Planned emergency thoracotomy

Planned emergency thoracotomy

Planned emergency thoracotomy implies an emergency thora cotomy performed as a planned procedure in the operating theatre, directed at the management of a specific injury . As such, the approach c hosen is dependent on the indication for surgery and the organ injured ( Table 29.5 ). Some organs are best approached through a median sternotomy . Otherwise the thoracotomy may be right or left sided, and these may be joined, producing the so-called ‘clamshell incision’. This gives excellent exposure for any surgeon who is not routinely entering the chest. Posterolateral thoracotomy is not used in the emergency situation because of the di ffi culties in positioning of the patient, except for specific access to certain posterior media stinal organs. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Patients who have su ff ered abdominal trauma can generally be classified into the following categories based on their physio - logical condition after initial resuscitation: /uni25CF physiologically ‘normal’ – investigation can be completed before treatment is planned; /uni25CF physiologically ‘non-compromised’ – investigation is more limited; it is aimed at establishing whether the patient can be managed non-operatively , whether angioembolisation can be used or whether surgery is required; /uni25CF physiologically ‘compromised’ – investigations need to be suspended as immediate surgical correction of the bleed - ing is required. A trauma laparotomy is the final step in the pathway to delineate intra-abdominal injury . Occasionally it is di ffi cult to determine the source of bleeding in the shocked, multiple injured patient. If doubt still e xists, especially in the presence of other injuries, a laparotomy may still be the safest option. - The key is to make a decision, as indecision leads to delay in - definitive control. - The patient’s physiology must be assessed constantly; if there is an indication that the patient is still actively bleeding, the source must be identified unless the patient is unstable and requires immediate surgery . Blood loss into the abdomen can be subtle and there may be no clear clinical signs. Blood - is not an irritant and does not initially cause any abdominal pain. Distension is subjective, and a drop in the blood pressure may be a very late sign in a young fit patient. Examination in compromised patients should take place either in the emergency department or in the operating theatre if the patient is deteriorating rapidly .

TABLE 29.5 Different approaches to the contents of the chest cavity. Approach Best for Left anterolateral Left lung and lung hilum thoracotomy Thoracic aorta Origin of left subclavian artery Left side of heart Lower oesophagus Right anterolateral Right lung and lung hilum thoracotomy Azygos veins Superior vena cava Infracardiac inferior vena cava Upper oesophagus Thoracic trachea Median sternotomy Anterior aspect of heart Anterior mediastinum Ascending aorta and arch of aorta Pulmonary arteries Carina of the trachea

Planned emergency thoracotomy

Planned emergency thoracotomy implies an emergency thora cotomy performed as a planned procedure in the operating theatre, directed at the management of a specific injury . As such, the approach c hosen is dependent on the indication for surgery and the organ injured ( Table 29.5 ). Some organs are best approached through a median sternotomy . Otherwise the thoracotomy may be right or left sided, and these may be joined, producing the so-called ‘clamshell incision’. This gives excellent exposure for any surgeon who is not routinely entering the chest. Posterolateral thoracotomy is not used in the emergency situation because of the di ffi culties in positioning of the patient, except for specific access to certain posterior media stinal organs. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Patients who have su ff ered abdominal trauma can generally be classified into the following categories based on their physio - logical condition after initial resuscitation: /uni25CF physiologically ‘normal’ – investigation can be completed before treatment is planned; /uni25CF physiologically ‘non-compromised’ – investigation is more limited; it is aimed at establishing whether the patient can be managed non-operatively , whether angioembolisation can be used or whether surgery is required; /uni25CF physiologically ‘compromised’ – investigations need to be suspended as immediate surgical correction of the bleed - ing is required. A trauma laparotomy is the final step in the pathway to delineate intra-abdominal injury . Occasionally it is di ffi cult to determine the source of bleeding in the shocked, multiple injured patient. If doubt still e xists, especially in the presence of other injuries, a laparotomy may still be the safest option. - The key is to make a decision, as indecision leads to delay in - definitive control. - The patient’s physiology must be assessed constantly; if there is an indication that the patient is still actively bleeding, the source must be identified unless the patient is unstable and requires immediate surgery . Blood loss into the abdomen can be subtle and there may be no clear clinical signs. Blood - is not an irritant and does not initially cause any abdominal pain. Distension is subjective, and a drop in the blood pressure may be a very late sign in a young fit patient. Examination in compromised patients should take place either in the emergency department or in the operating theatre if the patient is deteriorating rapidly .

TABLE 29.5 Different approaches to the contents of the chest cavity. Approach Best for Left anterolateral Left lung and lung hilum thoracotomy Thoracic aorta Origin of left subclavian artery Left side of heart Lower oesophagus Right anterolateral Right lung and lung hilum thoracotomy Azygos veins Superior vena cava Infracardiac inferior vena cava Upper oesophagus Thoracic trachea Median sternotomy Anterior aspect of heart Anterior mediastinum Ascending aorta and arch of aorta Pulmonary arteries Carina of the trachea

Planned emergency thoracotomy

Planned emergency thoracotomy implies an emergency thora cotomy performed as a planned procedure in the operating theatre, directed at the management of a specific injury . As such, the approach c hosen is dependent on the indication for surgery and the organ injured ( Table 29.5 ). Some organs are best approached through a median sternotomy . Otherwise the thoracotomy may be right or left sided, and these may be joined, producing the so-called ‘clamshell incision’. This gives excellent exposure for any surgeon who is not routinely entering the chest. Posterolateral thoracotomy is not used in the emergency situation because of the di ffi culties in positioning of the patient, except for specific access to certain posterior media stinal organs. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Patients who have su ff ered abdominal trauma can generally be classified into the following categories based on their physio - logical condition after initial resuscitation: /uni25CF physiologically ‘normal’ – investigation can be completed before treatment is planned; /uni25CF physiologically ‘non-compromised’ – investigation is more limited; it is aimed at establishing whether the patient can be managed non-operatively , whether angioembolisation can be used or whether surgery is required; /uni25CF physiologically ‘compromised’ – investigations need to be suspended as immediate surgical correction of the bleed - ing is required. A trauma laparotomy is the final step in the pathway to delineate intra-abdominal injury . Occasionally it is di ffi cult to determine the source of bleeding in the shocked, multiple injured patient. If doubt still e xists, especially in the presence of other injuries, a laparotomy may still be the safest option. - The key is to make a decision, as indecision leads to delay in - definitive control. - The patient’s physiology must be assessed constantly; if there is an indication that the patient is still actively bleeding, the source must be identified unless the patient is unstable and requires immediate surgery . Blood loss into the abdomen can be subtle and there may be no clear clinical signs. Blood - is not an irritant and does not initially cause any abdominal pain. Distension is subjective, and a drop in the blood pressure may be a very late sign in a young fit patient. Examination in compromised patients should take place either in the emergency department or in the operating theatre if the patient is deteriorating rapidly .

TABLE 29.5 Different approaches to the contents of the chest cavity. Approach Best for Left anterolateral Left lung and lung hilum thoracotomy Thoracic aorta Origin of left subclavian artery Left side of heart Lower oesophagus Right anterolateral Right lung and lung hilum thoracotomy Azygos veins Superior vena cava Infracardiac inferior vena cava Upper oesophagus Thoracic trachea Median sternotomy Anterior aspect of heart Anterior mediastinum Ascending aorta and arch of aorta Pulmonary arteries Carina of the trachea