REBOA Template
After contact with operation room for definite repair, <unstable vital sign, obvious bleeding, progression of hemoperitoneum> was still noted even with optimal resuscitation. After excluding massive thoracic injury, aortic injury, the patient was then put in supine position. The [left/right] inguinal region was sterilized with < chlorhexidine/B-I> and draped as usual. We measured the distance from inguinal region to <sternal notch/xiphoid process> After local anesthesia at regional skin,
We used <Seldinger technique to puncture common femoral artery under sonography guidance. The guidewire was introduced through puncture needle. We used 8 Fr vascular sheath to insert into common femoral artery through guidewire.
We made an incision from point 2 fingerbreadths lateral to the pubic tubercle and 1 cm above the pubic tubercle, extending caudally along the medial border of sartorius muscle until upper thigh. We dissected the femoral triangle and exposed the common femoral artery and the bifurcation. We ligated the distal end of common femoral artery and used cut-down method to approach the common femoral artery.
The occlusive balloon catheter was inserted into common femoral artery. The tip was sent to <Zone I/III> according to previous measured distance. After confirming the tip at appropriate location under CXR and no intraluminal device in contralateral femoral artery under sonography, the stylet was sent through catheter to fix the occlusive balloon. We then infused about 10 cc N/S to expand the balloon. The wave form of A line from common femoral artery disappeared and the systolic blood pressure of upper limb showed increment. We slowly deflated the balloon every <30 minutes in Zone I/60 minutes in Zone III> We continuous monitored the hemodynamic and the circulation of lower limb. The patient tolerated the whole procedure.
ED Thoracotomy Template
Due to [witness CPR<10 mins in blunt injury, witness CPR<15 mins in thoracic penetrating injury, massive hemothorax, cardiac tamponade, leading to INCA], we decided to perform ED thoracotomy.
After exclusion of head injury, non-viable injury, we put patient in supine position with bilateral arm fully abduction. We quickly sterilized the whole chest wall with < chlorhexidine/B-I> We made inframammary incision along the 4th intercostal space from posterior axillary line to sternum, following the curve of 5th rib. We used scalpel and scissor to dissect the chest wall muscle without injury to intercostal bundle. The pleura was opened and we introduced the rib spreader to exposed the whole pleural cavity. We checked the pericardium, aorta and lung as much as possible.
Tamponade was noted and we made an incision at pericardium with scalpel without injury to phrenic nerve. 400 cc bloody pericardial effusion was drained out. We then used scissor to open the hole longitudinally from aortic root to apex of heart. We checked the heart and there was one laceration hole at left atrium. We used fogarty balloon to occlude the laceration/We used 4-O prolone to repair the laceration without compromised the coronary vessels. Open cardiac massage was performed.
We retracted the lung anteriorly to expose the descending aorta. The pulmonary ligament was released. We used finger to dissected descending aorta from posterior vertebra and anterior esophagus. After fully open the pleura around aorta, we used Satinsky clamp to encircle the descending aorta and clamp it.
Diffuse chest wall oozing without obvious bleeding point was noted. We used gauze to pack the pleural cavity. One laceration wound was noted at lung and suture repair with 4-O Maxon was performed. Bleeding from hilum was noted, so Satinsky clamp was used for proximal control and clamp the pulmonary vessels and bronchus.
Due to poor exposure of ED thoracotomy, we made another mirror image incision at contralateral chest wall to perform Clamshell thoracotomy. The procedure was the same as ipsilateral procedure. The sternum was transected. We introduced second rib spreader to expose contralateral pleural cavity.
After aggressive procedures and large bolus resuscitation, ROSC was noted. Trauma 30 was activated and the patient was then sent to operation room for definite repair.
After aggressive procedures and large bolus resuscitation, persistent cardiac arrest was still noted even after CPCR for 30 minutes. We informed poor outcome to family and they decided DNR after full explanation. The patient was declared to death at 0:00 2025/3/13.