What are the steps during a thoracotomy in the emergency setting?

Emergency Thoracotomy Procedure in the Emergency Setting

In the emergency setting, thoracotomy should be performed using a left anterolateral incision or clamshell approach to open the chest, followed by opening the pleura and pericardium, controlling hemorrhage, clamping the injured aorta if necessary, and performing intrathoracic CPR. 1

Indications for Emergency Thoracotomy

Emergency thoracotomy is indicated in the following critical situations:

• Cardiac arrest or impending cardiac arrest due to penetrating trauma (typically within 15 minutes of arrest)
• Massive and progressive intrathoracic hemorrhage
• Pericardial tamponade
• Severe tracheal and bronchial injuries
• Penetrating cardiac injuries

The success rate varies significantly based on mechanism of injury: 7-21% overall, with higher rates for penetrating injuries (15.2% for stab wounds, 7.3% for gunshot wounds) 1.

Step-by-Step Emergency Thoracotomy Procedure

1. Initial Approach and Incision

• Position patient supine with left arm abducted
• Make a left anterolateral thoracotomy incision in the 4th or 5th intercostal space
• Extend from the sternum to the posterior axillary line
• If needed, convert to a "clamshell" approach by extending across the sternum to the right chest for better exposure 1

2. Chest Entry and Exposure

• Cut through intercostal muscles with scissors
• Use a rib spreader to expose the thoracic cavity
• Rapidly evacuate blood and clots from the pleural space

3. Pericardial Access and Management

• Identify and open the pericardium anterior and parallel to the phrenic nerve
• Evacuate pericardial blood/clots to relieve tamponade
• Inspect the heart for injuries 1

4. Hemorrhage Control

• For cardiac wounds:
  • Apply digital pressure to control bleeding
  • Place horizontal mattress sutures for definitive repair
• For lung parenchymal injuries:
  • Apply lung clamps
  • Perform pulmonary tractotomy, repair, lobectomy, or pneumonectomy as needed
  • Consider hilar clamping for massive hemorrhage 1

5. Aortic Cross-Clamping (if needed)

• Identify the descending thoracic aorta
• Bluntly dissect behind the aorta
• Apply a vascular clamp to temporarily redirect blood flow to coronary and cerebral circulation 1, 2

6. Cardiac Resuscitation

• Perform open cardiac massage by compressing the heart between the palms
• Ensure the heart is filled with blood before compression
• Maintain a rate of approximately 80 compressions per minute 1

7. Definitive Management

• If resuscitation is successful, prepare for immediate transfer to the operating room
• Maintain temporary control measures during transport 1

Special Considerations

Penetrating Cardiac Injuries

• Ultrasound examination can confirm pericardial trauma
• Monitor troponin levels to assess cardiac injury severity
• Immediate thoracotomy is indicated rather than pericardiocentesis for penetrating trauma 1

Aortic Dissection with Hemopericardium

• In cases of aortic dissection with hemopericardium, controlled pericardial drainage should be considered
• Aim to maintain blood pressure around 90 mmHg 1

Severe Lung Lacerations

• For severe lung lacerations where closed thoracic drainage is ineffective:
  • Consider repair, lobectomy, segmentectomy, unilateral lung resection, or hilar torsion depending on injury pattern 1

Outcomes and Prognostic Factors

Survival rates after emergency thoracotomy vary significantly:

• Overall survival: 8-13%
• Penetrating trauma: 22% (34% for stab wounds, 8% for gunshot wounds)
• Blunt trauma: 1-2% 2, 3

Survival correlates strongly with physiologic status at presentation:

• Patients with penetrating trauma in profound shock (BP < 60 mmHg): 64% survival
• Patients with mild shock (BP 60-90 mmHg) who subsequently arrest: 56% survival
• Patients with no signs of life in the field: virtually no survival 3

Pitfalls and Caveats

1. Timing is critical - Outcomes deteriorate rapidly with delays in performing thoracotomy
2. Proper patient selection - Emergency thoracotomy has very poor outcomes in blunt trauma with complete arrest
3. Infection risk - Universal precautions are essential due to blood exposure
4. Technical challenges - The procedure should ideally be performed by surgeons familiar with cardiothoracic injuries
5. Resource allocation - Consider the high mortality rate when deciding to perform this resource-intensive procedure 1, 4

Emergency thoracotomy is a last-resort, life-saving procedure that requires rapid decision-making and execution. When performed for appropriate indications by trained personnel, it can save lives in otherwise fatal situations.