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Clinical Procedures > Cardiothoracic Procedures
Emergency Bedside Thoracotomy
Article Last Updated: Apr 14, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Gretchen S Lent, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Coauthor(s):
Neel Kumar, MD, Chief Resident, Department of Emergency Medicine, Albert Einstein College of Medicine, Jacobi and Montefiore Medical Centers
Editors: Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
emergency department thoracotomy, EDT, emergency bedside thoracotomy, thoracotomy, traumatic arrest, penetrating thoracic injury, blunt thoracic injury, pericardiotomy, rib spreader, penetrating chest trauma, penetrating chest injury, chest wound, thoracic wound, blunt chest trauma, blunt chest injury
Since its introduction in 1900, the emergency department thoracotomy (EDT) has been a subject of intense debate. While some studies boast a 60% survival rate, others have argued that EDT is a futile procedure that places health care providers at significant personal risk. Further, indications for EDT have varied widely. For these reasons, the EDT remains a controversial but potentially lifesaving procedure in a select group of patients.1, 2 Assaults remain the second leading cause of death in US residents aged 15-34 years. In 2002, 9,369 gun deaths and 1,767 knife deaths were recorded in the United States. These statistics, combined with an increasing subset of patients with penetrating cardiac injuries3 for which EDT may be potentially lifesaving, should encourage every emergency physician to know the indications and steps to performing an EDT. The primary goals of EDT include the following4: If the patient survives the EDT, take him or her expediently to the operating room. For more information on the treatment of trauma, visit the Medscape Trauma Resource Center.
The indications for EDTs have been much debated.
To simplify the issue, The American College of Surgeons Committee on Trauma has instituted general guidelines on this subject.9 The decision to perform an EDT is determined by the presence of signs of life and the mechanism and location of injury. Increased thoracotomy survival rates are associated with the following: - Signs of life in the emergency department (ED)
- Thoracic injuries (as opposed to abdominal injuries): Although some studies have demonstrated up to a 10% neurologically intact survival rate for patients with penetrating abdominal injury undergoing cross clamping of the descending thoracic aorta as part of EDT, the use of the technique in this setting is variable.
- Penetrating injuries10 (as opposed to blunt injuries): Survival in blunt cardiac injury is significantly lower than with penetrating cardiac injury secondary to poor cardiac function (due to cardiac contusion) and a higher incidence of associated injuries such as cardiac rupture and aortic rupture.11, 12
- Stab wounds13 (as opposed to gunshot wounds [GSW]): GSW injuries are usually unable to spontaneously seal because of the large nature of the injury pattern. If patients present with any signs of life, they are usually in profound hemodynamic compromise.
Signs of life include the following: - Pupillary response
- Spontaneous ventilation
- Presence of carotid pulse
- Measurable or palpable blood pressure
- Extremity movement
- Cardiac electrical activity
Accepted indications for EDT Penetrating thoracic injury with the following conditions: - Previously witnessed cardiac activity (pre-hospital or in-hospital)
- Unresponsive hypotension (systolic blood pressure [SBP] <70 mm Hg) despite vigorous resuscitation14
Blunt thoracic injury with the following conditions: - Rapid exsanguination from the chest tube (>1,500 mL immediately returned)
- Unresponsive hypotension (SBP <70 mm Hg) despite vigorous resuscitation
Relative indications for EDT - Penetrating thoracic injury with traumatic arrest without previously witnessed cardiac activity
- Penetrating nonthoracic injury (eg, abdominal, peripheral) with traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
- Blunt thoracic injuries with traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
EDT should not be performed in patients under the following conditions:
- Blunt injury without witnessed cardiac activity (pre-hospital)15, 16
- Penetrating abdominal trauma without cardiac activity (pre-hospital)
- Nontraumatic arrest
- Severe head injury
- Severe multisystem injury
- Improperly trained team
- Insufficient equipment
- Most patients undergoing EDT are either comatose or will be sedated (and paralyzed) as part of airway management. Consequently, they do not require anesthesia.
- For patients who regain consciousness during the resuscitation and are not orotracheally intubated, the first consideration should be to intubate the patient for adequate control and comfort for the patient. If orotracheal intubation is not possible (eg, unsuccessful intubation or anticipated difficult intubation) adequate analgesic and amnestic agents are indicated. Ideally, agents that have minimal effects on the cardiovascular system should be used. For more information, see Procedural Sedation.
Personal protective equipment and preparation
- Gloves
- Sterile gloves
- Gown
- Face shield
- Povidone iodine (Betadine)
- Sterile drapes
To enter the chest cavity
- Scalpel, No. 10 or No. 20 blade
- Mayo scissors (alternatively, Metzenbaum scissors)
- Rib spreaders (eg, Finochietto)
- Trauma shears or saw (eg, Gigli)
To control hemorrhage and repair injury
- Tissue/tooth forceps
- Satinsky vascular clamps (large and small)
- Long and short needle holders (eg, Hegar)
- Nonabsorbable sutures (silk), 2-0 or larger, on large round-body needle
- Cardiovascular Ethibond sutures, 3-0
- Teflon pledgets
- Suture scissors
- Aortic clamp instrument
- Kelly clamp
- Skin stapler
- High-volume suction device
- Laparotomy packs
- Tonsil clamps
- Foley catheter, 20F with 30-mL balloon
- Laparotomy pads
- Teflon patches
- Internal defibrillator
- Chest tube, 30F
- The patient should be supine on the stretcher.
- Place several towels beneath the left scapula.
- Raise the patient’s left arm above the head. The patient’s arm may be secured in the elevated position with tape or restraints, if necessary.
Preparation
- Prepare the patient’s left and right chest with iodine.
- Drape the area with sterile sheets or towels.
- Airway control is typically indicated for all patients and is best performed through standard orotracheal techniques. If exposure to the thoracic organs is impeded because of frequent lung inflation, selective right mainstem intubation may be performed.
- A nasogastric tube may be passed to help differentiate the esophagus from the aorta. The procedure should not be delayed for passage of the nasogastric tube.
- In female patients, an assistant should retract the breast upward prior to incision.
Anterolateral thoracotomy approach - The incision is typically made in the fourth intercostal space, beginning at the sternum and extending to the posterior axillary line.
- The incision should be deep enough to partially transect the latissimus dorsi muscle.
- Time should not be taken to count the rib spaces.
- In patients with a suspected left subclavian injury, the incision may be made in the third intercostal space.
- A left-sided approach is made in all traumatic arrests and in patients with left-sided chest injuries. (A right-sided approach may be used in nonarrested patients with right-sided injuries.)
A skin incision is made in the left fifth intercostal space from the sternal border to the midaxillary line. - Separate the skin, subcutaneous fat, and superficial portions of the pectoralis and serratus muscles with a No. 20 scalpel blade.
- Stop ventilation momentarily just before entering the pleural cavity to allow the lung to collapse and minimize iatrogenic injury.
- Use a scalpel to make a small incision through the intercostal muscles.
- Place one blade of blunt-ended scissors into the hole; then, completely transect the intercostal muscles. The operator may insert the fourth and fifth fingers of his or her free hand into the intercostal space and gently push away the lung to prevent injury to it by the scissors.
- After transection of the intercostals muscles, place a rib spreader between the ribs to expose the intrathoracic contents. The rib spreader should be placed with the handle downward to permit for extension of the incision into the right chest if necessary.
- Upon visualization of the thoracic cavity, use suction to evacuate clots and blood.
- If injury to the right side of the heart is suspected, another incision can be made on the right, creating what is known as a clamshell (bilateral anterolateral thoracotomy).
- Alternatively, the sternum can be divided with trauma shears or a Gigli saw to extend the thoracotomy across the midline (called a trap door). Transection of the internal mammary arteries by this technique may result in significant bleeding once blood flow is restored.
Pericardiotomy - If the visualized thoracic contents do not reveal any obvious injury but cardiac injury is suspected, the pericardium should be opened. Visual inspection of the pericardium is not sensitive to rule out cardiac tamponade, and the pericardium should always be opened to assess for retro cardiac blood.
- Use tissue forceps to grasp the parietal pericardium and incise the pericardium with scissors.
- Enter the pericardium anterior to the phrenic nerve and near the diaphragm to avoid injury to the great vessels.
- The phrenic nerve, often difficult to visualize in the ED, is a tendonlike structure. Upon incision of the pericardium, take care to keep the point of the scissors parallel to the heart to prevent damage to the myocardium when extending the incision.
- Alternatively, after the initial incision into the pericardium, the operator can use his or her fingers to tear the pericardium. Such blunt dissection helps to avoid laceration of the phrenic nerve.
- The heart should be delivered from the pericardial sack for inspection.
Anatomy seen after a left-sided thoracotomy. (A) heart, (B) phrenic nerve, (C) cut and retracted pericardium, (D) diaphragm, and (E) lung.
Aortic cross-clamping - Cross-clamping the descending aorta redistributes the available blood flow to the coronary and cerebral arteries.
- Selective clamping of the descending aorta near the level of the diaphragm can also be used to control hemorrhage in abdominal vascular injuries.
- Clamping distally is ideal because it maximizes spinal cord perfusion and because the aorta is relatively mobile at this location.
- Retract the left lung superiorly to expose the aorta.
- Bluntly dissect the mediastinal pleura with a Kelly clamp to reveal the mediastinal structures. The aorta lies anterior to the vertebrae, whereas the esophagus lies anterior and medial to the aorta. While the aorta is said to feel rubbery, firm, and pulsatile, a hypotensive aorta is often difficult to distinguish from the esophagus.
Lateral view of the anatomy encountered on left-sided thoracotomy. - A nasogastric tube may be placed; palpation of this rigid tube is a way to differentiate the esophagus from the descending aorta.
- Occlusion of the aorta above the level of injury can be performed either through digital occlusion or with the use of an aortic tamponade instrument. Take care to not injure aortic or esophageal tissues.
- Organs that are distal to the aorta, including the bowel, kidneys, liver, and spinal cord, may become ischemic after occlusion.
- Clamp time should be limited to 30 minutes or less.
- However, one study found that patients who underwent cross-clamping of the aorta for up to 60 minutes in emergency thoracotomy had no significant decrease in organ function.
- Avoid cross-clamping the aorta in normotensive patients because the elevated afterload compromises cardiac circulation.17
Cardiac repair - Large wounds to the heart may be repaired with pledgetted sutures, incomplete mattress sutures, horizontal mattress sutures, or continuous running sutures. Nonabsorbable sutures, such as polypropylene or nylon, and even staple guns may be used.18 The coronary arteries must not be compromised during repair; this is usually accomplished with mattress sutures.
- Cardiac exsanguination may be temporized by placing a Foley catheter inside the wound, inflating the catheter balloon, and then withdrawing the catheter to occlude the defect. Clamp the catheter to prevent exsanguination.
- Digital occlusion may also be used to stop bleeding temporarily.
Other considerations - Perform internal cardiac massage with a 2-handed technique.
- Compared with standard cardiopulmonary resuscitation (CPR), which delivers up to 20% of the cardiac output, internal CPR produces up to 55% of the body's baseline perfusion.
- Internal defibrillation begins at 20 joules and increases to 40-50 joules. Avoid touching the coronary arteries with the paddles.
- Fluid resuscitation should begin after hemorrhage control. Warmed fluids, blood, and clotting factors are likely necessary.
- Inotropic support may be required after adequate fluid resuscitation in cases of cardiogenic shock.
- Bleeding vasculature may be temporized with atraumatic clamps or sutures and emergently repaired by a specialist.
- Control of the airway via standard orotracheal intubation technique is strongly advised prior to performing EDT. Selective intubation of the right mainstem bronchus is the preferred method. This allows for both ventilation and oxygenation of the patient via the right lung as well as decreased risk of injury to the left lung via decreased left lung expansion during a left-sided anterolateral thoracotomy. To intubate the right mainstem bronchus, directly visualize the vocal cords to pass the endotracheal (ET) tube into the trachea, and then blindly pass the ET tube to approximately 30 cm.
- Either prior to EDT or while the procedure is being performed, an assistant should pass a nasogastric tube to help distinguish the esophagus from the aorta upon exploration of the thoracic contents.
- Use the left anterolateral thoracotomy approach when the site of the injury is unknown and the patient’s status requires immediate intervention for possible intrathoracic injuries.
- Incision over the fifth rib with dissection into the fourth intercostal space provides the best access to the heart and great vessels. This incision is just beneath the nipple in men or along the inframammary fold in women.
- The rib spreaders should be placed with the handle downward to permit for extension of the incision into the right chest if necessary.
- Avoid making the incision too low. The location of the heart is commonly thought of as lower than it actually is.
- The incision should be made just above the rib to avoid injury to the intercostals neurovascular bundle.
- Gaining access to the thoracic cavity should take no longer than 1-2 minutes.
- EDT is a potentially lifesaving procedure; however, its complications must be weighed against its benefits. While overall survival from EDT is 4-33%, poor neurologic outcome commonly occurs after an EDT because of hypoperfusion-related ischemic damage.19 Anoxic brain damage that requires ongoing institutional care is frequent.
- Cardiac injury that resulted in the delayed diagnosis of ventricular septal defects, aortic valvular irregularities, atrial septal defects, and cardiac conduction defects have also been reported.
- The potential for transmission of blood-borne pathogens from the patient to the physicians performing the procedure is also a very real risk. The seroprevalence of the human immunodeficiency virus (HIV) in US urban EDs has been reported to range from 1.4-19%.20, 21, 22
- Specific complications of EDT include the following:
- Anoxic brain death in up to 50% of survivors
- Recurrent bleeding from chest wall or internal mammary artery
- Damage to the coronary arteries
- Damage to the esophagus during aortic cross-clamping
- Damage to the phrenic nerve
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
| Media file 1:
A skin incision is made in the left fifth intercostal space from the sternal border to the midaxillary line. |
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| Media file 2:
Anatomy seen after a left-sided thoracotomy. (A) heart, (B) phrenic nerve, (C) cut and retracted pericardium, (D) diaphragm, and (E) lung. |
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Media type: Illustration
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| Media file 3:
Lateral view of the anatomy encountered on left-sided thoracotomy. |
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Media type: Illustration
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Emergency Bedside Thoracotomy excerpt Article Last Updated: Apr 14, 2008
Topic originally published: Apr 14, 2008
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