Presentation
History of gunshot chest and collapse. In severe hypovolemic shock and reduced level of consciousness.
Patient Data
Portable ED X-rays confirm a left-sided hemothorax. There is a mild right-sided tracheal deviation partly technical and due to rotation at the time of exposure. The cardiothoracic ratio appears normal. There is a nasogastric tube, and the distal tip is poorly visualized on the chest X-ray. The ETT is at T2/T3 vertebral level and can be distally inserted. There are overlying ECG leads. A right mid to lower zonal intercostal drain is barely discernable on the asymmetric chest view. There is left hemithoracic surgical hardware overlying the patient.
There is surgical hardware overlying the left hemiabdomen and lower thorax. The nasogastric tube tip is identified within the distal stomach. There is a right inguinal access central venous pressure catheter. The bullet is placed within the left hypochondrium.
Photographs of the modified Burford-Finochietto rib retractor.
Photographs of the Satinsky vascular clamp, (two sizes).
The Satinsky vascular clamp is shown superimposed on the chest X-ray. The overlying rib retractor is better appreciated separately from the vascular clamp.
Case Discussion
An on-table thoracotomy was performed in the emergency department (ED). The larger hardware projected over the thorax and abdomen is a rib spreader (retractor) known as the Burford-Finochietto retractor and was utilized to open the lower thorax in ED in an attempt to clamp/ manage the source of massive acute hemorrhage in this patient with penetrating trauma. It has replaceable blades with fenestrations (windows) with a hand-cranked lever that allows a staged rib spread and allows the surgeon to lock the arms at each stage of the rib spreading during cardiothoracic surgery.
The smaller device is a Satinsky curved anastomotic clamp, utilized to clamp the thoracic aorta proximal to the site of thoracic aortic injury in an attempt to address the site of massive hemorrhage in this patient with penetrating trauma and thoracic aortic injury.
The resuscitation was unsuccessful and the patient demised shortly after presenting to the ED.
Enrique Finochietto, an Argentinian surgeon, modified the rib spreader originally invented by French surgeon Theodore Truffier.
Victor P. Satinsky, an American cardiothoracic surgeon of Russian descent, invented the vascular clamp bearing his name. This clamp is still widely used today.
Disclosure: I, Ashesh I Ranchod, have no actual or potential ethical or financial conflict of interest in relation to this device. This case is not intended to be a personal endorsement or recommendation of this product.
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