To thoracotomy, or not to thoracotomy?

aka Ruling the Resus Room 006

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’?

Answer and interpretation

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?

Answer and interpretation

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?

Answer and interpretation

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 becomes 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’?

Answer and interpretation

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:

Answer and interpretation

a) no signs of life?

Answer and interpretation

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?

Answer and interpretation

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?

Answer and interpretation

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?

Answer and interpretation

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?

Answer and interpretation

Emergency thoracotomy 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.

Answer and interpretation

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 thoracotomy.

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 thoracotomy 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?

Answer and interpretation

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

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 other web resources


Ruling the Resus Room 700

CLINICAL CASES

Resus Room Reflection

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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