What are the indications, recommended technique, and contraindications for performing a resuscitative emergency department thoracotomy in trauma patients?

Emergency Department Thoracotomy

Resuscitative emergency department thoracotomy should be performed immediately for penetrating chest trauma patients who arrest within 15 minutes of injury or arrive with signs of life, using a left anterolateral incision through the 4th-5th intercostal space, while blunt trauma patients without vital signs at the scene should not undergo the procedure. 1, 2

Primary Indications

Penetrating Trauma (Strong Indications)

• Cardiac arrest or impending cardiac arrest occurring within 15 minutes of injury from penetrating trauma 3, 1, 2
• Penetrating chest wounds with signs of life at the scene but lost during transport 2, 4
• Pericardial tamponade with Beck's triad (hypotension, muffled heart sounds, jugular venous distension) 3, 1, 2
• Profound shock (systolic BP <60 mmHg) or moderate shock (BP 60-90 mmHg) with subsequent arrest in penetrating trauma 5

The survival data strongly supports this approach: penetrating trauma patients have 22% overall survival, with stab wounds achieving 34% survival and cardiac tamponade cases reaching 64% survival when treated promptly 3, 5. Patients with thoracic penetration and directed cardiac injury have 21.4% survival compared to essentially zero for non-directed thoracotomies 6.

Damage Control Indications

• Initial chest tube drainage >1000 mL or ongoing drainage >200 mL/hour for >3 hours despite resuscitation 3, 1, 2
• Severe pulmonary laceration when closed thoracic drainage fails to relieve dyspnea or causes continuous hemorrhage 1, 2
• Severe tracheal or bronchial injuries when tracheotomy and closed drainage cannot alleviate dyspnea 3, 1, 2

Absolute Contraindications

Do Not Perform Emergency Thoracotomy If:

• No signs of life (full cardiopulmonary arrest with absent reflexes) on initial prehospital field assessment 5
• Blunt trauma with absent vital signs at the scene 5, 7, 6
• Severe head trauma with cardiopulmonary arrest 7
• Prolonged CPR >15 minutes before arrival 3

The evidence is unequivocal: zero patients with absent signs of life in the field survived in a series of 215 patients, and no blunt trauma patients without vital signs survived in multiple studies 5, 6, 8. This represents futile care that exposes healthcare workers to bloodborne pathogen risk without benefit 9.

Recommended Surgical Technique

Incision Selection

• Left anterolateral thoracotomy through the 4th-5th intercostal space from sternum to posterior axillary line is the initial approach 3, 1, 4
• Enter at the upper border of the rib to avoid neurovascular bundles 4
• Extend to clamshell approach (bilateral anterior thoracotomy with transverse sternotomy) when bilateral exposure needed or inadequate visualization 3, 1, 2
• Median sternotomy reserved for isolated cardiac and great vessel injuries 1, 2

The left anterolateral approach provides optimal access to the pericardium, descending aorta, proximal left subclavian arteries, and left hilum 3. The clamshell extension improves exposure of bilateral thoracic structures and the thoracic inlet 3.

Essential Maneuvers (In Order)

1. Open the pericardium with longitudinal incision anterior to the phrenic nerve to relieve tamponade 4
2. Control cardiac wounds with direct finger pressure initially, then repair with simple interrupted or running stitches 4
3. Clamp the descending aorta to redistribute blood flow to heart and brain 3
4. Perform open cardiac massage (intrathoracic CPR) 3
5. For massive pulmonary hemorrhage, twist and clamp the pulmonary hilum 4
6. Pack wounds with any available material if immediate suturing impossible 4

Concurrent Resuscitation Requirements

The procedure must be performed with simultaneous massive transfusion protocol, fluid resuscitation, and anti-shock treatment 3, 1. If heart resuscitation is successful, immediately transfer to the operating room for definitive surgical repair 3.

Critical Pitfalls to Avoid

• Do not delay seeking "proper" equipment in resource-limited settings—use any sharp cutting instrument sterilized with fire or alcohol, heavy scissors or wire cutters for rib spreading 4. Every minute of delay dramatically reduces survival 4.

• Recognize that patients remain at risk for tension pneumothorax even after thoracotomy, especially under positive pressure ventilation 2. This can cause death within minutes if unrecognized 2.

• Avoid complex repairs in the emergency setting—focus on simple suturing, packing, and clamping for damage control 2, 4. Definitive repair occurs in the operating room.

• Do not perform emergency thoracotomy for penetrating abdominal injuries without thoracic involvement—the role remains unproven with poor outcomes 6.

• Understand that operating room thoracotomy has significantly better survival (54%) than emergency department thoracotomy (13% overall) 5. Transport stable patients to the OR when feasible.

Realistic Survival Expectations

The overall survival for emergency department thoracotomy is 7.8-13%, but this varies dramatically by mechanism and presentation 5, 9:

• Stab wounds to chest: 16.8-34% 3, 5
• Gunshot wounds to chest: 4.3-8% 3, 5
• Blunt trauma: 2% 5
• Cardiac tamponade: 21.4-64% 5, 6
• Operating room thoracotomy: 54% 5

These numbers justify the aggressive approach in penetrating trauma with recent arrest but confirm the futility in blunt trauma without vital signs 5, 9, 7.