Indications for a Chest Tube and Thoracotomy

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Indications for a Chest Tube and Thoracotomy
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• Thoracic injury 20-25 deaths due to trauma
• Early discussion of thoracic injury in literature
• A rule of thumb frequency of organ damage is
  proportional to exposure

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The ER Thoracotomy an important practice

• Performed by surgeons and ER physicians alike
• Delays increase mortality

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Thoracotomy selectivity an equally important
practice
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Rationale for Thoracotomy

• Prevent arrest. Dont just respond to it!
• Best results for patients with penetrating trauma
  and vitals en route
• Factors to consider
• Time duration of external CPR in field
• Intubation during external CPR
• Electrical activity of the heart
• Neurologic status

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Objectives of Thoracotomy

• Release pericardial tamponade
• Control intra-thoracic bleeding
• Perform cardiac massage
• Cross-clamping the aorta
• And ultimately . . . to reestablish meaningful
  cardiac contraction and adequate tissue perfusion

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Indications for Thoracotomy
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Contraindications for Thoracotomy
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Performing a Thoracotomy

• Important points
• Several types of incisions exist
• Opening the chest is just the beginning
• Upon accomplishment, proceed immediately to the OR

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Thoracotomy Complications

• Infection and Pericarditis
• Arrhythmias
• Laceration of intra-thoracic structures
• Heart
• Lung
• Major vessels and coronary arteries
• Phrenic nerve

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The Chest Tube

• AKA tube thoracostomy
• A procedure used to evacuate an abnormal
  collection of fluid or air from the pleural space
• 1st described by Hippocrates
• Modern design with water seal described in 1872
• Popularized by influenza
• Widely used in WWII

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Rationale for Chest Tubes

• Fluid or air in the pleura disrupts pulmonary
  mechanisms based upon volume and rate of
  accumulation
• Respiratory muscle dysfunction
• Mechanical interference with ventilation
• Shunting of pulmonary blood flow
• V/Q mismatch
• Increased pulmonary blood flow resistance
• Eventual hypoxemia and acidosis

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Indications for Chest Tube Placement
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Indications to convert to Thoracotomy
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Contraindications

• Multiple adhesions
• Visceral pleural blebs
• Indications for thoracotomy as definitive
  treatment
• Bleeding diatheses
• Note these are not absolute, but must be taken
  into consideration when the clinical decision is
  made

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Complications

• Incorrect placement
• Infection
• Injury to the neurovascular bundle
• Injury to the long thoracic nerve
• Laceration of thoracic organs or vessels
• Laceration of abdominal organs