Resuscitative thoracotomy

Why are we operating?

The last operation in the book: opening the chest of a patient in extremis to relieve tamponade, control the hilum, or clamp the aorta.

Indication: Penetrating chest trauma with recent loss of signs of life; the indications are narrow because the returns are.

The operation in 4 steps

1. 01Left anterolateral thoracotomy

   Incision along the fifth intercostal space from sternum toward the axilla, entering the pleura fast.

2. 02Opening the pericardium

   The pericardium is opened longitudinally, anterior to the phrenic nerve, and clot delivered.

3. 03Cardiac wound and hilar control

   A cardiac wound is controlled with a finger then closed; massive lung bleeding is controlled by clamping or twisting the hilum.

4. 04Clamping the descending aorta

   The descending aorta is dissected off the oesophagus and clamped above the diaphragm.

Anatomy you need

The heart and great vessels as the left chest presents them; the descending aorta behind is what the clamp finds.

What can go wrong

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.