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OCTOBER8,2015GMT

EmergencyDepartmentThoracotomy
Indicationsandtechniqueofresuscitativethoracotomy
KarimBrohi,London,UK,September30,2006

"Thesurgeonwhoshouldattempttosutureawoundoftheheartwouldlosetherespectofhissurgicalcolleagues"
TheodoreBilroth,1882

Introduction
ManysurgeonsstillsharethepessimismofBilrothwhendiscussingemergencythoracotomy.Nevertheless,currentstudies
haveshownsurvivalratesapproaching60%inselectedgroupsofpatients.ShortlyafterBilrothdismissedsurgeryfor
cardiacinjury,thefirstreportofsuccessfulmanagementoftraumaticcardiacinjurywaspublishedbyRehnin1900.Thefirst
successful'prehospital'thoracotomyandcardiacrepairwascarriedoutbyHillonakitchentableinMontgomery,Alabamain
1902.

Emergencydepartmentthoracotomyisalifesavingprocedureinaselectgroupofpatients.Exactlywhothesepatientsareis
amatterofsomecontroversyinthetraumaliterature.Thereisasignificantamountofpublisheddataontheindicationsfor
andoutcomesofresuscitativethoracotomy.Howevertheresultsofinterventionsvarieswidely,asdoeseachunit's
experience,puclisheddatarangingfor11patientsin10yearsto950patientsin23years.
Moststudiesgivelittleindicationastowhathasgonebefore(apartfromphysiologicaldata).Prehospitaldatasuchastimeof
injury,paramediconscenetimeandtimeintheemergencydepartmentpriortothoracotomyarerarelygiven.Theuseof
prehospitalmanoeuversthatmayworsenoutcome,suchasexternalchestcompressionsandlargevolumefluid
resuscitation,arealsonotroutinelypublished.Similarly,theindicationsforperformingsurgeryarenotuniformand
inconsistentlyapplied,ornotrecordedatall.Thereareonly3prospectivestudiesintheliterature.

Indications
Whilethetechniqueofemergencythoracotomyisfairlystandard,theindicationsforperformingsurgeryremainasourceof
controversy.Thefollowingareasuggestedsetofguidelinesforgeneraluse.Inpracticethesewillvarywithlocalresources
andskillavailability.

AcceptedIndications
Penetratingthoracicinjury
Traumaticarrestwithpreviouslywitnessedcardiacactivity(prehospitalorinhospital)
Unresponsivehypotension(BP<70mmHg)
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Bluntthoracicinjury
Unresponsivehypotension(BP<70mmHg)
Rapidexsanguinationfromchesttube(>1500ml)

RelativeIndications
Penetratingthoracicinjury
Traumaticarrestwithoutpreviouslywitnessedcardiacactivity
Penetratingnonthoracicinjury
Traumaticarrestwithpreviouslywitnessedcardiacactivity(prehospitalorinhospital)
Bluntthoracicinjuries
Traumaticarrestwithpreviouslywitnessedcardiacactivity(prehospitalorinhospital)

Contraindications
Bluntinjuries
Bluntthoracicinjurieswithnowitnessedcardiacactivity
Multipleblunttrauma
Severeheadinjury

Rationale
Overallsurvivalofpatientsundergoingemergencythoracotomyisbetween4and33%dependingontheprotocolsusedin
individualdepartments.Themaindeterminantsforsurvivabilityofanemergencythoracotomyarethemechanismofinjury
(stab,gunshotorblunt),locationofinjuryandthepresenceorabsenceofvitalsigns.

MechanismofInjury
Forpenetratingthoracicinjurythesurvivalrateisfairlyuniformat1833%,withstabwoundshavingafargreaterchanceof
survivalthangunshotwounds.Isolatedthoracicstabwoundscausingcardiactamponadeprobablyhavethehighestsurvival
rate,approaching70%.Incontrast,gunshotwoundsinjuringmorethanonecardiacchamberandcausingexsanguination
haveamuchhighermortaility.
Blunttraumasurvivalratesvarybetween0and2.5%andsomeauthoritiessuggestthatthoracotomyforblunttraumashould
beabandonedaltogether.However,thisisanoversimplificationoftheliterature.Thereisadistinctsurvivalrateforpatients
withisolatedbluntthoracictraumawhoundergoemergencythoracotomy.Thisishighestforpatientswhoareseverely
hypotensiveintheemergencyroomandareexsanguinatingfromachestinjury.Bluntthoracictraumacausingtraumatic
arrestintheemergencydepartmentshouldalsoundergothoracotomy.Whetherthisshouldbeextendedtothosepatients
arrestinginthepresenceofprehospitalemergencyservicesisdebatable.

LocationofInjury
Almostallsurvivorsofemergencythoracotomysufferisolatedinjuriestothethoraciccavity.Cardiacinjurieshavethehighest
survivalrates,withimprovedoutcomeforsinglechamberversusmultiplechamberinjuries.Injuriestothegreatvesselsand
pulmonaryhilacarryamuchhighermortality.Injuriestothechestwallrarelyrequireemergencythoracotomybuttendto
haveagoodoutcome.
Therationaleforperformingthoracotomyforinjurytootherpartsofthebody,suchastheabdomenorpelvis,istocross
clampthedescendingaortaandsocontrolexsanguinationandredistributebloodflowtothevitalorgans.Penetratinginjury
totheabdomenmaybenefitfromthismanoeuverbutthoracotomyformultipleblunttraumahasanalmostuniversallypoor
outcome.

Presenceofvitalsigns
Thepresenceofcardiacactivity,ortheamountoftimesincelossofcardiacactivityisconsistentlyrelatedtotheoutcome
followingemergencythoracotomy.Inonestudyof152patients(Tyburski)survivalrateswere0%forthosepatientsarresting
atscene,4%whenarrestoccurredintheambulance,19%foremergencydepartmentarrestand27%forthosewho
deterioratedbutdidnotarrestintheemergencydepartment.
Survivalforblunttraumapatientswhoneverexhibitedanysignsoflifeisalmostuniformlyzero.Survivalforpenetrating
traumapatientswithoutsignsoflifeisbetween0and5%.

Resuscitation
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Whatdoesanddoesnothappenbeforeandduringtheemergencythoracotomyisasimportantastheoperativeprocedure
itself.Manypatientsdiebecauseofinappropriateinterventionsintheprehospitalorearlyinhospitalphase,becauseof
delayinperformingthoracotomyandduetopoorperioperativemanagement.
ALS/ACLSalgorithmsDONOTAPPLYtotraumaticarrest.
Theprimarycausesoftraumaticarrestarehypoxia,hypovolaemiaduetohaemorrhage,tensionpneumothorax,andcardiac
tamponade.Hypoxicarrestsrespondrapidlytointubationandventilation.Hypovolaemia,tensionpneumothoraxand
cardiactamponadeareallcharacterisedbylossofvenousreturntotheheart.Externalchestcompressionscanprovidea
maximumof30%ofcardiacoutputinthemedicalarrestsituationsandaredependentonvenousreturntotheheart.Chest
compressionsinthetraumapatientarewhollyineffective,mayincreasecardiactraumabycausingbluntmyocardialinjury
andobstructaccessforperformingdefinitivemanoeuvers.
Theadministrationofinotropesandvasopressorssuchasadrenalinetothehypovolaemicpatient(whoisalreadymaximally
vasoconstricted)causesprofoundmyocardialhypoxiaanddysfunction.

ManagementofTraumaticArrest
Immediatetreatmentoftraumaticarrestisdirectedattreatingthecauseofthetraumaticarrest.
Hypoxicarrest
Trachealintubationismandatoryandshouldbesecuredimmediately.Ventilationwith100%oxygenshouldrapidlyreverse
hypoxictraumaticarrestwithouttheneedforfurtherinterventions.Thisisespeciallytrueofpaediatricheadinjuries.
Tensionpneumothorax
Reliefoftensionpneumothoraxshouldbeaccomplisedrapidlyeitherbyneedlechestdecompressionorpreferablybilateral
thoracostomies(asperchesttubeinsertion).Bilateraltensionpneumothoracesmayexistandtheclassicsignsofatension
(trachealdeviation,unilateralhyperresonance)maynotbepresent.Tensionpneumothoracesshouldthereforebe
presumedandbilateraldecompressionundertakeninallcasesoftraumaticarrest.
Massivehaemorrhage
Performingbilateralthoracostomieshastheadvantageofidentifyingmajorhaemorrhageandwhichsideofthechestthe
majorinjuryison.Thiswilldeterminetheinitialincisionforthethoracotomy.
Thetreatmentofmassivethoracichaemorrhageiscontrolofhaemorrhage,notintravenousfluidtherapy.Fluidtherapyprior
tohaemorrhagecontrolworsensoutcomeinpenetratingthoracictrauma(andperhapsallpenetratingtraumapatients).If
thereisnoresponsetoasmall(500ml)fluidchallenge,fluidadministrationshouldbehalteduntilhaemorrhagecontrolis
achieved.
Cardiactamponade
Theclassicsignsofdistendedneckveinsandmuffledheartsoundsarealmostuniversallyabsentintraumaticcardiac
tamponade.Needlepericardiocentesismayalsofailasadiagnosticmeasureduetobloodinthepericardialsacbeing
clotted.FASTultrasoundscan,ifavailable,willindicatethepresenceofpericaridalfluid.Thepericardiummaybefelt
throughtheleftthoracostomytoassessforthepresenceoftamponade.
Anaesthesia
Patientsintraumaticarrestwillnotrequireinductionofanaesthesiapriortointubationandthoracotomy.Patientswhoare
hypotensivebutawakewillrequireamodifiedrapidsequenceintubation.Inductionofanaesthesiamayleadtoadramatic
lossofbloodpressureandcareshouldbetakenwiththechoiceofinductionagent.Ketamineand/oranopiate(suchas
fentanyloralfentanil)maybepreferabletothestandardintravenousinductionagents.Evenetomidatemaycausealarge
fallincardiacoutputinthehypovolaemicpatient.Anaesthesiamaybemaintainedwithaninfusionorbolusdosesof
intravenousanaesthetic.Musclerelaxationismaintainedthroughout.
FluidTherapy
Largevolumefluidtherapyshouldbeavoidedpriortohaemorrhagecontrol.Oncehaemorrhageiscontrolledpatientswill
needrapidcorrectionofhypovolaemiatorefilltheheartandrestoreperfusiontononvitalorgansystems.Patientswillbe
coldandprofoundlycoagulopathic.BloodandcomponenttherapyshouldbewarmedandadministeredrapidlyAFTER
haemorrhageiscontrolled.See'TransfusionforMassiveBloodLoss'.Administrationofcolloidsolutionsisnotindicated.
Inotropic/Vasopressoradministration
Asmentionedabove,theuseofadrenaline(orotherinotropes/pressors)iscontraindicatedinthepresenceof
hypovolaemia.Inotropesmayberequiredaftercontrolofhaemorrhageandcardiacrepair.Directmyocardialinjury,
ischaemicmyocardialinjury,acutecardiacdilatation,pulmonaryhypertensionandmediatorreleaseduetoglobaltissue
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ischaemiacanallleadtocardiogenicshockwhichmayrequireinotropicsupport.

OperativeTechnique
Theprimaryaimsofemergencythoractomyare:
Releaseofcardiactamponade
Controlofhaemorrhage
Allowaccessforinternalcardiacmassage
Secondarymanoeuversincludecrossclampingofthedescendingthoracicaorta.
Oncecontrolisachievedandcardiacactivityrestored,thepatientistransferredrapidlytotheoperatingroomfordefintive
management.

Equipment
Approach:
Scalpelwith10blade

CurvedMayoscissors
Ribspreader
Giglisaworlarge'trauma'shears

Haemorrhagecontrol:
McIndoe/Metzenbaumscissors
DeBakeyvascularforceps(long)
DeBakeyaorticclamp
Satinskyvascularclamp(large&small)
Mosquito/Dunhillarteryclips(10)
Long&shortneedleholders

3/0nonabsorbablesuture(nylon,polypropene)on
roundbodiedneedlesmultiple
2/0absorbableties(vicryl,pdsetc)multiple
Laparotomypacks
Teflonpledgetssmall.(10)

Highvolume,highdisplacementsuction

Approach
Asupineanterolateralthoracotomyistheacceptedapproachforemergencydepartmentthoracotomy.Aleftsidedapproach
isusedinallpatientsintraumaticarrestandwithinjuriestotheleftchest.Patientswhoarenotarrestedbutwithprofound
hypotensionandrightsidedinjurieshavetheirrightchestopenedfirst.

Inbothcasesitmaybecomenecessarytoextendtheincisionacrossthesternumtoaidaccessandvision.Witharightsided
thoracotomy,theleftchestwillhavetobeopenedifinternalcardiacmassagebecomesnecessary.
Gainingaccesstothethoraciccavityshouldtakenomorethan12minutes.Afterrapidskinpreparationwithlarge
antisepticsoakedswabs,askinincisionismadeinthe5thintercostalspacefromtheborderofthesternumtothemid
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axillaryline.Thisiscontinueddownthroughsubcutaneoustissuestoreachtheintercostalmusculature.Enterthechest
bluntlywithafingerthroughtheintercostalmuscles(aswithachesttubeinsertion).Theopeningisextendedwitha
combinationofheavyscissorsandbluntdissection.Takecarenottolaceratethelungatthisstage.Inserttheribspreaders
betweentheribsandopen.

Ifthethoracotomyhastobeextendedtotheothersideofthechest,repeatthethoracotomyontheotherside.Todividethe
sternum,alargepairoftraumashears(asusedtocuttheclothesoffpatients)willeasilygothroughthesternum.Otherwise
theGiglisawisusedtodividethesternum.ThefirsttimeyouseeaGiglisawshouldnotbethefirsttimeyouperforma
thoracotomy.Examineonetoseehowitisputtogetherandpracticetheactionneededtosawthroughbone.Oncethrough
thesternumtheribspreaderismovedtothemidlinetoopenthechestatthesternum.
Divisionofthesternumresultsintransectionoftheinternalmammaryarteries.Thesewillstarttobleedoncebloodpressure
isrestoredandwillneedclippingandligationsubsequently.

Reliefoftamponade
Thepericardiumisopenedlongitudinallytoavoiddamagetothephrenicnerve,whichrunsalongitslateralborder.Itis
difficulttovisualisethephrenicnerveintheemergencythoracotomy.Makeasmallincisioninthepericardiumwithascalpel
andthentearthepericardiumlongitunidallywithyourfingersthiswillavoidlaceratingthephrenicnerve.Extendthe
incisionwithscissorsuptotherootoftheaorta.Ifnecessarymoreaccesscanbegainedbyextendingthebaseofthe
incisionasaninverted'T'.Evacuateanybloodandclotfromthepericardialcavity.

Controlofhaemorrhage
Cardiacwounds
Cardiacwoundsshouldbecontrolledinitiallywithdirectfingerpressure.Largewoundsmaybecontrolledtemporarilybythe
insertionofafoleycatheterwithinflationoftheballoon.Theballoonmayobstructinfloworoutflowtractshoweveranditmay
alsoleadtoextensionofthelacerationifexcessivetractionisplacedonit.Satinskyclampscanbeplacedacrosswoundsof
theatriatocontrolhaemorrhage.Withextensivecardiacdamageitmaybenecessarytotemporarilyobstructvenousinflow
toallowrepair.Takecarealsonottomissposteriorcardiacwounds.Examinationoftheposteriorsurfaceoftheheart
requiresdisplacingitanteriorly,whichmayobstructvenousinflow.
Cardiacwoundscanbedirectlysuturedusingnonabsorbable3/0suturessuchasnylonorpolypropene.Bypassis
unnecessary,eveninthebeatingheart.Teflonpledgetsareunnecessaryintheleftventriclebut,ifavailable,maybeusedin
therightventricle.Withwoundsintheregionofthecoronaryvessels,mattresssuturesareusedtoavoidobstructing
coronaryflow.Atrialwoundsaresuturedusingacontinuoustechnique.
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Pulmonary&Hilarinjuries
Massivehaemorrhagefromthelungorpulmonaryhilumcanbetemporarilycontrolledwithfingerpressureatthepulmonary
hilum.ThismaybeaugmentedbyplacementofaSatinskyclampacrossthehilum.Thiscanhowevercauselacerationofthe
pulmonaryveinswhenusedemergentlybytheinexperiencedsurgeon.Analternativeistotieoffthepulmonaryhilumusing
trachealtubetieortapefromalaparotomypack.
Acuteocclusionofthepulmonaryhilumoftenleadstoimmediateacuterightheartfailure,especiallyintheyoungfitadult.
Thisneedstoberecognisedearlyandmanagedwithonlypartialorintermittentocclusionofthepulmonaryhilum.
Lesserhaemorrhagefromthelungparenchymascanbecontrolledwithatemporaryclamp.
Greatvesselinjuries
Smallaorticinjuriescanbesutureddirectlyusingthe3/0nonabsorbablesuture.Largerinjuries,especiallytothearchmay
requiretemporarydigitalocclusionandinsitutionofcardiacbypass.
Accesstothevascularstructuresofthesuperiormediastinumisdifficultwithananterolateralthoracotomy.Thesternummay
havetobesplitinthemidlineand/orasupraclavicularincisionusedtocontrolhaemorrhagefromsubclavianand
innominatevessels.Again,controlisachievedtemporarilywithdigitalpressureorproximal&distalclampapplicationprior
todefintiverepair.

Internalcardiacmassage
Intraumaticarrest,internalcardiacmassageshouldbestartedassoonaspossiblefollowingreliefoftamponadeandcontrol
ofcardiachaemorrhage.Atwohandedtechniqueproducesabettercardiacoutputandavoidsthelowriskofcardiac
perforationwiththeonehandedmanoeuver.

Aorticcrossclamping
Crossclampingofthedescendingthoracicaortaisusedroutinelyinsomecentresandnotatallinothersduringemergency
thoracotomy.Therationaleforclampingtheaortaistoredistributebloodflowtothecoronaryvessels,lungsandbrain,to
reduceexsanguinationfrominjuriesinthelowertorso.
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Theefficacyoftheaorticcrossclampinimprovingperfusionofthecoronaryarteriesandbrainisunclearhowever.Over
zealousfluidreplacementwiththeaorticclampinplacemayleadtoasignificantriseinafterloadandprecipitatecardiac
failure.Organsdistaltotheclampwillbecomeischaemicandthisincludesthespinalcordwhentheclampisplacedhigher,
attheaorticisthmus.Clamptimeshouldideallybe30minutesorless.Onremovaloftheclampthereisreperfusionofthe
ischaemiclowertorso,andproductsofanaerobicmetabolismandactivatedinflammatorymediatorsarereleasedbackinto
thesystem.Thismayleadtomyocardialdepressionandsubsequentsystemicinflammatoryresponsesyndrome.
Crossclampingofthedescendingthoracicaortashouldpossiblybereservedforpatientswithpotentialexsanguinating
injuriestothedistaltorso.
Crossclampingisdoneideallyatthelevelofthediaphragm,tomaximisespinalcordperfusion.Otherwisejustbelowtheleft
pulmonaryhilum.Thelungisretractedanteriorlyandthemediastinalpleuraincised.Bluntdisectionisusedtoseparatethe
aortafromtheoesophagusandprevertebralfascia.Thisdissectionshouldbeenoughtoplaceaclampacrosstheaortabut
notcomplete,toavoidavulsingaorticbranchessupplyingthecordandthorax.

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Prospective
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Retrospective
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Opencardiacmassageversusexternalcardiaccompression
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Circulation196531(suppl):171
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Thoracicaorticcrossclamp
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