Technique of Cross-Clamping of Descending Thoracic Aorta During Emergency Department Thoracotomy

Cross-clamping of the descending thoracic aorta is one of the operative maneuvers, that can be necessitated in an Emergency Department Thoracotomy and it is important for the Emergency Department medical staff to theoretically familiarize itself with its technique before need arises.

Endovascular Versus Open: Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta or Thoracotomy for Management of Post-Injury Noncompressible Torso Hemorrhage

Non-compressible torso haemorrhage (NCTH) (i.e., bleeding from anatomical locations not amenable to control by direct pressure or tourniquet application) is a leading cause of potentially preventable death after injury. In select trauma patients with infra-diaphragmatic NCTH-related hemorrhagic shock or traumatic circulatory arrest, occlusion of the aorta proximal to the site of hemorrhage may sustain or restore spontaneous circulation. While the traditional method of achieving proximal aortic occlusion included Emergency Department thoracotomy (EDT) with descending thoracic aortic cross-clamping, resuscitative endovascular balloon occlusion of the aorta (REBOA) affords a less invasive option when thoracotomy is not required for other indications. In this manuscript, we review the innovation, pathophysiologic effects, indications for, and technique of EDT and partial, intermittent, and complete REBOA in injured patients, including recommended methods for reversing aortic occlusion. We also discuss advantages and disadvantages of each of these methods of proximal aortic occlusion and review studies comparing their effectiveness and safety for managing post-injury NCTH. We conclude the above by providing recommendations as to when each of these methods may be best when indicated to manage injured patients with NCTH.

A First Report: Two Cases of Survival and Full Recovery After Blunt Cardiac Rupture Requiring Emergency Department Thoracotomy

Blunt traumatic cardiac rupture is an uncommon event in trauma and survival is rare. While multiple isolated accounts of repair of blunt cardiac rupture have been reported in the literature, there is not a single report of survival from right ventricular rupture following an emergency department thoracotomy (EDT). We report 2 cases where patients have survived such injuries and have made a full recovery. These patients are from a single institution who lost pulses on arrival to the emergency department; then underwent EDT with relief of cardiac tamponade with hemorrhage control by temporary closure, and subsequent definitive repair of right ventricular rupture in the operating room. Both were multiply injured and survived to discharge without neurologic sequelae and have made a full recovery back to their baseline function. This setting may represent an important use of EDT among blunt trauma patients, where time to survival and recovery may dependent on the speed of hemorrhage control and return of cardiac activity.