What are the indications for a thoracotomy?

Indications for Thoracotomy

Immediate thoracotomy is indicated for cardiac tamponade due to penetrating trauma to the heart and chest, as well as for patients with penetrating chest trauma who have initial chest tube output of 1,000 ml or persistent output of 200 ml/hr for more than 3 hours. 1

Emergency Thoracotomy Indications

Life-Threatening Conditions Requiring Immediate Thoracotomy

• Cardiac tamponade from penetrating trauma 2, 1
• Cardiac arrest or impending cardiac arrest due to thoracic trauma 2, 1
• Massive and progressive intrathoracic hemorrhage 1
  • Initial chest tube drainage > 1000 ml 1
  • Persistent chest tube output of > 200 ml/hr for more than 3 hours 1
• Severe tracheal and bronchial injuries where thoracic closed drainage cannot relieve dyspnea 2
• Penetrating cardiac injuries 2, 1

Other Significant Indications

• Severe pulmonary lacerations when closed drainage is ineffective 2
• Penetrating trauma of thoracic great vessels with progressive hemorrhage 2
• Combined thoracoabdominal wounds with confirmed thoracic involvement requiring intervention 2
• Flail chest with respiratory failure (surgical fixation may be performed) 2

Approach and Technique

The surgical approach depends on the specific injury pattern:

• Left anterolateral thoracotomy is the preferred initial approach for most emergency thoracotomies 2, 1
• Clamshell approach (bilateral anterolateral thoracotomy with transverse sternotomy) may be used when greater exposure is needed 2, 1

Survival Outcomes

Survival rates after emergency thoracotomy vary significantly based on mechanism of injury:

• Overall survival: 8-13% 1
• Penetrating trauma survival: 22% 1
  • Stab wounds: 34% 1
  • Gunshot wounds: 8% 1

Important Considerations

Pre-Thoracotomy Assessment

• Ultrasound examination can confirm pericardial trauma 2, 1
• Troponin levels should be monitored to assess cardiac injury severity 2
• ECG to rule out acute myocardial infarction as a cause of symptoms 2

Cautions and Pitfalls

• Pericardiocentesis as a bridge to thoracotomy may be considered but immediate thoracotomy is preferred for penetrating trauma 2, 1
• Chest tube output alone may not be a reliable indicator for thoracotomy in blunt trauma patients, particularly those who have undergone prior procedures and are coagulopathic 3
• Higher mortality rates are associated with blunt trauma (73%) compared to penetrating trauma (22%) 3
• The procedure should ideally be performed by surgeons familiar with cardiothoracic injuries 1

Special Scenarios

• In aortic dissection with hemopericardium, controlled pericardial drainage of very small amounts may temporarily stabilize the patient to maintain blood pressure around 90 mmHg 2
• For esophageal injuries near the thoracic area, repair surgery should be performed if evacuation time is too long 2

Procedural Steps

1. Position patient supine with left arm abducted
2. Make left anterolateral thoracotomy incision in the 4th or 5th intercostal space
3. Open the pericardium anterior and parallel to the phrenic nerve
4. Evacuate pericardial blood/clots to relieve tamponade
5. Inspect heart for injuries and manage with appropriate techniques
6. Control hemorrhage and repair injuries as indicated

Thoracotomy is a major surgical procedure with significant post-operative pain that can lead to respiratory complications if not managed properly 4. The decision to perform emergency thoracotomy requires careful evaluation of scientific, ethical, social, and economic factors 5.