What are the indications for open thoracotomy (surgical incision into the thorax) in patients with chest trauma?

Indications for Open Thoracotomy in Chest Trauma

Open thoracotomy in chest trauma is indicated for resuscitative purposes in cardiac arrest/impending arrest within 15 minutes, massive progressive hemorrhage (>1000 mL initial or >200 mL/hour for 3+ hours), cardiac tamponade, severe pulmonary laceration with failed chest tube management, and major airway injuries unresponsive to conservative measures. 1, 2

Resuscitative Emergency Thoracotomy

Perform immediate thoracotomy for patients in cardiac arrest or impending cardiac arrest occurring within 15 minutes of injury onset, using a left anterolateral incision or clamshell approach. 3, 1 This must be done with concurrent blood transfusion, fluid resuscitation, and anti-shock treatment. 1

Key Technical Steps:

• Open the pleura and pericardium 3, 1
• Clamp the injured aorta 3, 1
• Perform intrathoracic CPR 3, 1
• If heart resuscitation is successful, immediately transfer to the operating room for definitive repair 3

Survival Expectations:

The evidence shows dramatically different outcomes based on mechanism: penetrating thoracic trauma yields 9-38% survival rates, while blunt trauma survival is only 1-2%. 4, 5 Patients with blunt trauma presenting without signs of life have essentially zero survival and this procedure should be abandoned in such cases. 6

Damage Control Thoracotomy for Hemorrhage

Proceed with urgent thoracotomy 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, 7

Critical Caveat for Blunt Trauma:

Unlike penetrating injuries where chest tube output reliably predicts need for surgery, blunt trauma patients frequently have nontherapeutic thoracotomies when chest tube output alone is the indication. 8, 9 In blunt trauma, only 1.7% of patients require urgent thoracotomy, and 93% of these present in refractory shock from active hemorrhage—not just elevated chest tube output. 8 Exercise extreme caution when deciding to operate on blunt trauma based solely on chest tube drainage, particularly if the patient has undergone prior procedures and is coagulopathic. 9

Cardiac Injuries

Perform thoracotomy for penetrating cardiac injuries with hemodynamic instability, pericardial tamponade with Beck's triad, or severe heart contusion. 1

• In hemodynamically unstable patients, proceed directly to emergent thoracotomy 3
• In hemodynamically stable patients with penetrating chest trauma, perform bedside cardiac ultrasound first to diagnose occult cardiac injury 3
• Ultrasound examination can confirm pericardial trauma and guide immediate lifesaving actions 3
• Watch for the false-negative scenario: cardiac injury decompressing into the hemithorax through a pericardial rent may present as large hemothorax without pericardial effusion 3

Cardiac injuries account for 46% of stab wounds and 14% of gunshot wounds requiring thoracotomy. 8

Severe Pulmonary Lacerations

Operate when closed thoracic drainage fails to relieve dyspnea or leads to continuous hemorrhage. 3, 1, 7

Surgical options include: 3, 1

• Direct repair
• Lobectomy
• Segmentectomy
• Unilateral lung resection
• Hilar torsion for temporary control

Major Airway Injuries

Perform surgical repair for severe tracheal and bronchial injuries when tracheotomy and closed thoracic drainage cannot alleviate dyspnea. 3, 1 If skilled thoracic surgeons are unavailable, prioritize evacuation. 3

Great Vessel Injuries

In progressive chest hemorrhage from penetrating trauma of thoracic great vessels, perform urgent thoracotomy to repair damaged vessels or perform vascular bypass. 3

For blunt trauma, descending thoracic aorta or arch vessel tears account for 48% of patients requiring thoracotomy. 8 These patients typically present with shock (48%) or have angiographically-defined great vessel injuries (48%). 8

Surgical Approach Selection

Use anterolateral left thoracotomy as the initial approach for most damage control situations, providing access to pericardium, descending aorta, and left hilum. 1

• Extend to clamshell incision when bilateral exposure is needed or visualization is inadequate 1
• Use median sternotomy for isolated cardiac and great vessel injuries 1
• Make the incision in the 4th or 5th intercostal space, extending from sternum to mid-axillary line 2
• Divide intercostal muscles along the superior border of the lower rib to avoid neurovascular bundle injury 2

Damage Control Principles

If the patient develops severe coagulopathy, profound hypothermia, or severe acidosis during the procedure, abort definitive repair and transition to damage control surgery. 2

• Pack all bleeding sites with laparotomy pads 2
• Achieve temporary hemostasis without attempting complex repairs 2
• Never delay thoracotomy in unstable patients for additional imaging or "optimization"—immediate surgical control is required 2