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Case report
Cardiac tamponade: a case of kitchen floor thoracotomy
  1. K D Wright1,
  2. K Murphy2
  1. 1London Helicopter Emergency Medical Service, Helicopter Emergency Medical Service (HEMS) London, Royal London Hospital, London, UK
  2. 2London Ambulance Service, Helicopter Emergency Medical Service (HEMS) London
  1. Correspondence to:
 Mr K D Wright, Emergency Department, John Radcliffe Hospital, Headley Way, Oxford, UK;
 kwright{at}doctors.org.uk

https://doi.org/10.1136/emj.19.6.587

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    Successful thoracotomy in the prehospital environment is becoming more widely accepted.1,2 Here we present the case of cardiac arrest secondary to penetrating chest injury and the successful prehospital thoracotomy that followed. The resuscitation was associated with the spontaneous return of motor activity and later, hospital discharge. The implication for the immediate need for anaesthesia and paralysis is discussed together with a description of the surgical technique.

    CASE REPORT

    A teenage male youth sustained a stab wound to the left chest, in the third intercostal space at the junction of the medial and middle thirds of the clavicle. This wound was part of a deliberate self harm attempt. On arrival of the medical team—15 minutes from 999 call—he was thrashing and taking a few agonal breaths, this rapidly deteriorated to cardiac arrest within the first few seconds of assessment.

    The patient was placed on the floor of his first floor flat and endotracheal intubation was undertaken by the medical team paramedic; cannulation was achieved by a first responder paramedic and the medical team doctor undertook bilateral thoracostomies in the right and left 4th intercostal space, midaxillary line. This revealed a small haemothorax on the left side. The thoracostomies were joined by a skin incision using a 22 blade scalpel through skin and subcutaneous fat. Heavy duty shears were placed through the thoracostomy and used to cut through muscle and sternum thus making a large clamshell thoracotomy.

    With the chest open the pericardium was visualised as a blue, tense sac. Mosquito forceps were used to tent the pericardium and it was incised with scissors and widely opened. A large clot was removed and the operator's right index finger used to occlude a hole in the posterior aspect of the left upper heart. As the hole was occluded the heart began to fill …

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