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.

   Why: The left chest is the door to the pericardium, the pulmonary hilum and the descending aorta at once; speed is the entire point, because the brain is on empty.

2. 02Opening the pericardium

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

   Why: Tamponade physiology means a heart strangled by 100 ml of clot; releasing it is the single intervention most likely to restore output, and the phrenic nerve is the structure the incision must respect.

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.

   Why: Digital control works and buys time to suture on a moving target. The hilar twist stops both bleeding and air embolism from a shattered lung by closing its vessels and airway in one manoeuvre.

4. 04Clamping the descending aorta

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

   Why: The clamp redistributes what little circulation exists to the heart and brain, and slows bleeding below the diaphragm. It is a loan at ruinous interest: every minute clamped is ischaemia the gut, kidneys and cord must repay.

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.