Resuscitative Thoracotomy

Reviewed and revised 19 April 2024

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/extra-thoracic haemorrhage that benefits from aortic clamping/manual occlusion
-> time since loss of vitals – generally cited as <10 minutes since penetrating, <5 minutes since blunt

Timing of loss of vitals can be difficult as patients may be obtunded, have extremely low blood pressures but still technically have an output or pre-hospital care may be frantic. Therefore, some grace is given to these times in suitable cases (i.e. young, limited comorbidities.)

REQUIREMENTS

• ETT
• Bilateral chest decompression with finger thoracostomy being the preferred method
• Shock or arrest with a suspected correctable intrathoracic lesion
• Specific diagnosis (cardiac tamponade, penetrating cardiac lesion or aortic injury)
• Evidence of ongoing thoracic haemorrhage
• Extra-thoracic haemorrhage in a patient in whom aortic cross-clamping/manual occlusion may be beneficial

INDICATIONS

Accepted

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

Contra-indications

• Penetrating injury + no signs of life and CPR > 10min
• Blunt injury + no signs of life > 5 minutes
• Multiple severe blunt trauma
• Non-survivable head injury

RESUSCITATION IN TRAUMATIC ARREST

1. Intubate (reverses hypoxia) and alleviates potential airway obstruction
2. Bilateral finger thoracostomies, with drains not being required immediately (can place these once ROSC achieved, thoracostomies can be re-fingered in the case of tension re-accumulating)
3. Large bore access (14g ACF, RIC Line, MAC Sheath, Swan Sheath) and balanced transfusion through rapid infuser device
4. Resuscitative Thoracotomy
5. Limit crystalloid as this worsens outcome in penetrating thoracic trauma unless haemorrhage controlled
6. Limit inotropes and pressors until circulation restored (will need once defect repaired)

TECHNIQUE

1. Don full PPE including gown, safety glasses and double-glove (for potential of sharps injury on broken ribs/scalpel)
2. Provide most sterile field possible with chlorhexidine/iodine solution
3. Start on the left side by extending your thoracostomy incision with a scalpel through skin, medially to the sternum and laterally to the mid-axillary line.
4. Insert heavy duty scissors into thoracostomy incision through intercostal muscle into pleural cavity and further incise intercostals from sternum to mid-axillary line
5. Insert ‘Finochietto’ rib-spreader or similar, ensuring the handle is positioned in the axilla (ensuring that you don’t block access to a clamshell), and spread the ribs to gain access to the left pleural cavity
6. Sweep the left lung out of the field
7. Use artery forceps or similar to ‘pick-up’ the pericardium and carefully incise the pericardium to create a large window to relieve tamponade and access the heart. Cephalad-Caudal incision to avoid transection/injury of the left phrenic nerve that traverses the pericardium.
8. Deliver the heart from the pericardium and inspect for injuries
9. Insert hand along the posterior aspect of the left pleural cavity until you find the descending aorta and provide manual occlusion to the aorta. This helps to increase afterload and thereby increases perfusion to the coronary arteries and brain.
10. Consider extending your thoracotomy to a clamshell if there is potential pathology for you to address in the contralateral pleural cavity
11. Extending the thoracotomy means repeating steps 4 and 5 and then using heavy scissors or a Gigli saw to bisect the sternum to complete the clamshell thoracotomy

Goals:

• Relieve cardiac tamponade
• Control haemorrhage from trauma to heart and repair defects in heart chamber(s)
• Perform internal cardiac massage
• Occlude aorta to increase blood flow to heart and brain (manual occlusion or cross-clamp)
• Control life threatening thoracic bleeding
• Control bronchovenous air embolism

Potential interventions:

• Relieve tamponade (Cephalad-Caudal incision through pericardium avoiding L phrenic nerve)
• Repair cardiac wounds (non-absorbable sutures 3-0, Staples, occasionally foley catheter) being careful not to injure or occlude coronary vasculature
• Mitigate massive lung or hilar bleeding with finger/hilar twist/direct repair (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 or manual compression at level of diaphragm (limits spinal cord ischaemia)
• Address profuse bleeding from intercostal or internal mammillary vessels
• Perform internal cardiac massage
• Internal Defibrillation/Intracardiac adrenaline

References and Links

LITFL

• Groombridge C, Miers J. Thoracotomy. LITFL
• Nickson C. To thoracotomy, or not to thoracotomy?. 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
• 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.
• Moore EE, Knudson MM, Burlew CC, Inaba K, Dicker RA, Biffl WL, Malhotra AK, Schreiber MA, Browder TD, Coimbra R, Gonzalez EA, Meredith JW, Livingston DH, Kaups KL; 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. 

Social media and web resources

• CLIC-EM — Validating the Select Use of ED Thoracotomy
• EMCrit Podcast 36 — Traumatic Arrest
• EMCrit Podcast 83 – Crack to Cure: ED Thoracotomy
• EMI — Learning points from a first time emergency thoracotomy
• Resus.ME — Prehospital Thoracotomy
• ScanCrit — Traumatic Cardiac Arrest (2013)
• Trauma Professional’s Blog — ED thoracotomy practice guideline
• Trauma Professional’s Blog — Part 1: getting in, Part 2: the heart and Part 3: Clamping the Aorta
• Trauma Professional’s Blog — Foley catheter used to plug a hole in the heart