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10 Fluids, Blood Substitutes, andNew Tools
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83
relative hypotension and minimally acceptable degrees of
perfusion until denitive hemorrhage control. Rationale for
this strategy is rooted in the ATLS guidelines that hemorrhage control is the most important management strategy and
that over-resuscitation leads to further coagulopathy and
bleeding. Current EAST guidelines address this strategy
with only level III evidence advocating that uid be withheld
until active bleeding is managed or titrated with 250 mL
boluses to a palpable radial pulse. Currently there is no formal denition of what constitutes permissive hypotension as
some state systolic blood pressure (SBP) at 90 mmHg or
>70mmHg while others advocate for a mean arterial pressure (MAP) of 50mmHg. It is important to emphasize that
permissive hypotension is appropriate for penetrating trauma
but should not be employed for specic subgroups like those
with TBI or the elderly.
Bickell completed a landmark trial evaluating delayed uid
versus standard uid resuscitation in penetrating torso injuries. Patients either received standard IV uid or no IV uid
until reaching the operating room. Of the 598 patients, there
was signicant improved survival as well as shorter hospital
stay in the delayed IV uid group. This study has been criticized regarding selection bias as its randomization method of
alternate days is suited to the difcult prehospital environment
but is not really random. Several later studies have found no
difference in mortality based on the volume of prehospital
resuscitation. A retrospective analysis from USC/LA County
reexamined the question and found no difference in mortality
based on the volume of prehospital uids administered.
Another series of mixed mechanism patients from Maryland
Shock Trauma failed to nd any difference in mortality
between a conventional resuscitation and a permissive hypotension group. A cost-effectiveness meta-analysis from Britain
found no benet or savings to the use of prehospital uids but
only examined four clinical trials and found methodological
aws in most of them. The body of literature to support delaying denitive resuscitation until after source control of hemorrhage is obtained although most of it is animal models.
10.7 Conclusion
Fluid management in the injured is one the most important
and not surprisingly controversial topics in the eld of traumatology. Mainstream guidelines emphasize the need for
rapid, denitive hemorrhage control and a shift toward blood
products away from crystalloids early in the resuscitation.
The use of blood substitutes may be warranted in austere
environments and during blood shortages. The preferred
ratio for component therapy is 1:1:1; however, whole blood
appears to be emerging as the optimal resuscitation strategy
instead of component therapy for massive transfusion.
Important Points
• The cornerstone of treating hemorrhage is to stop the
source of bleeding.
• Initial resuscitation with isotonic crystalloids should be
considered if blood products are not available or if the
patient has class I hemorrhagic shock without ongoing
bleeding.
• Hypertonic solutions do not appear to be superior to isotonic solutions in terms of overall mortality.
• Only specic blood substitutes provide similar outcomes
to the current standard of care.
• Increasing the plasma/platelets/RBC ratio to 1:1:1 is
associated with improved lower early deaths due to
hemorrhage.
• TEG should be used when available to guide resuscitation
during acute traumatic blood loss.
• Whole blood may yield improved early survival in massive transfusion compared to component therapy.
• Tranexamic acid and FFP are useful pre-hospital adjuncts
that have been shown to decrease early mortality.
• Autotransfusion devices are an important adjunct to massive transfusion to provide rapid restoration of red cell
mass when blood supplies become exhausted.
10.6.1 Elderly Population
Traditionally the trauma population is younger, particularly
those involved in penetrating injuries. Therefore, limited experience is available with permissive hypotension in the elderly.
Using the National Trauma Data Bank, Bridges etal. retrospectively evaluated the interaction between permissive hypotension and age. Elderly were 66 ± 0.6 and had a greater
overall mortality (35.1–29%) when compared with younger
population. Though previous literature has shown increased
mortality in elderly patients with SBP less than 110, this study
demonstrated no interaction between age and SBP, suggesting
that permissive hypotension in the elderly may be safe.
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Emergency Department Thoracotomy
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SiminGolestani, AustinEagleton, andCarlosV.R.Brown
11
Emergency Department Thoracotomy (EDT), also known as
resuscitative thoracotomy, can be used as an adjunct during
the resuscitation of penetrating trauma patients who have
sustained a cardiac arrest. EDT should be performed liberally in penetrating trauma patients who fall into specic categories, particularly those with a suspected cardiac injury or
cardiac tamponade. Appropriate preparation of personnel
and equipment is required to perform EDT in a safe and efcient manner. EDT provides the opportunity to release cardiac tamponade, repair cardiac injuries, cross-clamp the
descending thoracic aorta to improve cerebral and coronary
perfusion during resuscitation, control hemorrhage within
the chest, and perform internal cardiac massage and debrillation. This chapter will focus on the indications, preparation, equipment, and technique for EDT in penetrating
trauma patients, as well as discuss the effects of specic circumstances on the decision to perform an EDT.
11.1 Background
Since its rst application in the late 1800s, there continues to
be controversy surrounding the role of EDT in the management of trauma patients. There are clearly select patients
who will benet from liberal use of EDT, particularly in the
setting of penetrating trauma with recent loss of pulses.
11.1.1 Safety
Clear indications for the use of EDT are required as resource
utilization and health care provider safety are major concerns. Injuries from sharp instruments, as well as the higher
rate of bloodborne pathogens seen in trauma patients, make
this a high-risk procedure that should only be performed by
trained personnel.
11.1.2 Training
As EDT is infrequently performed, the opportunities for
training are limited, particularly for physicians who are less
familiar with thoracic procedures. Training that combines
didactic learning with simulation training is necessary to
allow trainees the opportunity to walk through the steps of
the thoracotomy in a controlled, non-emergent setting. New
realistic simulations and focused courses have been found to
be effective in preparing trainees for performing thoracotomy procedures independently when indicated. These simulation models can be as simple as a mannequin with plastic
internal organs or high-delity simulations with beating
hearts. Both of these models have the ability to increase
condence and familiarity of physicians with performing
EDTs.
S. Golestani (*)
General Surgery Residency, Dell Medical School, University of
Texas at Austin, Austin, TX, USA
e-mail: Simin.Roward@ascension.org
A. Eagleton
Department of Surgery, University of Texas at Tyler Health
Science Center, Tyler, TX, USA
C. V. R. Brown
Division of Acute Care Surgery, Dell Medical School, University
of Texas at Austin, Austin, TX, USA
e-mail: Carlos.Brown@austin.utexas.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_11
11.1.3 Indications
In 2001, the American College of Surgeons—Committee on
Trauma developed practice management guidelines for EDT
and published several evidence-based Level II recommendations. The indications for patient selection and patient survival
have been continually evaluated, and both the Eastern
Association for the Surgery of Trauma (EAST) and the Western
Trauma Association (WTA) have produced updated recommendations on patient selections for EDT based on injury mechanism and location and presence of signs of life. Per EAST
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S. Golestani et al.
guidelines, pulseless patients with thoracic penetrating trauma
and signs of life (pupillary response, spontaneous ventilation,
carotid pulse, measurable blood pressure, extremity movement,
or cardiac electrical activity) should undergo a thoracotomy. In
patients with blunt injuries without any sign of life thoracotomy
was recommended against. For all other patients, conditional
recommendations were given to proceed with EDT. The Western
Trauma Association also concluded that timing of initiation of
cardiopulmonary resuscitation is often a guiding factor for
whether to proceed with EDT.EDT is considered futile when
CPR exceeds 10min for blunt trauma or 15min for penetrating
trauma. Penetrating neck or extremity wounds with greater than
15min of CPR also indicates non- salvageability. Other centers
have more restrictive practices for blunt mechanisms and proceed with EDT only for patients with CPR ongoing <5min or
witnessed cardiac arrest.
Historically, overall survival has been quite poor following EDT (5–10%). Mortality after EDT is largely dependent
on the mechanism and location of injury, as well as evidence
of prehospital signs of life. Survival after EDT for blunt
trauma was dismal and usually <1% while survival after penetrating trauma was improved at about 10% and higher for
stab wounds (~15%) than for gunshot wounds (~5%).
Furthermore, while patients with injuries to multiple body
regions had a survival close to zero, patients with isolated
abdominal, thoracic, and particularly cardiac injuries had
reasonable survival rates of about 5%, 10%, and 20%,
respectively, after EDT.
Recent metanalyses have shown that although still low,
the survival rate for thoracotomy patients is now higher than
previously reported. Overall rates are now closer to 19.9–
29%, with stab wounds again showing a higher likelihood of
survival than gunshot wounds (stab wounds 45.6% vs. gunshot wounds 18.7%). Blunt trauma continues to have low
survival at 7.6% and almost no return of spontaneous circulation in the emergency department.
11.1.4 Focused Assessment withSonography
forTrauma (FAST)
The FAST exam contributes important information to the
decision to perform an EDT, and as such the ability to perform an accurate and rapid cardiac FAST is an important
skill. In patients who present with no signs of life, if the
FAST exam shows no cardiac activity, it conrms that the
patient will have no survival benet with the performance of
an EDT.The cardiac view of the FAST exam will also show
the presence of cardiac tamponade, which can be relieved
with an EDT with potential life-saving outcomes. Despite
the information the cardiac FAST exam can provide, it does
not necessarily predict survival in those ultimately undergoing EDT, regardless of cardiac wall motion. Following an
EDT, there is still a role for an abdominal fast exam, which
can determine the need for an exploratory laparotomy with
high sensitivity.
11.1.5 Resuscitative Endovascular Balloon
Occlusion oftheAorta (REBOA)
The recent development and increased use of REBOA for
aortic occlusion has brought into question the use of EDT
solely for the purpose of aortic occlusion. For select groups
of hypotensive patients with blunt or penetrating trauma
without cardiac tamponade, REBOA may be a useful tool. In
non-thoracic penetrating trauma patients specically,
REBOA has the possibility of being benecial in 38.6% of
patients. REBOA is contraindicated in the setting of a penetrating chest injury or when an obvious cardiac or thoracic
injury is suspected. Although more research is indicated,
some studies have evaluated EDT in comparison to REBOA
in abdominal hemorrhage and have found REBOA to be
associated with lower mortality. Additionally, in a small
group of patients receiving REBOA, the rate of spontaneous
circulation was higher in comparison to those receiving open
chest cardiac massage. The bias in patient selection between
REBOA and EDT patients brings the validity of any research
result into question. The role of the REBOA in the management of trauma patients in cardiac arrest continues to evolve.
The decision to perform an EDT or place a REBOA must be
made based on individual patient characteristics and
injuries.
11.1.6 Organ Donation
Even if a patient does not survive to discharge post EDT,
occasionally they are able to become organ donors and save
the lives of many patients on the transplant list. The rate of
organ donation in trauma patients has historically been low.
In patients who undergo an EDT, 2–4% of them have the
potential to become organ donors. Any decision to perform
an EDT should be done with the goal of resuscitating the
patient while following all institutional algorithms, so that
once the stage of organ procurement is reached, it is done
ethically and without any conict of interest. The most common organs donated by patients post EDT are kidneys, followed by livers. Depending on the nature of the injuries,
heart and lung transplants are also possible.
11.1.7 Special Considerations
Both pediatric and geriatric patients warrant special consideration for EDT.For all adult patients, liberal use of EDT should
11 Emergency Department Thoracotomy
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be undertaken in patients who meet criteria. The effect of
advanced age on outcomes of EDT is varied, a multicenter
analysis has found that age is not a predictor of mortality.
However, previous studies have shown that age is an independent predictor of mortality in patients over 60, and that there is
100% futility in patients over the age of 57. Pediatric patients
between the ages of 15 and 18 should undergo similar treatment algorithm to that of adults. Patients between the ages of
0 and 14 who have suffered a blunt thoracic injury have been
shown to have extremely low rates of survival, even with witnessed loss of pulses. In these cases, withholding EDT should
be considered due to lack of benet.
The indications for an EDT remain the same in a pregnant
patient, as the primary goal should be resuscitation of the
mother. If the fetus is viable, a concurrent EDT and Cesarian
section can be performed, as perimortem C sections should
be performed within 4min of cardiac arrest. Although there
is high mortality and low survival of the fetus with these procedures, survival of both the mother and the fetus have been
described in limited case reports.
11.2 Preparation
EDT requires preparation of both personnel and equipment
and requires a team approach to be carried out in an organized and efcient manner. All health care providers (technicians, nurses, emergency medicine physicians, and surgeons)
involved in the care of a patient requiring an EDT need to be
familiar with the basic maneuvers before and during the procedure. This preparation may come in the form of didactic
education, patient simulations, or potentially with experience during previous EDTs. Keeping all physicians and staff
safe during the procedure is important, and all non- essential
personnel should be advised to stay away from sharps and
blood exposure. Furthermore, the individual performing the
EDT must be prepared to identify and repair injuries within
the chest as well as provide resuscitative maneuvers during
EDT. If personnel and resources are not available, and/or
there is no individual willing or able to perform maneuvers
required during EDT, then this procedure should not be part
of the resuscitative plan.
11.3 Equipment
If the personnel are available and capable of performing an
EDT, then the necessary equipment should be readily accessible in the trauma resuscitation room. Equipment for EDT
should be stored within a single operative tray and all instruments should be loose within the tray for easy handling.
Though a standard thoracotomy tray would sufce to perform EDT, a scaled-down version should be prepared to
remove unnecessary instruments. An EDT tray should be
stocked with a #10 scalpel blade (already secured to a handle), a pre-assembled retractor (Finochietto or Balfour
retractor), curved Mayo scissors (short and long), several
forceps (short and long, toothed and smooth), needle drivers
(short and long), a variety of large clamps (Satinsky clamps,
Debakey aortic aneurysm clamps, Duval lung clamps), and
an instrument to perform a transverse sternotomy (heavy
shears, Lebsche knife, Gigli saw). Consideration should be
given to having at least one additional EDT tray available
should a right thoracotomy be required during resuscitation.
Suture should be readily available for cardiac or vascular
repair; the author prefers a 2–0 Prolene suture on a large
tapered needle. The resuscitation room should be equipped
with adequate lighting, laparotomy pads or towels, and wall
suction, all to allow adequate visualization during the
procedure.
11.4 Technique
Prior to patient arrival, the trauma team should be assembled
and don universal precautions for personal protection. Once
the decision to perform an EDT has been made, quickly evaluate the location of penetrating wounds, as right-sided thoracic wounds may prompt a simultaneous right thoracotomy
during EDT (discussed later). As you perform the EDT, the
remainder of the trauma team should concomitantly secure a
denitive airway with endotracheal intubation, establish
large bore intravenous access for uid and blood resuscitation, and place a right tube thoracostomy to better evaluate
for a potential source of hemorrhage in the right chest.
Though most operative procedures require sterile technique,
the life-saving and emergent nature of EDT does not allow
time to perform a sterile procedure. Splashing iodine onto
the chest prior to incision provides no antimicrobial efcacy
and merely makes the instruments wet and slippery, making
the procedure more difcult. As time is crucial and the
patient cannot be prepared in the usual sterile fashion, EDT
should be performed without preoperative antibiotics, complete surgical skin prep, or standard wound draping
(Fig.11.1).
To begin the EDT, place the patient in the supine position
with the left arm abducted, widening the rib spaces and
allowing optimal access via a left anterolateral thoracotomy.
Begin the procedure with a generous curvilinear skin incision over the left chest, extending from the left lateral edge
of the sternum medially to the anterior edge of the latissimus dorsi laterally. In a female, retract the breast superiorly
and the incision should follow the inframammary crease. In
a male (Fig.11.2), center the incision over the fourth or fth
intercostal space by positioning the curvilinear incision just
inferior to the left nipple–areolar complex. Make the initial
90
Steps of an Emergency Department Thoracotomy
1.
2.
3.
4.
5.
6. internal cardiac massage.
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entering the thoracic cavity
posterior retraction of the lung
exploration/repair of cardiac injuries
anterior retraction of lung
aortic cross-clamping
Fig. 11.1 Steps of an EDT
S. Golestani et al.
Fig. 11.3 Incision extended through skin, subcutaneous tissue, and
most thoracic musculature
Fig. 11.2 Skin incision for emergency department thoracotomy in a
male patient
incision through the skin, subcutaneous fat, much of the thoracic musculature (Fig. 11.3), and should be down to the
intercostal space and ribs with the rst (or at the most second) pass of the scalpel. Once you reach the intercostal
space, use the curved Mayo scissors to puncture the intercostal muscles and parietal pleural, just superior to a rib as
you would for a tube thoracostomy, then spread the scissors
widely. Once you have created a large pleural opening, use
the scissors to enlarge the incision medially and laterally,
taking care to avoid the neurovascular bundle and allowing
enough space to place a thoracic retractor. Place your thoracic retractor and open widely (Fig.11.4). Keep in mind
this is an emergent procedure done relatively quickly, so
fracturing ribs while opening the retractor may be unavoidable. While fractured ribs should not alter the course of your
EDT, make sure to protect yourself and your assistant from
sustaining injury from the sharp edges of the fractured ribs.
Once you place and spread the retractor, extend your incision with Mayo scissors through all muscular layers and
parietal pleura medially and laterally, to include the full
length of your skin incision. Now you should be able to
fully open the retractor and adequately visualize the left
pleural cavity.
Fig. 11.4 Left anterolateral thoracotomy with retractor in place and
opened widely
Once you have completed positioning your retractor and
adequately lengthening the incision, you should rst turn
your attention to the pericardium. Complete the remainder of
the exploration in a systematic manner. Your assistant should
retract the left lung posteriorly, allowing visualization of the
anterior mediastinum and pericardium. Locate the phrenic
nerve following its cranio-caudal path along the lateral
aspect of the pericardium (Fig.11.5). While taking care not
to injure the phrenic nerve, use forceps to grasp the pericardium 1cm anterior to the nerve and make an incision with
scissors. The initial incision should allow you to conrm the
presence of pericardial blood. Occasionally, a tense cardiac
tamponade will be present, making it difcult to grasp the
pericardium with forceps. In these cases, you may make the
initial pericardiotomy with a small stab incision using a scal-
Phrenic
Tamponade
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phrenic
nerve
Fig. 11.5 The phrenic nerve following its cranio-caudal path along the
lateral aspect of the pericardium
nerve
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Fig. 11.6 Extension of pericardiotomy with scissors
pel. Next, lengthen the pericardiotomy cranially and caudally with scissors, about 1cm anterior and parallel to the
path of the phrenic nerve (Fig.11.6). By enlarging the pericardial incision, you can evacuate pericardial tamponade and
deliver the heart into the wound. This will allow you to repair
any cardiac injury that may be present.
If the heart is in asystole, then repair is obviously quite
easy. However, if there is an organized cardiac rhythm, you
will need to gently stabilize the heart in order to perform the
repair. You should be able to x most cardiac injuries with a
simple interrupted suture repair; the author usually uses a
2–0 polypropelene suture on a tapered needle. You do not
need to use pledgets during the initial repair, but if the tissue
tears during repair, you may consider adding pledgets to
reinforce the repair. You may also use a running stitch, gure-
Fig. 11.7 Horizontal mattress repair of laceration adjacent to a coronary artery
of- eight, or horizontal mattress. If the cardiac wound is in
close proximity to a coronary artery, you may need to alter
your approach. If the injury is near a distal coronary artery,
then a repair that ligates the artery distally should be well
tolerated by the myocardium. However, if the injury is near
the proximal portion of a coronary artery (particularly the
left anterior descending artery), the ligation will surely lead
to a massive myocardial infarction and death. In these cases,
you should perform a horizontal mattress suture around the
laceration and the coronary artery, so as not to ligate the
myocardial blood supply (Fig.11.7).
If the repair proves difcult or you are not accustomed to
performing cardiac repairs, a few optional approaches exist.
You may temporize bleeding from a cardiac wound by placing a urinary catheter through the laceration and inating the
balloon (Fig.11.8), then applying gentle traction after making sure to clamp the proximal part of the catheter. Rather
than placing sutures, you may be able to repair the laceration
with a skin stapler and perform the denitive suture repair in
a delayed fashion in the operating room. You may also con-
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S. Golestani et al.
Right
atrial
appendagte
Foley
catheter
Fig. 11.9 Temporary control of right atrial laceration with a Satinsky
clamp
Fig. 11.8 Temporary control of cardiac laceration using a urinary
catheter
trol the bleeding from a cardiac laceration using a Satinsky
clamp, particularly for right atrial lacerations (Fig. 11.9).
Finally, if the wound is on the posterior surface of the heart,
you can elevate the heart by grasping the apex with a Duval
lung clamp to allow visualization (Fig.11.10). If the heart is
beating while elevating the apex, venous return to the heart
may be impeded and lead to cardiac arrest, so you should
perform this maneuver gently and only elevate enough to
complete the repair. After cardiac repair, or if no cardiac
wound is identied, attention should be turned to the
descending thoracic aorta.
The left lung should now be retracted anteriorly by your
assistant. You should evacuate any signicant hemothorax to
allow visualization of the descending thoracic aorta. The
descending thoracic aorta lies posterior and medial in the left
chest, running along the left, anterior thoracic spine. With the
left lung retracted anteriorly and the left chest evacuated of
blood, you should recognize the thick, white, muscular
descending aorta (Fig.11.11). Remember, the esophagus lies
anterior and medial to the descending thoracic aorta and you
should keep its position in mind when cross-clamping the
thoracic aorta in order to avoid iatrogenic esophageal injury.
Before you can reliably apply a cross-clamp, you must incise
the parietal pleura that covers the descending thoracic aorta.
In order to avoid injury to the intercostal arteries, you should
incise the parietal pleura just anterior to the aorta, taking care
Fig. 11.10 Elevation of the tear with a Duval clamp grasping the apex
in order to repair a posterior cardiac laceration
not to injure the esophagus. You should grasp the parietal
pleura with forceps and make the initial incision with scissors. You can perform the remainder of the exposure bluntly
with nger dissection of the parietal pleura off of the aorta,
both in cranial and caudal directions. Keep in mind you do
not need to circumferentially mobilize the descending aorta,
as this wastes precious time and may cause iatrogenic injury
to intercostal branches. Once you have swept away the parietal pleura, you should cross-clamp the descending aorta
with a Debakey aortic aneurysm clamp or Satinsky clamp
(Fig.11.12).
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Fig. 11.11 Cross-clamp of the descending thoracic aorta with a
Satinsky clamp
Fig. 11.12 Internal cardiac massage
Cross-clamping the descending thoracic aorta during
EDT improves resuscitation via three mechanisms. First,
when you begin internal cardiac massage, having the thoracic aorta cross-clamped will improve cerebral blood ow
and perfusion pressure during systole. Similarly, the coronary arteries, which ll during diastole, will receive better
perfusion during internal cardiac massage. Finally, aortic
cross-clamping will slow down intra-abdominal hemorrhage
until a denitive abdominal operation can be performed. You
should cross-clamp the thoracic aorta as distally as possible
to maintain adequate perfusion to the spinal cord during the
cross-clamp time. Furthermore, you should remove the aortic cross-clamp as soon as possible, and preferably within
30min. Once you have successfully applied the aortic cross-
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Fig. 11.13 Internal debrillation paddles
clamp, you can turn your attention to internal cardiac
massage.
With the pericardium already opened widely and the heart
delivered into the wound (with or without a previous cardiac
repair), you should be able to easily evaluate the heart’s
rhythm and contractility. Patients with an organized rhythm
and adequate contractility do not need internal cardiac massage but may require intravenous drugs such as atropine and
epinephrine to support heart rate and blood pressure. Patients
with asystole should receive internal cardiac massage. To
begin, cup your hands and place one anterior and one posterior to the heart. Using the palm of each hand, begin internal
cardiac compression at a rate of about 100 beats/min, compressing the heart from its apex to its base. Take care to use
only your palms, to avoid iatrogenic injury from point
pressure on the heart from your ngers or thumbs.
Simultaneously, the patient should receive intravenous ACLS
drugs, providing at least 1min of internal cardiac massage to
assist with resuscitation. If the patient develops ventricular
brillation, use internal paddles and debrillate with an initial setting of 10–15J.The internal paddles should be positioned with one paddle anterior and one paddle posterior to
the apex of the heart (Fig.11.13). Continue with internal cardiac massage, debrillation, and ACLS protocols until the
patient has a return of spontaneous cardiac activity or you
decide the care is futile.
At any point during the EDT, you may be required to control hemorrhage from a variety of sources, including the
chest wall, spine, heart, lungs, or pulmonary vasculature.
Repair of cardiac injuries has been previously described in
this chapter. Bleeding from the chest wall or its associated
vessels (intercostal, internal mammary) can usually be controlled with simple clamping and ligation using nonabsorbable sutures or vascular clips. Occasionally, bleeding from
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