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
- Ruling the Resus Room 005 — To thoracotomy, or not to thoracotomy?
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
- 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
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a 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 three amazing children.
On Twitter, he is @precordialthump.
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Hi Chris, I was just wondering about the indication ‘severe head injury’ you have listed here . My understanding was that a suspected severe head injury, and certainly a likely non-survivable head injury, were more contraindicative.
Cheers,
Rich