Emergency Thoracotomies

Ascending aorta

• ■

  Two main coronary arteries originate from the root of the ascending aorta.

  • ■

    The left main coronary artery branches into the left anterior descending artery (LAD) and the circumflex artery to supply the left heart.

  • ■

    The right coronary artery branches into the right posterior descending artery and acute marginal arteries to supply the right heart, sinoatrial (SA) node, and atrioventricular (AV) node.

Aortic arch and its branches

• ■

  Innominate (brachiocephalic) artery: first branch of the aortic arch

• ■

  Left common carotid artery

• ■

  Left subclavian artery

Thoracic (descending) aorta

• ■

  Begins just distal to the left subclavian artery on the left side of T4 vertebra and continues as the abdominal aorta at the level of T12 vertebra.

  

• ■

  Enters the abdominal cavity through the aortic opening of the diaphragm

• ■

  Branches

  • ■

    Bronchial arteries: one on each side to supply the lungs

  • ■

    Mediastinal arteries: multiples branch to supply mediastinal lymph nodes and areolar tissues

  • ■

    Pericardial arteries

  • ■

    Esophageal arteries: four or five branches from the anterior surface of the thoracic aorta

  • ■

    Superior phrenic arteries

  • ■

    Posterior intercostal arteries

    • ■

      First and second posterior intercostal arteries: branches from superior intercostal artery branch of costocervical trunk of the subclavian artery

    • ■

      Lower nine posterior intercostal arteries: branches from posterior thoracic aorta

  • ■

    Anterior intercostal arteries

    • ■

      Upper five or six anterior intercostal arteries: branches from the internal thoracic artery

    • ■

      Remaining anterior intercostal arteries: branches from the musculophrenic branch of internal thoracic artery

Internal mammary (internal thoracic) artery

• ■

  Branch from the subclavian artery

• ■

  Vagus nerves are located medial, and phrenic nerves are lateral to the internal mammary artery.

• ■

  Terminal branches

  • ■

    Musculophrenic artery

  • ■

    Epigastric artery

Brachiocephalic vein

• ■

  Left brachiocephalic vein

  • ■

    Most superficial structure in the superior mediastinum posterior to the manubrium

  • ■

    Covered with the remnant of thymus and mediastinal fat

  • ■

    Aortic arch, innominate artery, left common carotid artery, and left subclavian artery are posterior and inferior to the left brachiocephalic vein.

• ■

  Right brachiocephalic vein joins the left brachiocephalic vein to form the superior vena cava at the right parasternal level in the second intercostal space.

Superior vena cava

• ■

  Situated lateral to the ascending aorta

• ■

  Distal part covered with pericardium

Thoracic part of trachea

• ■

  Situated in the superior mediastinum

• ■

  Trachea divides into right and left bronchus at carina, which corresponds to the level of T5 vertebra and sternal angle.

• ■

  Right bronchus

  • ■

    Shorter and vertical compared to the left bronchus and divides into the upper, middle, and lower lung lobes bronchi.

• ■

  Left bronchus

  • ■

    Divides into the left upper and lower lung lobes bronchi

Thoracic esophagus

• ■

  Located on the right side of the thoracic aorta in the upper chest, then courses anterior to the thoracic aorta at the level of the diaphragm, and then enters the abdomen on the left side of the abdominal aorta at the level of T12 vertebra.

Azygos vein

• ■

  Situated in the right posterior chest

• ■

  A continuation of the right ascending lumbar vein

• ■

  Drains in the superior vena cava

Accessory hemiazygos vein

• ■

  Situated posterior and lateral to the descending thoracic aorta in the left chest

• ■

  Connects the azygos vein in the right chest

Hemiazygos vein

• ■

  Continuation of the left ascending lumbar vein

• ■

  Connects the azygos vein in the right posterior chest

Heart and pericardium

• ■

  The pericardium covers the part of the ascending aorta, pulmonary artery, pulmonary veins, distal superior vena cava, and distal inferior vena cava.

• ■

  The left phrenic nerve descends on the lateral surface of the pericardium near the apex.

• ■

  The right phrenic nerve is situated lateral to the inferior vena cava.

Pulmonary artery trunk

• ■

  Originates from the right ventricle and branches into the right and left pulmonary arteries

• ■

  The right pulmonary artery is situated posterior to the aorta and superior vena cava.

• ■

  The left pulmonary artery is situated anterior to the left mainstem bronchus.

Pulmonary veins

• ■

  There are four pulmonary veins: two on the left side, two on the right side.

• ■

  The pulmonary veins drain oxygenated blood from the lung to the left atrium.

Pulmonary hilum

• ■

  Right hilum

  • ■

    Contains right epiarterial bronchus, right hypoarterial bronchus, right pulmonary artery, two right pulmonary veins, right bronchial artery, and right bronchial vein

  • ■

    Bronchus is located posteriorly.

  • ■

    Pulmonary artery is located anteriorly and superiorly.

  • ■

    Pulmonary veins are located anteriorly and inferiorly.

• ■

  Left hilum

  • ■

    Contains left bronchus, left pulmonary artery, two left pulmonary veins, left bronchial arteries, and left bronchial vein

    • ■

      Bronchus is located posteriorly.

    • ■

      Pulmonary artery is located anteriorly and superiorly.

    • ■

      Pulmonary veins are located anteriorly and inferiorly.

• ■

  Covered superiorly, anteriorly, and posteriorly by pleura

• ■

  At the inferior border of the hilum, the pleura forms the inferior pulmonary ligament that connects the lower lobe of the lung to the diaphragm.

• ■

  The inferior pulmonary veins are in close relation with the inferior pulmonary ligament, and it is the most inferior structures at the pulmonary hilum.

Thoracic duct: located in the right posterior chest medial to the azygos vein

Vagus nerve

• ■

  Left vagus nerve

  • ■

    Located between the left subclavian and left common carotid artery and descends on the anterior surface of the aortic arch

  • ■

    The left recurrent laryngeal nerve branch of the left vagus nerve loops around the aortic arch and travels in the tracheoesophageal groove.

• ■

  Right vagus nerve

  • ■

    Located on the anterior surface of the right subclavian artery

  • ■

    The right recurrent laryngeal nerve loops around the subclavian artery and travels posteriorly to the common carotid artery in the tracheoesophageal groove.

Resuscitative emergency department thoracotomy (EDT)

Penetrating or open chest trauma

Hemothorax with an initial chest tube output of 1000–1500 mL

Cardiac tamponade

Penetrating cardiac injury

Tracheobronchial injury

Major vessel injuries

The majority of patients who survive an EDT for penetrating injury are neurologically intact.

Survival following EDT for a stab wound is substantially greater than for a gunshot wound.

Patients with blunt injuries who survive after EDT have poor neurologic outcome.

Survival following cardiac arrest secondary to trauma is universally poor.

Patients who had thoracotomy performed within 5 minutes of losing vital signs following penetrating trauma, the chance of survival is variable.

EDT may be justifiable when vital signs are lost and there is immediate access to surgical intervention.

Increased thoracotomy survival rates are associated with signs of life in the emergency department (ED).

Strong recommendation: Definite benefit after EDT

• ■

  Pulseless patients in the ED with signs of life after penetrating thoracic trauma

Conditional recommendation: Patients may benefit after EDT

• ■

  Pulseless patients in the ED without signs of life after penetrating thoracic trauma

• ■

  Pulseless patients in the ED with signs of life after penetrating extrathoracic trauma

  • ■

    All extrathoracic injury locations such as the neck, abdomen, and extremities may not have equivalent salvage rates after EDT.

  • ■

    Does not apply to patients with isolated cranial trauma

• ■

  Pulseless patients in the ED without signs of life after penetrating extrathoracic trauma

  • ■

    All extrathoracic injury locations, such as the neck, abdomen, and extremities, may not have equivalent salvage rates after EDT.

  • ■

    Does not apply to patients with isolated cranial injuries

• ■

  Pulseless patients in the ED with signs of life after blunt trauma

No recommendation

• ■

  Pulseless patients in the ED without signs of life after blunt trauma

Presence of pupillary response

Presence of spontaneous breathing

Cardiac electrical activities

Presence of carotid pulse

Measurable or palpable blood pressure

Presence of spontaneous extremity movement

Penetrating trauma patients

• ■

  Cardiac arrest with <10 min CPR on arrival in ED

• ■

  Pulseless electrical activity (PEA)

• ■

  Witnessed cardiac activity prehospital or in ED

• ■

  Precordial wound in a patient with prehospital cardiac arrest

• ■

  Possible indication in penetrating abdominal injury with at least one field SOL and <15 minutes CPR.

• ■

  Penetrating nonthoracic injury (abdominal, peripheral) with traumatic arrest and previously witnessed cardiac activity (prehospital or in hospital)

Blunt trauma

• ■

  Loss of signs of life within 5 minutes of arrival in the ED

• ■

  Persistent hypotension (SBP <70 mm Hg) despite resuscitation

• ■

  Witnessed cardiac activity prehospital or in the ED

• ■

  Rapid exsanguination from the chest tube (>1500 mL of blood return)

• ■

  Profound hypotension (<70 mm Hg) in a patient with a truncal wound who is unconscious or for whom an operating room is unavailable