Operative Note (Trauma Thoracotomy/Resuscitative Thoracotomy)

Note title: Operative Note – Trauma Thoracotomy / Resuscitative Thoracotomy

Date/time of note entry: [Date and time of note entry]

Procedure date and time: [Date] [Start time] to [End time / Unable to determine: reason]

Location: [ED / OR / ICU / other]

Patient identifiers: [Full name and MRN / Trauma alias and MRN] (If identity is unknown, use trauma alias and MRN only; do not speculate.)

Encounter type: [Trauma activation level / other encounter type]

Team

• Primary surgeon: [Name], [Role/level]
• Assistants: [Name(s) and role(s)]
• Anesthesia: [Anesthesiologist/CRNA name / None due to ongoing CPR]
• Key steps by operator (if multiple): [Specify who performed critical maneuvers such as thoracotomy incision, pericardiotomy, aortic cross-clamp placement, or cardiac repair if performed by different operators] (Omit if single operator performed all steps. Additional staff documented in trauma record.)

Indication

• Mechanism of injury: [penetrating / blunt / other]
• Suspected injury region: [thoracic / extrathoracic / mixed / Unable to determine: reason]
• Prehospital summary: [One-line prehospital course]

Physiologic status immediately prior to thoracotomy:

• Signs of life: [present / absent / Unable to determine: reason] (If present, specify: [spontaneous movement / respiratory effort / pupillary response / organized electrical activity / palpable pulse])
• Initial cardiac rhythm: [PEA / VF/VT / asystole / organized activity / Unable to determine: reason]
• Perfusion status: [Pulses: present/absent] [SBP: value or Unable to determine] [End-tidal CO2: value mmHg or Unable to determine]
• Prehospital CPR duration: [minutes / Unable to determine: reason]
• ED CPR duration prior to thoracotomy: [minutes / Unable to determine: reason]

Indication statement: [1–3 sentence rationale for resuscitative thoracotomy based on mechanism and physiologic status]

Consent: [Obtained from surrogate / Not obtained due to emergency; emergency exception applies]

Time-out: [performed / abbreviated / not performed: reason] (If abbreviated, note that correct patient, procedure, and laterality were verbally confirmed to extent possible.)

Pre-Thoracotomy Resuscitation

(Omit this section entirely if information is unavailable due to acuity.)

• Airway: [Spontaneous / BVM / Supraglottic airway / ETT / Surgical airway]
• Chest decompression prior to thoracotomy: [none / needle / finger thoracostomy / chest tube; side(s)]
• POCUS findings: [Pericardial effusion: present/absent] [Cardiac activity: present/absent] [Other relevant findings]
• Massive transfusion protocol: [activated / not activated]

Procedures Performed

(List only procedures actually performed, in chronological order.)

• [Left anterolateral thoracotomy, interspace]
• [Right anterolateral thoracotomy, interspace]
• [Extension to clamshell thoracotomy]
• [Pericardiotomy with evacuation of blood/clot]
• [Open cardiac massage]
• [Internal defibrillation, energy level(s), number of attempts]
• [Temporary cardiac wound repair: method and location]
• [Descending thoracic aortic cross-clamp, level]
• [Pulmonary hilum control: side, method]
• [Intrathoracic hemorrhage control: method, site]
• [Chest tube placement: side, size, number]
• [Temporary chest closure / open chest management: technique]

Operative Findings

• Pleural space and lungs: [Hemothorax volume and side; lung injury location and bleeding status; air embolism if suspected/visualized / Unable to assess: reason]
• Pericardium and heart: [Tamponade present/absent; cardiac activity on opening; cardiac injury: chamber, size, bleeding severity / Unable to assess: reason]
• Great vessels and mediastinum: [Injury identified or suspected; descending aorta findings if inspected / Unable to assess: reason]
• Diaphragm: [Injury or extension / Intact / Unable to assess: reason]
• Other findings: [Additional relevant findings]

(If no surgically correctable injury was identified, state explicitly.)

Procedure Narrative

[Concise chronological narrative covering: patient positioning; incision type and interspace; sterile prep status; immediate actions on entry (decompression, pericardiotomy, cardiac activity assessment); hemorrhage control maneuvers with methods; resuscitative measures (open cardiac massage quality/response, internal defibrillation attempts); reassessment and decision point (ROSC achieved or basis for futility determination); closure method. If patient expired, document basis for termination and time resuscitation stopped.]

Resuscitation Timeline

(For unknown times, document "Unable to determine" and reference source record if available.)

• Arrival time: [Time / Unable to determine]
• Arrest time: [Time / Unable to determine]
• Thoracotomy incision: [Time]
• Pericardiotomy: [Time / Not performed]
• Aortic cross-clamp ON: [Time / Not performed]
• Aortic cross-clamp OFF: [Time / Clamp in place on transfer / Not applicable]
• ROSC: [Time / Not achieved]
• Decision-to-transfer: [Time; destination: OR / ICU / Not applicable]
• Termination of resuscitation / Time of death: [Time / Not applicable]

Estimated Blood Loss and Transfusion

• Estimated blood loss: [Numeric estimate / massive/unmeasurable / Unable to estimate]
• Pleural blood evacuated: [Approximate volume and side(s)]
• Transfusion products: [RBC, FFP, platelets, whole blood units; or reference anesthesia/code record for totals]

Drains, Tubes, and Retained Items

• Chest tubes: [Side, size, number]
• Pericardial drain: [Placed with details / Not placed]
• Packing intentionally retained: [Location and type / None]
• Temporary closure materials: [Type and location / None]
• Clamps/devices left for transfer: [Item, location, plan for removal / None]

Counts

• Sponge count: [correct / incorrect / not performed: reason]
• Sharps count: [correct / incorrect / not performed: reason]
• Instrument count: [correct / incorrect / not performed: reason]
• Mitigation if counts not performed: [Methodical wound exploration: yes/no] [Imaging planned/performed: type]
• If discrepancy: [Actions taken and result]

Post-Procedure Condition and Disposition

• Condition: [ROSC status; rhythm; SBP range; or CPR ongoing]
• Disposition: [To OR for definitive surgery / To ICU / To morgue] [Receiving team and transport mode if applicable]
• Next priorities: [Brief statement of immediate next steps or notifications]

Post-Procedure Plan

(Include only if patient survives to ongoing care; omit if death occurred.)

• Open chest management: [Plan if applicable]
• Chest tube management: [Suction/water seal; output monitoring]
• Antibiotics: [Agent, dose, duration / Not given]
• Imaging plan: [Studies when stable]
• Resuscitation goals: [Transfusion targets; lactate/ETCO2 goals; vasopressor plan]
• Critical handoff information: [Aortic clamp time; retained devices; pending tasks]

Authentication: [Author name], [Role/Title], [Date/time of signature]

(If this note is intentionally brief due to acuity, additional details may be added by addendum when clinically feasible.)