TissueDB/Simulators/Emergency Department Thoracotomy Simulator (Misra)

The Emergency Department Thoracotomy Simulator (Misra) is a low-cost bench-top task trainer, built from a re-purposed CPR mannequin torso fitted with handcrafted plastisol-coated organ models, for practising emergency department thoracotomy (EDT).^[1] EDT is the rapid bedside opening of the chest in a patient with profound refractory shock or recent loss of vital signs from penetrating thoracic injury. On the trainer a resident can practise the essential steps it reproduces: using the instruments and rib retractor on an anterolateral left thoracotomy, performing pericardiotomy with release of cardiac tamponade, and cross-clamping the descending aorta.

Source — every material, build step and cost on this page is drawn from Misra et al. 2024 unless a cell notes otherwise. (Misra et al., 2024)

1. Obtain a commercial CPR mannequin torso. The authors used an unused inventory unit; specific make and model are not stated.
2. Remove the mannequin's standard internal parts to make cavity space for the organ models (the source does not enumerate which parts).
3. Position the left-side anatomical rib set (3B Scientific) at the location of the left 4th, 5th, and 6th intercostal spaces; fix in place with zip ties at the anchor points.

1. Take one of the two soft packing foam blocks (16 in × 10 in × 4 in / 40.6 cm × 25.4 cm × 10.2 cm).
2. Handcraft the foam block into a lung shape (the source does not specify the method or tools).
3. Wrap the shaped foam in a layer of pink-coloured gauze.
4. Coat the gauze-wrapped foam with medium-density liquid plastisol (Bait Plastics LLC) for the surface feel and tissue characteristic described in Methods. Plastisol curing time is not stated.

1. Form gauze structures for the heart, aorta, and esophagus (the heart and aorta are described as cone-shaped; the esophagus shape is not specified in source).
2. Coat each gauze structure with medium-density liquid plastisol.
3. Insert a nasogastric (NG) tube through the esophagus model lumen so it remains in place after coating. The NG tube serves as a tactile differentiator from the aorta during the procedure.
4. Fill a disposable shower cap with red-dyed artificial fluid and tie it to the heart model to simulate pericardial tamponade. Use one filled shower cap per training run.

1. Pour medium-density liquid plastisol with skin-tone pigment into sheets sized 10 in × 18 in (≈25.4 cm × 45.7 cm). Allow to set (curing time not stated).
2. Pour medium-density liquid plastisol with fat-coloured pigment into sheets sized 10 in × 18 in (≈25.4 cm × 45.7 cm). Allow to set.
3. Produce ten pairs (skin + fat) per gallon of plastisol — enough for one initial build plus replacement skin/fat sheets across ten training runs.

The source does not detail the assembly sequence; arrange each completed model in its anatomical position within the mannequin shell, consistent with the left-side anterolateral thoracotomy approach.

1. Place the lung model inside the chest cavity adjacent to the rib set, on the left side.
2. Place the heart model in the central mediastinal position with the shower-cap tamponade reservoir tied in place.
3. Lay the aorta and the esophagus (with NG tube) in the posterior mediastinum so the aorta is accessible to the descending-aorta cross-clamping technique and the NG tube distinguishes the esophagus by palpation.
4. Place a skin/fat pair across the left chest wall over the rib anchor area to form the cutaneous surface for the incision; a penetrating wound can be represented in this surface.

1. Replace the skin/fat pair from the previous run with a fresh pair.
2. Replace the shower-cap tamponade reservoir with a fresh shower cap filled with red-dyed fluid, and re-tie to the heart model.
3. Re-position any organ models displaced during the previous procedure.

The Misra EDT Simulator was designed around the essential steps of an anterolateral left thoracotomy: using the instruments and rib retractor, performing pericardiotomy with release of cardiac tamponade, and cross-clamping the descending aorta. Beyond that scope:

• It is an anatomical, tactile model only; it does not reproduce physiology (no perfusion, pulse, respiratory motion, or haemodynamic feedback).
• In the source study, indication recognition was taught through discussion rather than on the trainer; pair the simulator with discussion-based scenario teaching to cover the decision to perform EDT.
• It was evaluated with PGY 3–5 senior general-surgery residents only (n = 9). Effectiveness has not been studied with junior residents, attending surgeons outside the institution, emergency-medicine learners, or pre-clinical medical students.
• The study was single-centre at OhioHealth Riverside Methodist Hospital, Columbus, Ohio; reproducibility outside the originating institution was not formally assessed. The published cost breakdown and material specifications are the principal mechanism the authors offer for external reproducibility.
• Familiarity bias is documented as a limitation: simulation-group residents practised on the trainer before being scored, which the authors note may inflate the observed effect size.

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