You have just finished the evening ward round at your tertiary hospital 11:30 pm.

Your registrar is
paged for a trauma call to the Emergency Department, and you accompany him to the resuscitation
area.

You arrive, and see a pale young male patient on the ED trolley with a bandage on his anterior left
chest which is bloody. There is an ED doctor currently performing an IV cannulation, and another ED
doctor is on the phone.

The senior ED nurse gives you a brief handover:

“This is James. He is 21. He has been stabbed in the left chest with a knife. He is awake and alert, it
hurts him to breathe, but his chest sounds clear and equal according to our doctor. He is tachycardic
pulse 130. There doesn’t seem to be any other injuries.”

The ED doctor tells you that the cardiothoracic surgeon is 20 minutes away, and the surgeon and
surgical registrar are currently occupied in theatre with a “hot AAA”.

Your registrar then states to you that the patient has stopped breathing and has lost output. The
monitor shows

 Oxygen Saturation 82% with no pulsations

 non invasive blood pressure of 67/60,
 Pulse 150
.

Outline your immediate management of this patient.

Expected answers (Bold: candidate must state to pass) Score

1. Outline your immediate management of this patient.

Time critical situation. Patient will die unless immediate steps are taken. Patient is
in Pulseless electrical activity (PEA). Differential diagnosis, cardiac laceration,
cardiac tamponade, tension pneumothorax.

Commence CPR, Assign registrar to manage the airway and initiate intubation.
Ensure cannulation is successful. Perform finger thoracostomy or needle
decompression. Get RN to get chest drain kit and thoracotomy tray. Brief attempt
at USS looking for tamponade or PTX. Order O negative blood from blood bank
and initiate massive transfusion protocol.

2. How would you perform a finger thoracostomy?

Finger thoracostomy: 4th intercostal space mid axillary line. Arm above the head,
antiseptic used, PPE, sterile gloves. Incision and use of forceps to blunt dissect or
the finger until the finger enters the thoracic cavity, and allow passage of air.
Improvement of vital signs and a hiss indicates success.

3. How would you perform a needle decompression?

Needle decompression: 2nd intercostal space, nipple line, large bore cannula,
insert perpendicular and remove needle (14G). Saline dropped at the top of the
cannula to detect bubbles, or expect a hiss. A temporary measure procedure.

4. Needle decompression and finger thoracostomy are unsuccessful at

improving the patient parameters; the patient remains in PEA without
output despite ongoing CPR and adrenaline as per ACLS. The patient is
intubated. Describe how you would perform am emergency thoracotomy.
Start by drawing where on the chest you would perform the incisions
(provide a picture of the chest).
Expected answers (Bold: candidate must state to pass) Score

Describe either a L thoracotomy or a Clamshell approach.

Incision should be 5th intercostal space, starting from the costochrondral junction
and continuing to the midaxillary line following the upper border of the sixth rib.
The inframammary fold may be used as a guide. Bilateral if clamshell approach
used.
 PPE, Thoracotomy tray opened, lighting, patient positioned (L arm abducted,
wedge under patient).
 Blunt dissection, cut with scissors. Cut all layers.
 Insert rib spreaders (handle towards axilla). If clamshell, candidate should
describe how to cut the sternum (prompt).
 Pericardial sac is incised. Avoid the phrenic nerve (prompt).
 Identify the cardiac injury.
 Either describe using a foley catheter or vicryl sutures to close the cardiac
laceration, avoiding LAD
 Ligate internal mammary arteries after resuscitation is succesful

5. Describe how you would perform direct cardiac massage?

Compress the heart between two flat hands in a hinged clapping motion.

6. What are the indications and contraindications for emergency thoracotomy

Penetrating thoracic injury with the following conditions:

 Previously witnessed cardiac activity (pre-hospital or in-hospital)

 Unresponsive hypotension (SBP <70mmHg) despite vigorous resuscitation

Blunt thoracic injury with the following conditions:

 Rapid exsanguination from chest tube (>1,500mL immediately returned)

 Unresponsive hypotension (SBP <70mmHg) despite vigorous resuscitation

Relative indications for emergency thoracotomy

 Penetrating thoracic injury with traumatic arrest without previously without

previously witnessed cardiac activity
 Penetrating non-thoracic injury (e.g. abdominal, peripheral) with traumatic arrest
with previously witnessed cardiac activity (pre-hospital or in-hospital)
 Blunt thoracic injuries with traumatic arrest with previously witnessed cardiac
activity (pre-hospital or in-hospital)

Contraindications for emergency thoracotomy

 Blunt injury without witnessed cardiac activity (pre-hospital)

 Penetrating abdominal trauma without cardiac activity (pre-hospital)
 Non-traumatic cardiac arrest (prompt)
 Severe head injury
 severe multisystem injury
 Improperly trained team
 Insufficient equipment