Annotation for Point C
RT in this context refers to a thoracotomy performed at the ﬁrst patient contact, before anesthetic induction. This is commonly referred to as an emergency department thoracotomy but should be differentiated from an operative RT. On patient arrival and determination for the need of RT, the patient’s left arm should be placed above the head to provide unimpeded access to the left chest. The thoracot omy incision starts on top of the sternum and is carried transversely across the chest in the inframammary fold, with gentle curvature toward the patient’s axilla. A clamshell thoracotomy should be the initial incision in a hypotensive patient with a penetrating wound to the right chest. This provides immediate, direct access to a right-sided pulmonary or vascular injury while still allowing access to the heart from the left side for open cardiac massage. If a bilateral thoracotomy is performed, the rib retractor should be placed at the sternum to enhance separation of the chest wall. If the sternum is divided transversely, the internal mammary vessels must be ligated when perfusion is restored. If the pericardium is not tense with blood, it should be picked up at the apex with toothed forceps and sharply opened with scissors. The pericardium should be opened from the apex toward the aortic root, anterior to the phrenic nerve. If tense pericardial tamponade exists, a knife or the sharp point of a scissors is often required to initiate the pericardotomy incision, with care taken not to injure the heart. Although occlusion of the thoracic aorta is typically performed after pericardotomy, this may be the ﬁrst maneuver on entry into the chest for patients sustaining extrathoracic injury and associated major blood loss.