blood drainage (hemothorax) 2

9. Perform digital exploration:

   • For pericardial tamponade: Feel anteriorly and medially for the pericardium
   • For tension pneumothorax: Break up any adhesions to allow air release
   • For hemothorax: Allow blood to drain

10. If pericardial tamponade is suspected:

    • Extend the incision anteriorly if needed
    • Locate and incise the pericardium anterior to the phrenic nerve
    • Evacuate blood clots
    • Perform digital cardiac massage if needed

11. For resuscitative purposes:

    • Consider extending to a full thoracotomy if necessary
    • The left-sided incision or clamshell approach can be used to open the chest fully
    • Open the pleura and pericardium
    • Clamp the injured aorta if needed
    • Perform intrathoracic CPR 1

12. Insert chest tube if available, or leave the incision open temporarily if chest tube not available

Post-Procedure Management

• Continue resuscitation efforts
• Prepare for immediate transfer to operating room if successful
• Monitor for air leaks, continued bleeding
• Administer antibiotics
• Prepare for definitive surgical repair

Potential Complications

• Injury to intercostal vessels
• Lung parenchymal injury
• Infection
• Damage to internal thoracic structures
• Ineffective decompression

Effectiveness and Outcomes

• Survival rates for penetrating thoracic trauma after emergency thoracotomy: 7-21% 1
• Higher success rates in patients who:
  • Lose vital signs for less than 45 minutes
  • Have stab wounds (15.2% survival) versus gunshot wounds (7.3% survival) 1
  • Receive the procedure within 15 minutes of cardiac arrest 1

Cautions

• The procedure should be performed by trained personnel when possible
• Universal precautions must be taken due to blood exposure risk
• The procedure has very low success rates in blunt trauma (1-2%) 3
• Consider the risk-benefit ratio before performing in patients with prolonged cardiac arrest

This life-saving procedure should be performed without delay in appropriate circumstances, as studies show that rapid intervention for penetrating thoracic trauma can significantly improve survival outcomes when performed correctly and for the right indications.