Resuscitative / trauma thoracotomy (cardiac, lung and thoracic vessel injury)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• death despite surgery
• brain damage from low blood flow before the heart restarted
• massive blood transfusion
• lung injury and air leak
• removal of part or all of a lung
• injury to phrenic nerve, oesophagus or internal mammary artery
• wound or chest infection
• later heart valve or septal defect needing heart surgery

Pre-operative details for this operation

1. Mechanism of injuryStabGunshotBluntentry wound site, time of injury
2. Signs of lifeon arrival and at decision: pulse, BP, ECG rhythm, pupils, gasping, movement; time of loss of pulse; minutes of CPR before thoracotomy
3. Contraindications excludedprolonged cessation of vital signs; injury obviously incompatible with life; no surgical service to take over care
4. IndicationPenetrating chest injury with recent or imminent loss of vital signsBlunt injury with pericardial tamponade or exsanguination (considered; criteria stricter)Planned thoracotomy in OT for bleeding / tamponade
5. FAST / eFAST findingspericardial fluid, pleural fluid, pneumothorax
6. Airway and linesintubation time, IV / IO lines, chest drains and their output
7. ConsentEmergency without consent: reason recordedWritten, relativeWritten, patient

Anaesthesia and position

1. AnaesthesiaNone (cardiac arrest), ventilatedGeneral
2. Ventilation during entryHeld brieflyRight main bronchus intubationDouble-lumen tube
3. PlaceEmergency departmentOperation theatre
4. Position and preparationsupine, left arm up; quick povidone-iodine over chest and both sides; draping if time
5. Staff protectionPPE worn by all

Operative findings

1. Left pleural cavityvolume of blood, active bleeding source
2. PericardiumTense, tamponadeNot tenseOpened by injuryvolume of blood and clot released
3. Heartchamber, site and length of wound, relation to coronary arteries, rhythm on opening, air in coronary veins
4. Lunglobe, peripheral or deep tract, hilar injury, air leak
5. Great vessels / internal mammary / intercostal vessels
6. Diaphragm and right chestif clamshell done

Procedure (steps)

1. IncisionLeft anterolateral, 4th-5th spaceClamshellMedian sternotomyPosterolateralfrom parasternal border to mid- / posterior axillary line, along the rib curve
2. Pleura enteredintercostal muscles cut with scissors at the upper border of the rib; Finochietto retractor
3. Blood evacuated, bleeding controlledpressure, then vascular clamp
4. Pericardiotomyleft phrenic nerve seen on the lateral pericardium; small opening (hemostats, or scalpel nick if tense) anterior to the nerve, then opened widely in the long axis (head to foot) in front of and parallel to the nerve; midline with sternotomy; tamponade released
5. Temporary control of cardiac woundFinger pressureFoley catheter balloonVascular clamp (atrium)Skin staples
6. Cardiorrhaphynon-absorbable 2-0 or 3-0 on large taper needle; figure-of-eight / horizontal mattress / continuous; mattress under a coronary vessel; pledgets only if tearing
7. Open cardiac massagetwo hands, apex to base; duration
8. Internal defibrillationjoules (10-50 J), number of shocks
9. Drugsdrug, dose, route (IV / intracardiac), time, as given by the resuscitation team
10. Descending aorta cross-clamp2-4 cm above the diaphragm; left lower lobe retracted up, inferior pulmonary ligament divided if needed; aorta is the first structure felt on the spine, oesophagus anteromedial (nasogastric tube helps); mediastinal pleura opened, minimal dissection; clamp time on and off (removed once carotid pulse returns)
11. Lung procedureNonePneumonorrhaphyTractotomyWedge resectionNon-anatomical lobectomyPneumonectomyHilar clamp / hilar twiststapler and load used
12. Air embolismair in coronary veins? source controlled, ventricle aspirated
13. Internal mammary arterieschecked after removing retractor; ligated if divided

Closure, drains and dressing

1. PericardiumClosed loosely, opening left at baseLeft open (dilated heart)continuous 2-0
2. Chest drainsnumber, size, site (mid-axillary line; under sternum after sternotomy)
3. Chest wallClosed in layersTemporary closure (vacuum dressing)muscles with heavy absorbable figure-of-eight; sternum with steel wires
4. Epicardial pacing wiresNot placedPlacedsite, pacer settings
5. Skin

Specimens and implants

1. SpecimensNoneResected lung for HPE
2. Implantssternal wires (number), pledgets, stapler cartridges used

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. ICU, ventilatedcontinue resuscitation and warming
2. Chest drain outputhourly; report heavy or rising blood loss
3. Cardiac monitoringcontinuous ECG; pacer settings if wires placed
4. Neurological checkGCS and pupils once sedation allows
5. BloodsHb, clotting, ABG, lactate
6. Chest X-raydrain and tube position, lung expansion
7. Echocardiographyearly and at follow-up, to look for septal, valve or wall-motion defects and late pericardial effusion
8. Staff exposurereport any needlestick or sharps injury at once

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery