DECIDEReserved for: in extremis, deteriorating, with proven tamponade on ultrasound. · No signs of life and PEA on arrival: do not start. · Ultrasound in the primary survey is what finds tamponade.
STEPS · ◆ KEY STEP — LOGGED WITH ITS TIME
SEQUENCE — STEP BY STEP
Splash prep with chlorhexidine or iodine — no delay for full asepsis.
Extend the left thoracostomy along the 5th ICS, sternum to mid-axillary line.
Clamshell only when needed — extend with heavy shears.
Insert the Finochietto, open widely, sweep the left lung out of the way.
Pericardium: tent with forceps, cut vertically in front of the phrenic. Deliver the heart.◆ PERICARDIUM OPENED
Cardiac wound: finger first, then staples, 3-0 suture, or a Foley balloon.
Internal massage two-handed at ~100/min; internal defibrillation for VF starting ~10–20 J.
Aorta: hand down the posterior chest wall, compress against the spine or cross-clamp.◆ AORTA CROSS-CLAMPED
ROSC: control the mammary bleeding, sedate, ventilate, move toward the OR.
CLAMSHELL EXTENSION — WHEN THE RIGHT CHEST IS BLEEDING
Massive blood from the right thoracostomy is the reason to extend to a clamshell.
1. Mirror the incision on the right — same 5th ICS, sternum to the table.
2. Divide the sternum transversely — Gigli saw, Lebsche knife or heavy shears.
3. Lift the anterior chest wall up, hinging it open. Both pleural cavities are now open.
4. Find and clamp BOTH internal mammary arteries.
5. Pack, then find the source: hilum, great vessels, lung.
CLOSE THE HEART — USE THE FASTEST METHOD THAT HOLDS
Finger first. Direct pressure on the hole while somebody sets up the repair.
Foley 16 Fr through the wound, balloon up with 5–10 mL, gentle traction, clamp the port.
Skin stapler — staples across the defect, perpendicular. Fastest in a bleeding field.
Pledgeted suture 2-0 or 3-0 non-absorbable, horizontal mattress over pledgets.
Near a coronary: pass the suture underneath the vessel.
Atrium: a side-biting clamp or a purse string is usually quicker than pledgets.
HILAR TWIST — MASSIVE UNILATERAL LUNG BLEEDING
For massive bleeding from one lung, or air embolism from a deep lung injury.
1. Divide the inferior pulmonary ligament first.
2. Rotate the lung 180° around the hilum — clockwise on the right, anticlockwise on the left.
3. Bleeding stops, and so does ventilation to that lung. Note the time.
4. Alternative: clamp the whole hilum, or simply compress it in your hand.
EQUIPMENT
PPE first: gown, double gloves, eye protection.
Scalpel with a large blade (No. 10/20); chlorhexidine or iodine for a splash prep.
Heavy Mayo scissors / tough-cut shears for intercostal muscle and pleura.
Finochietto rib spreader + Gigli saw (or heavy scissors) for the sternum — the clamshell kit.
Artery forceps (to tent the pericardium) + long forceps.
For the cardiac wound: 3-0 nylon or prolene on a large needle, skin stapler, Foley.
Vascular (aortic) cross-clamp if available; internal defibrillation paddles.
Rib spreader — Finochietto. Crank handle down, toward the axilla.
Lebsche knife, Gigli saw, or heavy trauma shears for the sternum.
Teflon pledgets, and a side-biting clamp for an atrial wound.
Vascular clamp for the hilum, and a second one for the aorta.
Running in parallel: ETT in place, large-bore access (14 g / RIC / MAC sheath), blood products at the bedside.
IN THE KIT — 9 ITEMS · TRAUMA CART · SHELF A
Finochietto rib spreader×1
Gigli saw with handles — or heavy shears for the sternum ×1
Mayo scissors, heavy×1
Scalpel No. 20 blade×1
Long artery forceps — to tent the pericardium ×2
Vascular (aortic) cross-clamp — if stocked ×1
3-0 monofilament on a large needle — nylon or prolene, for the cardiac wound ×3
Skin stapler — the fast option for a ventricular wound ×1
Foley 16 Fr + 20 mL syringe — balloon tamponade of a cardiac wound ×1
Lebsche knife or heavy trauma shears — the sternum, if no Gigli saw ×1
Teflon pledgets×1 pack
Side-biting (Satinsky) clamp — for an atrial wound ×1
Vascular clamp for the hilum — a second clamp ×1
ALSO NEEDED — NOT IN THE KIT
PPE (gown, double gloves, eye protection) and splash prep are on the cart. Internal paddles live with the defibrillator.
DRAFT — not yet assembled or signed off. The decision is the procedure. Do not open this to browse it — resealing needs a full re-check.
FIGURE
Follow the infra-mammary crease bilaterally and cut the sternum transversely — pericardium opened vertically, in front of the phrenic nerve.
INCISION 5TH ICS BILATERAL · AXILLA TO AXILLA
PERICARDIUM: LONG VERTICAL CUT · ANTERIOR TO PHRENIC