Management of Emergency Open Thoracostomy in Trauma
Emergency open thoracostomy in trauma requires immediate debridement and suturing of the open pneumothorax wound, followed by closed thoracic drainage to prevent tension pneumothorax development. 1
Initial Assessment and Immediate Management
Open pneumothorax presents with progressive dyspnea, sucking or hissing sounds through the chest wall wound, and foamed blood at the injury site. 2 The immediate priority is preventing air entry through the chest wall defect while maintaining adequate ventilation.
Primary Interventions
Perform immediate debridement and suturing of the open pneumothorax wound as this can be accomplished even in early treatment facilities. 1
Insert a chest drainage tube in the fourth/fifth intercostal space for closed thoracic drainage after wound closure to evacuate residual air and blood. 1
Maintain airway patency and ensure tissue perfusion under limited fluid resuscitation principles while controlling pain. 1
Critical Pitfall to Avoid
After applying a chest pad or closing an open pneumothorax, patients remain at significant risk for developing tension pneumothorax, especially under positive pressure ventilation. 1, 2 Continuous monitoring is essential, as tension pneumothorax can cause death within minutes if unrecognized. 2
Monitoring for Tension Pneumothorax
Check for kinking in the chest tube or connecting tube first if signs of tension pneumothorax develop after drainage tube placement. 1
Ensure secure connection from the connecting tube to the liquid seal and drainage equipment to maintain proper function. 1
Recognize tension pneumothorax by progressive dyspnea, tracheal shift, congested neck veins, shock, pallor, and cold extremities. 2
When Conservative Management Fails
Indications for Emergency Thoracotomy
Damage control thoracotomy (DCT) should be performed when:
Initial drainage volume after closed thoracic drainage exceeds 1000 ml or drainage continues at more than 200 ml per hour for over 3 hours despite anti-shock treatment. 1
Closed thoracic drainage cannot relieve dyspnea or leads to continuous hemorrhage in severe pulmonary lacerations. 1, 3
Severe heart contusions or severe tracheal/bronchial injuries are present. 1
Surgical Approach
The left-sided anterolateral thoracotomy approach is the preferred initial incision for damage control thoracotomy, providing optimal exposure of the pericardium, descending aorta, proximal left subclavian arteries, and left hilum. 1, 3
The clamshell approach can be used if necessary to improve exposure of the pericardium, heart, and thoracic inlet structures, though it provides insufficient exposure of the esophagus and trachea. 1
Median sternotomy is the most practical incision for reaching the heart and great vessels, with access to hilar structures and portions of the lungs. 1
Resuscitative Emergency Thoracotomy
For patients with cardiac arrest or impending cardiac arrest (usually within 15 minutes), resuscitative emergency thoracotomy should be performed with effective blood transfusions, fluid infusions, and anti-shock treatments. 1
Technical Steps
Use the left-sided incision or clamshell approach to open the chest. 1
Open the pleura and pericardium, clamp the injured aorta, and perform intrathoracic CPR. 1
If heart resuscitation is successful, immediately prepare for transfer to the operating room for definitive surgical treatment. 1
Success Rates and Patient Selection
The success rate of resuscitative emergency thoracotomy ranges from 7-21%, but is higher in patients who lose vital signs for less than 45 minutes or experience cardiac arrest after arriving alive at treatment facilities with less than 15 minutes of closed chest CPR. 1 For penetrating thoracic trauma, overall survival rates are 9-12% but can reach 38% in selected cases, while blunt trauma survival is only 1-2%. 4, 5
Associated Injuries Requiring Attention
Massive hemothorax presents with chest pain, shortness of breath, attenuated breath sounds on the injured side, and signs of shock. 1, 2 Insert drainage tube in the fourth/fifth intercostal space for closed thoracic drainage. 1
Pericardial tamponade may develop from penetrating or blunt injury. 1 Beck's triad, low QRS voltage on ECG, and echocardiography support the diagnosis. 1 Pericardiocentesis should be performed at the subxiphoid site or cardiac apex, preferably with ultrasound guidance. 1
Complications of Pre-Hospital Open Thoracostomy
Open thoracostomies carry a 10.6% complication rate, with most complications related to operator error or infection. 6 Pneumothoraces are missed in 2.2% of cases. 6 Chest ultrasound can effectively rule in pneumothorax and may reduce the rate of missed cases. 6