To thoracotomy, or not to thoracotomy?

aka Ruling the Resus Room 005

Revised and reviewed 2nd October 2012

A 26 year old man has been BIBA as a priority following a serious chest injury. The trauma team has been assembled and the patient is transferred onto the trauma table. You glance at the emergency thoracotomy tray and wonder if you’ll need to use it…

Questions

Q1. What is the definition of ‘emergency thoracotomy’?

Definitions vary widely, but a useful definition of emergency thoracotomy is:

“a thoracotomy performed prehospital, in the emergency department or elsewhere that is an integral part of the initial resuscitation of a patient”

Q2. What are the contraindications to emergency thoracotomy in the seriously ill trauma patient?

The indications and contraindications for emergency thoracotomy are controversial, and may vary between institutions.

In general, the following are considered contraindications to performing an emergency thoracotomy:

  • prehospital CPR performed for >15 minutes after penetrating chest injury without response
  • prehospital CPR performed for >10 minutes after blunt chest injury without response
  • the presence of coexistent injuries that are unsurvivable, e.g. severe head trauma
    (an exception maybe the patient who is a potential organ donor)
  • asystole is the presenting rhythm, and there is no pericardial tamponade

Furthermore, it makes little sense to perform an emergency thoractomy in settings where there is no hope of providing definitive surgical interventions following the procedure.

The Moore et al (2011) study, which collected data from 18 US trauma centers, suggests that emergency thoracotomy is not as hopeless as once believed — hence blunt trauma alone is not listed as a contraindication. Also, compared to the recommendations of Hunt et al (2005) — as featured in EMCrit Podcast 36: Traumatic Arrest — longer CPR times are allowed (10 and 15 minutes, rather than 5 and 10 minutes for blunt and penetrating trauma respectively). Even with these increased time allowances there are still a few reported cases of patients with both penetrating or blunt chest trauma who have survived following even longer periods of CPR.

Q3. When considering the indications for emergency thoracotomy, how is the physiological status of the patient classified?

Survival rates directly correlate with the patient’s physiological status. This physiological status needs to be taken into account when considering the indications for an emergency thoracotomy.

According to Lorenz et al (1992) the patient’s physiological status can be classified as follows:

I — no signs of life (see Q4)

II — pulseless electrical activity

III — profound shock: SBP<60 mmHg; transient / no response to fluid resuscitation.

IV — mild shock: SBP 60-90 mmHg; stable response to fluid resuscitation.

It ibecomes evident that your patient was stabbed in the left side of his chest. The paramedics reported signs of life at the scene.

Q4. In the context of severe chest trauma what are considered ‘signs of life’?

According to Hunt et al (2005) ‘signs of life’ include:

  • presence of a pulse or spontaneous movements
  • GCS>3
  • presence of pupillary reflexes, corneal reflexes or gag reflexes
  • evidence of cardiac electrical activity on ECG, or contractile activity on bedside ultrasound
    (this information is rarely available in a prehospital setting)

The definition of what constitute ‘signs of life’ in this setting remains surprisingly controversial. As implied by the contraindications listed in Q2, emergency thoracotomy is essentially futile unless the patient has, or recently had, some signs of life.

Q5. Should emergency thoracotomy be performed if he now has:

a) no signs of life?

Only if:

  • the patient had definite signs of life at the scene, and
  • none of the contraindications listed in Q2 are present.

b) pulseless electrical activity?

Only if there is evidence of:

  • intrathoracic hemorrhage
  • severe extrathoracic hemorrhage
  • pericardial tamponade
  • systemic air embolism

c) a systolic blood pressure <60 mmHg; transiently or non-responsive to fluid resuscitation?

Only if there is evidence of:

  • intrathoracic hemorrhage
  • severe extrathoracic hemorrhage
  • pericardial tamponade
  • systemic air embolism

The indications are the same as for scenario (b) above.

d) a systolic blood pressure between 60 and 90 mmHg; stable response to fluid resuscitation?

No

If possible, he should be urgently transferred to an operating theatre for an urgent thoracotomy instead.

Q6. What are the therapeutic measures that may be provided by emergency thoracotomy and what are their physiological rationales?

Emergency thoractomy allows the following therapeutic interventions to be performed:

  1. Release of pericardial tamponade —
    improves cardiac output and control of cardiac haemorrhage
  2. Control of intrathoracic vascular or cardiac haemorrhage —
    facilitates  fluid resuscitation by ‘turning off the tap’
    improves cardiac output and myocardial perfusion
  3. Control of massive air embolism or bronchopleural fistula —
    resolves myocardial ischaemia and hence  improves myocardial contractility as well as prevents neurological injury
  4. Open cardiac massage —
    improves resuscitative cardiac output and coronary perfusion especially with limited ventricular filling pressures
  5. Occlusion of the descending aorta (cross-clamping) —
    Redistribution of limited blood volume to myocardium and brain as well as limiting subdiaphragmatic losses.

Q7. Describe your approach to a patient who presents with blunt chest trauma who has signs of life on arrival in the ED, but then has a cardiac arrest.

Assess and manage the patient in a setting appropriately staffed and equipped for resuscitation using a coordinated team-based approach.

Perform the following key actions:

  1. secure the airway by endotracheal intubation and commence ventilation and oxygenation.
  2. seek and treat tension pneumothorax
    e.g. bedside ultrasound and bilateral finger thoracostomies.
  3. seek and treat pericardial tamponade
    e.g. bedside ultrasound and emergency thoractomy.

If the patient has arrested and both tension pneumothorax and pericardial tamponade have been excluded, some experts would cease resuscitation at this point. Others would argue that there may be a role for emergency thoractomy if performed within 10 minutes of the arrest and the patient is actively resuscitated during this time.

Q8. How effective are closed chest cardiac compressions and resuscitation drugs such as adrenaline in the resuscitation of the arrested trauma patient?

Closed chest cardiac compressions and standard resuscitation drugs such as adrenaline are ineffective in the resuscitation of arrested trauma patients.

Despite this, CPR is routinely performed in such patients, especially in the prehospital setting. At best, CPR can be viewed as a temporising measure until emergency thoracotomy can be performed. It is far more important to give these patients blood products — not drugs — during resuscitation, while attempting to control the source of hemorrhage.

References

Lifeinthefastlane.com

Journal articles and textbooks

  • Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma — a review. Injury. 2006 Jan;37(1):1-19. Epub 2005 Apr 20. Review. PMID: 16410079.
  • Lorenz HP, Steinmetz B, Lieberman J, Schecoter WP, Macho JR. Emergency thoracotomy: survival correlates with physiologic status. J Trauma. 1992 Jun;32(6):780-5; discussion 785-8. PMID: 1613839.
  • Moore EE, Knudson MM, Burlew CC, et al; WTA Study Group. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011 Feb;70(2):334-9. PMID: 21307731.

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Comments

  1. Gerard Fennessy says

    Great post Chris,
    One of the things our cardio-thoracic director has suggested is that the trainees spend a few days in theatre with the CTS team -- just to get the feel for cracking a chest and a view of the heart and surrounding structures. I can’t imagine doing an emergency thoracotomy, but one of these days it might just save a life. (I like the title too, has a familiar ring about it)

  2. says

    interesting synthesis on the subject
    even if in France, there’s very few experience of emergency thoracotomy : patients are transported directly by emergency doctors to operative room where only cardiac or thoracic surgeon can dot it.

    • says

      Thanks for the comment -
      Obviously what is done in any given center needs to be protocolised according to the resources and skill set available. In most non-trauma centers emergency thoracotomy has a questionable cost-benefit ratio in any circumstance. In cutting edge trauma centers (and the prehospital systems with access to them) the envelope is being pushed further and further with some surprising results.
      Chris

  3. pbsherren says

    Great post.

    Just a few thoughts and comments.

    http://www.ncbi.nlm.nih.gov/m/pubmed/21131854/

    The paper above reviews London HEMS experience of purely pre hospital clam shell thoracotomies. A comparable survival rate (18%) to in hospital medical cardiac arrests.

    Interestingly in the survival group the procedures were carried out by anaesthetists/EM docs, often performing the procedure for the first time. Simulation and mental rehearsal of the procedure is key. The mind is a powerful simulation tool!

    Also although CT experience would be useful for mediastinal anatomy it would not necessarily be of use for entering the chest as most emergency thoracotomies in CT are median sternotomies or resternotomies. Prehospital / ED thoracotomies would ideally be a clam shell incision ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726527/ ). The left anterolateral thoracotomy from my understanding is the approach of choice in America but does limit the exposure of mid line structures, making any repair of cardiac wounds difficult.

    Keep up the good work

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  1. [...] to perform emergency thoracotomy, check this case-based Q&A: Ruling the Resus Room 005 — To thoracotomy, or not to thoracotomy? ReferencesGreaves, I. Porter, K. Garner, J. (2009). Trauma Care Manual 2nd Ed. London: Hodder [...]

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