Resuscitative Thoracotomy

Reviewed and revised 11 March 2016

OVERVIEW

Resuscitative thoracotomy is a thoracotomy performed prehospital, in the emergency department or elsewhere that is an integral part of the initial resuscitation of a patient; an alternate term is emergency thoracotomy

  • survival 4-33%
  • determinants of survival include mechanism of injury, the location of injury and the presence or absence of vital signs
  • best outcomes in:

-> penetrating chest
-> those exsanguinating from chest tube
-> isolated chest trauma
-> cardiac injuries
-> abdominal trauma that benefits from aortic clamping
-> time since loss of vitals

REQUIREMENTS

  • ETT
  • shock or arrest with a suspected correctable intrathoracic lesion
  • specific diagnosis (cardiac tamponade, penetrating cardiac lesion or aortic injury)
  • evidence of ongoing thoracic haemorrhage

INDICATIONS

Accepted

  • penetrating injury + arrest + previous signs of life
  • blunt injury + arrest + previous signs of life

Relative

  • penetrating injury + no signs of life and CPR < 15min – blunt injury + signs of life in field or during transport -> arrest 15 min
  • blunt injury + no signs of life
  • multiple blunt trauma
  • severe head injury

RESUSCITATION IN TRAUMATIC ARREST

  • 1. Intubate (reverses hypoxia)
  • 2. Insert bilateral chest drains (or thoracostomies)
  • 3. Resuscitative Thoracotomy
  • 4. Limit fluid as this worsens outcome in penetrating thoracic trauma unless haemorrhage controlled
  • 5. Limit inotropes and pressors until circulation restored (will need once defect repaired)

TECHNIQUE

Goals

  • relieve cardiac tamponade
  • perform open cardiac massage
  • occlude aorta to increase blood flow to heart and brain
  • control life threatening thoracic bleeding
  • control bronchovenous air embolism

1. Full aseptic technique.
2. Scalpel through skin and intercostal muscles to mid axillary line.
3. Insert heavy duty scissors into thoracostomy incisions.
4. Cut through sternum.
5. Lift up (clam shell)

-> relieve tamponade (longitudinal incision through pericardium)
-> repair cardiac wounds (non-absorbable sutures, 3.0)
-> stop massive lung or hilar bleeding with finger (partial or intermittent occlusion may be performed to avoid right heart failure)
-> identify aortic injuries (repair with 3.0 non-absorbable sutures or use finger)
-> consider aortic cross clamping at level of diaphragm (limits spinal cord ischaemia)

References and Links

LITFL

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.

Social media and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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