When is thoracotomy (surgical incision into the chest cavity) indicated in trauma cases?

Indications for Thoracotomy in Trauma

Thoracotomy in trauma is indicated for resuscitative purposes in cardiac arrest/impending arrest (within 15 minutes), and for damage control in massive intrathoracic hemorrhage (>1000 mL initial drainage or >200 mL/hour for 3+ hours), severe cardiac/pulmonary injuries, and major airway disruption. 1, 2

Resuscitative Emergency Thoracotomy

Primary indication: Cardiac arrest or impending cardiac arrest occurring within 15 minutes of onset, caused by penetrating or blunt trauma 1, 2

Key Performance Parameters:

• Penetrating trauma with profound shock (BP <60 mmHg) or mild shock (BP 60-90 mmHg) with subsequent arrest: Survival rates of 64% and 56% respectively 3
• Overall survival for penetrating injuries: 9-38% depending on mechanism (stab wounds 34%, gunshot wounds 8%) 3, 4
• Blunt trauma survival: Only 1-2%, making this a relative contraindication 3, 4, 5

Critical Exclusion Criterion:

Absolute contraindication: Patients with no signs of life on initial prehospital assessment (full cardiopulmonary arrest with absent reflexes) should NOT undergo emergency thoracotomy—survival rate is 0% 3

Technical Approach:

• Left-sided anterolateral incision or clamshell approach for optimal exposure 1
• Must be performed with concurrent blood transfusions, fluid resuscitation, and anti-shock treatment 1, 2
• Open pleura and pericardium, clamp injured aorta, perform intrathoracic CPR 1

Damage Control Thoracotomy

Mandatory indications requiring immediate surgical intervention 1:

1. Massive Progressive Hemorrhage:

• Initial chest tube drainage >1000 mL 1, 2
• Ongoing drainage >200 mL/hour for >3 hours despite anti-shock treatment 1, 2
• Failure to improve or rapid deterioration after temporary improvement 1

2. Severe Pulmonary Laceration:

• Closed thoracic drainage fails to relieve dyspnea 1
• Continuous hemorrhage despite chest tube placement 1, 2, 6
• Surgical options include repair, lobectomy, segmentectomy, or hilar torsion for temporary control 1

3. Cardiac Injuries:

• Pericardial tamponade with Beck's triad (hypotension, muffled heart sounds, distended neck veins) 6
• Severe heart contusion 1
• Penetrating cardiac injuries with hemodynamic instability 1, 6

4. Major Airway Injuries:

• Severe tracheal and bronchial injuries when tracheotomy and closed drainage cannot alleviate dyspnea 1

5. Great Vessel Injuries:

• Progressive chest hemorrhage from penetrating trauma to thoracic great vessels requiring urgent vascular repair 1, 6

Common Pitfalls to Avoid

Blunt trauma thoracotomy based solely on chest tube output: This leads to high rates of non-therapeutic thoracotomy, especially in coagulopathic patients who have undergone prior procedures 7. Exercise extreme caution—mortality exceeds 73% in blunt trauma thoracotomy 7

Delayed intervention in penetrating cardiac injury: Early diagnosis and immediate surgical repair provide the only chance of survival 1, 6. Ultrasound confirmation of pericardial injury and monitoring troponin levels improve diagnostic accuracy 1

Inadequate surgical expertise: Emergency thoracotomy requires trained surgeons experienced in cardiothoracic injuries 5. The procedure should not be attempted without proper training and preparation 5

Surgical Approach Selection

• Anterolateral left thoracotomy: Initial approach for most damage control situations, providing access to pericardium, descending aorta, and left hilum 1, 6
• Clamshell extension: When bilateral exposure needed or inadequate visualization 1, 6
• Median sternotomy: For isolated cardiac and great vessel injuries 1