Resuscitative Thoracotomy

David Ray Velez, MD

Also Known as: “ED Thoracotomy” or “ER Thoracotomy”

Goals and Outcomes

Goals

Immediately Restore Cardiac Output
- Release Pericardial Tamponade
- Perform Open Cardiac Massage
Control Major Thoracic Hemorrhage
Temporarily Occlude the Descending Thoracic Aorta
Evacuate Massive Air Embolism

Survival/Outcomes

Overall: 7.4-8.5%
Penetrating Trauma: 9.0-15.0%
- Isolated Penetrating Cardiac Injury: 17.3-35.0% – Best Outcomes
- Penetrating Abdominal Injury: 4.0-7.0%
Blunt Trauma: 1.4-2.7%

General Indications

Western Trauma Association (WTA) Algorithm (2012)

CPR with No Signs of Life:
- Penetrating Trauma:
  - < 15 Minutes of Prehospital CPR
  - < 5 Minutes of Prehospital CPR with Penetrating Trauma to the Neck or Extremity
- Blunt Trauma:
  - < 10 Minutes of Prehospital CPR
Consider for Profound Refractory Shock (CPR with Signs of Life or SBP < 60 mmHg)

EAST Guidelines (2015)

Penetrating Trauma:
- Thoracic Injury
  - Pulseless with Signs of Life After Injury – Strong Recommendation
  - Pulseless without Signs of Life After Injury – Conditional Recommendation
- Extra-Thoracic Injury
  - Pulseless with Signs of Life After Injury – Conditional Recommendation
  - Pulseless without Signs of Life After Injury – Conditional Recommendation
Blunt Trauma:
- Pulseless with Signs of Life After Injury – Conditional Recommendation
- Pulseless without Signs of Life After Injury – Recommend Against

General Approach

Incision
Open Pericardial Sac – Typically the First Step
ACLS Measures as Indicated
- Cardiac Massage
- Internal Defibrillation
- Intracardiac Epinephrine
Cross-Clamp Aorta
Control Any Overt Hemorrhage
Aspiration if Air Embolism Suspected
*Order May Vary Depending on Presentation

Incision

Left Anterolateral Thoracotomy (Some Prefer a “Clamshell” Bilateral Anterolateral Thoracotomy)
Place Left Arm Above the Head
Incision at the Left Intercostal Space #4-5
- Just Under the Nipple or Inframammary Fold
- Extend from the Sternum All the Way Down to the Bed Along the Curvature of the Rib
Enter Along Superior Margin of Lower Rib Using a Curved Mayo Scissors to Cut Through the Intercostals
Use a Rib Spreader (Finochietto Retractor) to Retract

Pericardiotomy/Open Pericardial Sac

Open Pericardium Anterior and Parallel to the Phrenic Nerve
Evacuate Any Pericardial Clot
Control Any Active Bleeding
- Digital Pressure on Ventricles or Vascular Clamps on Atrium
- Definitive Repair May Be Delayed Until Initial Resuscitation is Complete
*Always Open – Some Consider it Acceptable to Skip if No Tamponade or There Are Obvious Non-Cardiac Injuries

Cardiac Massage and Internal Defibrillation

Cardiac Massage
- Induced Cardiac Output:
  - External Compressions: 20-25% of Baseline
  - Internal Massage: 60-70% of Baseline
- Two-Hand Hinged “Clapping” Technique
- Do Not Use Fingertips or One-Hand with the Thumb Which May Penetrate the Myocardium
Internal Defibrillation (If in Ventricular Fibrillation)
- One Paddle on the Anterior Surface and One on the Posterior Surface
- Maximum of 50 J – Do Not Need to “Clear” from Touching the Patient Due to Low Energy
Also Consider Intracardiac Epinephrine to the Left Ventricle

Cross-Clamp the Aorta

Indicated if Hypotension (SBP < 70 mmHg) Persists After Pericardiotomy
Retract the Left Lung Superiorly and Anteriorly
- May Need to Divide the Inferior Pulmonary Ligament (Risks Injury to the Inferior Pulmonary Vein)
Dissect the Thoracic Aorta
- Incise the Mediastinal Pleura
- Bluntly Separate the Esophagus from the Aorta
  - Esophagus Lies Anterior to the Aorta
  - Consider Orogastric Tube Placement to Assist in Differentiation
  - Take Care to Avoid Cross-Clamping the Esophagus
  - Both May Appears Flaccid in Hypotensive Patient Making Identification Difficult
- Bluntly Separate the Aorta from the Posterior Vertebrae
Clamp the Aorta Just Above the Diaphragm
- Use a Large DeBakey or Satinsky Clamp

Finochietto Retractor ¹

Pericardium and Phrenic Nerve Anatomy ²

Internal Defibrillation ¹

Aorta Cross-Clamp ¹

Anesthesiology Can Right Main-Stem the Endotracheal Tube to Reduce Left Lung Ventilation if Necessary for Visualization and Access

Control Hemorrhage

Cardiac Injury
- Control Injury to the Heart First
- Often Use 3-0 Prolene (Non-Absorbable)
- Often Perform Simple Running in the Atrium and Vertical Mattress in the Ventricles
- May Require Buttressing with Teflon or Pericardial Pledgets
Lung Injury
- Can Clamp Parenchyma
- Can Clamp Hilum (From Superior to Inferior – Does Not Require Mobilization)
- “Pulmonary Hilar Twist”
  - First Divide the Inferior Pulmonary Ligament
  - Rotate the Lower Lobe Anteriorly Over the Upper Lobe
  - *Last Choice – High Morbidity and May Require Pneumonectomy if Maintained for Prolonged Periods of Time
Control Any Other Obvious Sites of Bleeding

Evacuate Air Embolism

Air Embolism May Occur From Traumatic Bronchovenous Communications
- Due to Relatively High Bronchoalveolar Pressure and Low Pulmonary Venous Pressure
- Often Seen as Acute Decompensation Shortly After Intubation and Positive-Pressure Ventilation
Cross-Clamp the Hilum of the Suspected Source to Prevent Propagation
Place in Trendelenburg Position
Aspirate Air from the Apex of the Left Ventricle and Aortic Root

Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006 Mar 24;1:4. (License: CC BY-2.0)
Gray H. Anatomy of the Human Body (1918). Public Domain.