What is the approach and management for an emergency thoracotomy (emergency thoracic surgery)?

Emergency Thoracotomy: Approach and Management

Resuscitative Emergency Thoracotomy

Emergency thoracotomy should be performed immediately for patients with penetrating trauma who experience cardiac arrest or impending cardiac arrest within 15 minutes of onset, using a left-sided anterolateral incision or clamshell approach. 1, 2

Key Indications for Resuscitative Thoracotomy:

• Penetrating cardiac injuries with witnessed arrest: Patients with penetrating trauma in profound shock (BP <60 mmHg) or mild shock (BP 60-90 mmHg) with subsequent cardiac arrest have survival rates of 64% and 56% respectively 3

• Cardiac tamponade: Emergency thoracotomy with pericardiotomy is indicated when pericardiocentesis fails or is unavailable, particularly in traumatic cardiac arrest 2, 1

• Timing is critical: The procedure must occur within 15 minutes of cardiac arrest onset, with concurrent blood transfusions, fluid resuscitation, and anti-shock treatment 2, 1

Absolute Contraindication:

• Do not perform emergency thoracotomy if the patient has absent signs of life (full cardiopulmonary arrest with absent reflexes) on initial prehospital field assessment 3

• Blunt traumatic cardiac arrest has only 1-2% survival and represents a relative contraindication 4, 3

Damage Control Thoracotomy

Immediate surgical intervention is required for massive progressive hemorrhage when initial chest tube drainage exceeds 1000 mL or ongoing drainage exceeds 200 mL/hour for more than 3 hours despite anti-shock treatment. 1, 2

Specific Indications:

• Severe pulmonary laceration: When closed thoracic drainage fails to relieve dyspnea or continuous hemorrhage persists, surgical options include repair, lobectomy, segmentectomy, or hilar torsion for temporary control 1, 2

• Cardiac injuries: Severe heart contusion, penetrating cardiac injuries with hemodynamic instability, or pericardial tamponade with Beck's triad 1

• Major airway injuries: Severe tracheal and bronchial injuries when tracheotomy and closed drainage cannot alleviate dyspnea 1, 2

Surgical Approach Selection

Use an anterolateral left thoracotomy as the initial approach for most damage control situations, as it provides optimal access to the pericardium, descending aorta, proximal left subclavian arteries, and left hilum. 1, 2

Approach Algorithm:

• Left anterolateral thoracotomy (5th intercostal space): First-line for most resuscitative and damage control situations; allows exposure of pericardium, heart, descending aorta, and left hilum 2, 1

• Clamshell extension: Add when bilateral exposure is needed, inadequate visualization occurs, or access to right-sided structures is required 1, 2

• Median sternotomy: Reserved for isolated cardiac and great vessel injuries when the patient is stable enough for positioning 1, 2

• Right thoracotomy: Consider for isolated right-sided injuries, though less commonly used in emergency settings 2

Essential Technical Maneuvers

During the Procedure:

• Open the pleura and pericardium immediately to release tamponade 2, 1

• Clamp the descending aorta to redistribute blood volume and perfuse coronary and carotid arteries 2, 5

• Perform open cardiac massage if needed for cardiac arrest 6, 5

• Control hemorrhage directly from cardiac, pulmonary, or great vessel injuries 6, 4

• Treat systemic air embolism if present 6

Critical Pitfalls to Avoid

• Never perform emergency thoracotomy without concurrent aggressive resuscitation: Blood transfusions and fluid resuscitation must be ongoing 2, 1

• Do not delay in patients meeting criteria: Delayed surgical treatment (>24 hours) increases morbidity and reduces odds of successful primary repair 2

• Avoid this procedure in blunt trauma with prolonged prehospital arrest: Survival is approximately 1-2% and resources may be better allocated 4, 3

• Ensure surgical expertise and backup are available: The procedure should only be performed where immediate cardiothoracic surgery backup is available for emergency sternotomy if complications arise 2

Outcome Expectations

• Overall survival for emergency thoracotomy: 7.8-13% across all trauma types 7, 3

• Penetrating cardiac injuries: 22-38% survival, with stab wounds having better outcomes (34%) than gunshot wounds (8%) 3, 4

• Blunt trauma: 1-2% survival, making it a relative contraindication 4, 3

• Best outcomes: Patients who reach the operating room for emergency thoracotomy have 54% survival 3