ED Thoracotomy: Is it Just the First Part of the Autopsy?

Updated: 26 August 2011

It ‘s 2 am, Saturday morning. A 26 year-old male is rushed into the emergency department. He had been involved in a heated domestic dispute and received a single stab wound to the left side of his chest with a kitchen knife.

On arrival in the trauma bay his vitals are:

T 36 C, P 136/ min, BP 83/42 mmHg, RR 30, SpO2 93% on 15L/min O2 via non-rebreather mask, and GCS  9

You place two 16G IV lines and intubate the patient.

Following a period of progressive hypotension your patient suffers a cardiac arrest. ECG monitoring confirms pulseless electrical activity (PEA). An emergency thoracotomy is performed. This relieves his pericardial tamponade and stabilises the patient prior to transfer to the operating room.

Emergency Thoracotomy

Thoracic trauma is a leading causes of death in all age groups and accounts for 25-50% of all traumatic injuries. Most thoracic trauma patients require only conservative management, but a subset of these patients will deteriorate in the pre-hospital environment or in the emergency department and require an emergency thoracotomy.

Emergency thoracotomy can be defined as  thoracotomy “occurring either immediately at the site of injury, or in the emergency department or operating room as an integral part of the resuscitation process”.

When to perform an emergency thoracotomy is controversial. Some experts describe emergency thoracotomy  as a ‘futile’ procedure, with survival rates around 9-12% for penetrating trauma. Yet some institutions report survival rates up to 38%. Blunt chest trauma on the other hand has a survival rate following cardiac arrest of only 1-2%.

Factors associated with increase likelihood of emergency thoracotomy success include:

• Signs of life in the ED
• Penetrating thoracic injury
  • Survival rates following blunt cardiac trauma is significantly lower than with penetrating cardiac injuring secondary to poor cardiac function (due to cardiac contusion) and a higher incidence of associated injuries such as cardiac rupture and aortic rupture.
• Stab wounds generally have and increased survival rate compared to gun shot wounds (GSW)
• Thoracic injuries(as opposed to abdominal injuries):
  • However, some studies suggest there is up to a 10% neurologically intact survival rate for patients with penetrating abdominal injury undergoing cross clamping of the descending aorta as part of emergency thoracotomy.

Reasons to perform emergency thoracotomy

• Haemorrhage control
• Release of cardiac tamponade
• Internal or open cardiac massage
• Treatment of air embolus
• Cross-clamping of descending thoracic aorta

Accepted indications for emergency thoracotomy

Penetrating thoracic injury with the following conditions:

• Previously witnessed cardiac activity (pre-hospital or in-hospital)
• Unresponsive hypotension (SBP <70mmHg) despite vigorous resuscitation

Blunt thoracic injury with the following conditions:

• Rapid exsanguination from chest tube (>1,500mL immediately returned)
• Unresponsive hypotension (SBP <70mmHg) despite vigorous resuscitation

Relative indications for emergency thoracotomy

• Penetrating thoracic injury with traumatic arrest without previously without previously witnessed cardiac activity
• Penetrating non-thoracic injury (eg. abdominal, peripheral) with traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
• Blunt thoracic injuries with traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Image from: www.wjes.org

Contraindications for emergency thoracotomy

• Blunt injury without witnessed cardiac activity (pre-hospital)
• Penetrating abdominal trauma without cardiac activity (pre-hospital)
• Non-traumatic cardiac arrest
• Severe head injury
• severe multisystem injury
• Improperly trained team
• Insufficient equipment

What Equipment do you need?

Preparation for emergency thoracotomy

• Ultrasound machine
• Overhead theatre lights switched on
• Overhead suction gantry positioned
• Unpacked thoracotomy tray
• Defibrillator with internal paddles available
• Ensure all staff wearing protective equipment, eye glasses, face mask, x-ray aprons and gowns, sterile gloves

Thoracotomy tray should contain

• Retractors, scissors, forceps, scalpels
• Needle holder, curved artery forceps
• Vascular clamps, curved artery forceps, Crawford clamps
• Internal defibrillation paddles
• Skin stapler, sutures, surgical ties

Stepwise approach to performing an emergency thoracotomy (clamshell method)

• Intubate the patient, administer 100% oxygen and ventilate.
• obtain large-bore IV access x2, initiate massive transfusion protocol, and commence resuscitation with blood products.
• Prepare thoracotomy tray and don personal protective equipment.
• Positon patient supine with the side to be operated on elevated to 15° by a wedge and the arm abducted.
• Incise through skin and subcutaneous tissue in the 5th intercostal space, starting from the costochrondral junction and continuing to the midaxillary line following the upper border of the sixth rib. The inframammary fold may be used as a guide.
• Divide the muscle, periosteum and parietal pleura in one layer with scissors and blunt dissection. Chest wall bleeding is usually minimal although internal thoracic arteries need to be ligated later as significant hemorrhage will occur as circulation is restored.
• Insert a rib-spreading retractor with the handle towards the axilla. Further distraction may be obtained by dividing the sixth rib posteriorly.
• To extend the incision to the right side, use strong scissors, bone cutters or a Gigli saw to cut through the sternum and into the right fifth intercostal space, mirroring the incision above.
• A bulging pericardium is incised vertically anterior to the phrenic nerve. The lung may need to be retracted to identify the phrenic nerve.
• Place a finger over any cardiac defect. If experienced, consider placing a sterile Foley catheter through the cardiac wound, inflate the balloon, then apply gentle traction to close the hole. Fluid may be directly infused into the heart if other venous access is unavailable; otherwise keep the catheter clamped.
• Close myocardial defects with buttressed Vicryl sutures avoiding the coronary arteries. Further procedures are undertaken as necessary, depending on the operator’s skill level.
• Hilar clamping may be required in the case of significant lung laceration or air embolism from bronchial-vascular communication.
• Perform internal cardiac massage  compressing the heart between two flat hands in a hinged clapping motion. Defibrillate using small internal paddles either side of the heart with energy settings of 15-30 J (or biphasic equivalent).

This video shows an emergency thoracotomy being performed:

The LITFL team highly recommends listening to this podacst by Scott Weingart: EMCrit Podcast 36 — Traumatic Arrest. Also, for an update on when to perform emergency thoracotomy, check this case-based Q&A: Ruling the Resus Room 005 — To thoracotomy, or not to thoracotomy?

References

• Greaves, I. Porter, K. Garner, J. (2009). Trauma Care Manual 2nd Ed. London: Hodder Arnold.
• Fitzgerald, M. et.al. (2010). Emergency physician credentialing for resuscitative thoracotomy for trauma. Emergency Medicine Australasia. 22, 332-336. PMID: 20629696
• Hunt, P. Greaves, I. & Owens, W. (2006). Emergency thoracotomy in thoracic trauma-a review. Injury. 37, 1-19. PMID: 16410079
• Lent, G. & Kumar, N. (2009). Emergency Bedside Thoracotomy. emedicine.com
• Meredith, W. & Hoth, J. (2007). Thoracic Trauma: When and How to Intervene. Surgical Clinics of North America. 87, 95-118. PMID: 17127125
• Wise, D. et.al. (2004). Emergency thoracotomy: “how to do it”. Emergency Medicine Journal. 22-24. PMID: 1726527