REVIEW

Emergency thoracotomy in thoracictrauma–—a review

P.A. Hunt a,*, I. Greaves a, W.A. Owens b

Injury, Int. J. Care Injured (2006) 37, 1—19

www.elsevier.com/locate/injury

aDepartment of Academic Emergency Medicine, James Cook University Hospital,Marton Road, Middlesbrough, Cleveland TS4 3BW, UKbDepartment of Cardiothoracic Surgery, James Cook University Hospital,Marton Road, Middlesbrough, Cleveland TS4 3BW, UK

Accepted 14 February 2005

KEYWORDSEmergencythoracotomy;Blunt thoracic trauma;Penetrating thoracictrauma

Summary Thoracic trauma is one of the leading causes of death in all age groupsand accounts for 25—50% of all traumatic injuries. While the majority of patients withthoracic trauma can be managed conservatively, a small but significant numberrequires emergency thoracotomy as part of their initial resuscitation. The procedurehas been advocated for evacuation of pericardial tamponade, direct control ofintrathoracic haemorrhage, control of massive air-embolism, open cardiac massageand cross-clamping of the descending aorta.

Emergency thoracotomy can be defined as thoracotomy ‘‘occurring either imme-diately at the site of injury, or in the emergency department or operating room as anintegral part of the initial resuscitation process’’. Following emergency thoracotomy,the overall survival rates for penetrating thoracic trauma are around 9—12% but havebeen reported to be as high as 38%. The survival rate for blunt trauma is approximately1—2%. The decision to perform emergency thoracotomy involves careful evaluation ofthe scientific, ethical, social and economic issues.

This article aims to provide a review of the current literature and to outline thepathophysiological features, technical manoeuvres and selective indications foremergency thoracotomy as a component of the initial resuscitation of trauma victimswith thoracic injury.# 2005 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Historical background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Definitions of emergency thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Pathophysiology of thoracic trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

* Corresponding author. Tel.: +44 1642 282898 (O)/01642310340 (R); fax: +44 1642 854122.E-mail address: paulantonyhunt@doctors.org.uk (P.A. Hunt).

0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2005.02.014

2 P.A. Hunt et al.

Haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Pericardial tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Systemic air embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Junctional trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Physiological status at presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Prognosis following thoracic trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Indications and contraindications for emergency thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Emergency thoracotomy in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Pre-hospital care considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10On-scene thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Other measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Technique of thoracotomy and adjunct manoeuvres. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Approach and access to the thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Pericardiotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Haemorrhage control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Adjunctive manoeuvres. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Internal cardiac massage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Aortic cross-clamping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Measures following successful thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Discontinuation of resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Risks to medical staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Other options for management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Pericardiocentesis and subxiphoid pericardiotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Digital thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16FAST examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Introduction

The evolution of more efficient transport systemsand improvements in pre-hospital care haveincreased the number of patients arriving at hospitalin extremis following major trauma. Traumatic inju-ries still constitute one of the leading causes ofdeath in all age groups,56 with penetrating and bluntthoracic trauma accounting for 25—50% of all inju-ries,53 as well as being a contributing cause in 50% offatal civilian trauma.65

The majority of patients with thoracic traumacan be managed non-operatively, with or withouttube thoracostomy. 51 As a result, careful monitoringof vital signs, appropriate fluid replacement andanalgesia constitute adequate therapy in up to90% of such patients. However, there is still a small,but significant (10—15%), subgroup of thoracictrauma victims who require emergency thoracot-omy.48,84

Emergency thoracotomy has become an estab-lished procedure in the management of life-threa-tening thoracic trauma.19,23 Indications forthoracotomy are constantly evolving and contro-

versy still surrounds the procedure, especially inblunt trauma. Emergency thoracotomy allows eva-cuation of pericardial tamponade, direct control ofintrathoracic haemorrhage, control of massive air-embolism, open cardiac massage and cross-clamp-ing of the descending aorta to redistribute bloodflow and limit subdiaphragmatic haemorrhage.6,36

Hitherto, most of the experience of this proce-dure has been gained in the USA and in South Africa.This article reviews the current literature and out-lines the pathophysiological features, technicalmanoeuvres and selective indications for emer-gency thoracotomy, as a component of the initialresuscitation of trauma victims with thoracic injury.

Historical background

Records describing chest trauma and its treatmenthave survived from antiquity. An ancient Egyptiantreatise, the Edwin Smith Surgical Papyrus (circa3000—1600 BC), contains a series of trauma casereports, including thoracic injuries. One such exam-ple states: ‘‘. . . If thou examinest a man having a

Emergency thoracotomy in thoracic trauma–—a review 3

wound in his breast, penetrating to the bone [with]perforation of the manubrium of his sternum, thoushouldst press the manubrium of his sternum withthy fingers, (although) he shudders exceedingly . . ..Thou shouldst bind it with fresh meat the first day;thou shouldst treat it afterward with grease, honey[and] lint every day, until he recovers . . .’’.20

Homer describes thoracic wounds as early as 950BC in The Iliad and the second century Greek phy-sician, Claudius Galen, also noted that left ventri-cular injuries were the most rapidly fatal of allcardiac injuries.33 While severe chest injuries weregenerally considered to be fatal during the times ofthe ancient Greeks and Romans, special attentionwas rarely paid to them, even into themodern era ofwarfare.

John Hunter, serving as an Army surgeon in 1761,remarked that while little had been done for victimsof significant thoracic trauma, something probablycould be accomplished for the good of the patient.His only contribution, however, was the tentativesuggestion that a haemothorax might be treated byallowing the fluid to run out of the wound.

Baron Dominique-Jean Larrey, Napoleon’s sur-geon and the early developer of the triage system,made similar recommendations concerning thoracicinjuries in 1829.8 Otto Hoche wrote in 1940 that ofthe 11 million wounds, sustained by soldiers of thearmies of Great Britain, the United States, Franceand Germany in World War I, there were 660,000wounds of the chest (6% of all wounds), of which 56%were fatal. Hoche’s collected figures also show thatof 12,350 soldiers killed in action, 20% had chestwounds.42 It was not until World War II that guide-lines were established for treating thoracic injuries;the understanding and treatment of thoracic injuryadvanced dramatically during the Vietnam War era.

The concept of thoracotomy as a resuscitativemeasure began with Schiff’s promotion of opencardiac massage in 1874. This was followed byBlock’s suggestion in 1882 that thoracotomy beapplied in the repair of cardiac lacerations. Twodecades passed before Ludwig Rehn successfullysutured a right ventricular wound in a human.67

Only at the start of the 20th century did emergencythoracotomy begin to come into routine use for thetreatment of cardiac wounds and anaesthesia-induced cardiac arrest.9

In the succeeding century, a more selectiveapproach to emergency thoracotomy evolved, asalternative procedures have become established,not least the advocacy of closed chest compressionby Kouwenhoven et al. in 1960, which virtuallyeliminated the need for open cardiac resuscita-tion.49 In 1967, Beall et al. aroused interest inemergency room thoracotomy in moribund patients

with penetrating chest trauma.5 Following this,literature relating to emergency thoracotomy, inthe early 1970’s, specifically addressed three basicissues:

Why should emergency thoracotomy be performed?Where should it be performed?When is it (or, perhaps more importantly, when is itnot) appropriate to perform thoracotomy?

While the first two issues were considered early,in a flurry of research activity, the third issue stillremains controversial; most clinicians agree thatthe question is related to the ability to predict o-utcome following thoracic trauma.19

Definitions of emergency thoracotomy

There are numerous different terms for emergencythoracotomy. These depend on the circumstances inwhich the procedure is performed, the status of thepatient and the location of the procedure itself.Examples include emergency department thoracot-omy, emergent thoracotomy, early thoracotomy,resuscitative thoracotomy, etc. This can make inter-pretation of the available data and comparison ofstudies difficult, due to the use of the terms inter-changeably. In general, emergency thoracotomy canbe undertaken at any stage of the resuscitativeprocess, and so can be defined in terms of theurgency of the procedure in relation to the patients’physiological status.

Thereby, emergency thoracotomymay be definedas that occurring either immediately at the site ofinjury, in the emergency department, or in theoperating room, as an integral part of the initialresuscitation. An urgent thoracotomy is one thattakes place under more controlled circumstancesand in the context of appropriate physiologicalstability and hitherto successful resuscitation.Lastly, an elective (or formal) thoracotomy one thatis performed during the course of elective surgicalaccess to the thorax, such as for coronary arterybypass surgery.

Pathophysiology of thoracic trauma

The incidence and causes of thoracic trauma varywidely in different parts of the world. Thoracictrauma ranks third behind head and extremitytrauma in major accidents in the United States,with motor vehicle accidents being the most com-mon aetiology.53 In large, American cities and partsof South Africa, black males have a 1 in 20 chance of

4 P.A. Hunt et al.

Table 1 Major causes of thoracic injury in Europe 87

Mechanism Proportion (%)

Road traffic accident 60Industrial accidents 15Domestic incidents 10Sporting injuries 10Interpersonal conflict or suicide 5

being fatally stabbed, or shot, before the age of30.23 Experience in the UK is more limited, withreports containing higher proportions of patientswith blunt injuries.72 Table 1 shows the relativecauses of thoracic trauma in Europe. In Englandand Wales, the annual death rate from stabbingand gunshot wounds is fewer than 200, althoughrising. Nevertheless, the figures are increasing forall casualties from road traffic accidents, with morethan 60,000 admissions per year.87 In motorcycleaccidents, 75% of fatally injured riders had an injuryto the thoracic region, compared to 20% of non-fatally injured riders.50 Along with head trauma,thoracic injuries are also a major cause of death inpedestrians involved in road traffic accidents.43

The main consequences of chest trauma occur asa direct result of its combined effects on respiratoryand haemodynamic functions. Death following thor-acic injury is often secondary to impairment ofoxygen delivery and/or transport. Factors deter-mining oxygen transport capacity include pulmonarygas exchange, cardiac output, haemoglobin concen-tration and oxygen—haemoglobin affinity.

Several compensatory mechanisms exist inresponse to the physiological changes resulting fromthoracic trauma, although these can be rapidlyexhausted. The therapeutic goal is to augment, orsupplement, these compensatory mechanisms dur-

Figure 1 Summary of the pathophysiological co

ing acute resuscitation, the major two interventionsbeing ventilatory support and the arrest of haemor-rhage (including surgical repair of cardiovasculardisruptions). Impairment of oxygen transportmechanisms and the resultant hypoxia can alsocontribute to other primary causes of mortality,particularly brain injury. Figs. 1 and 2 illustratethe physiological processes that occur as a resultof thoracic trauma.69,81

Blunt thoracic trauma is almost exclusively theresult of rapid deceleration, or crushing, in roadtraffic accidents. The most common intra-thoracicinjuries sustained following blunt trauma are hae-mothorax, great vessel disruption and lung contu-sion.47 Injuries resulting from blunt trauma can bepredicted from knowledge of the type of incident, asshown in Table 2.87 Newman and Jones showed thatunrestrained drivers have a higher incidence of ribfractures and corresponding intrathoracic injuriesfor frontal and rollover mechanisms than dorestrained drivers.64 However, restraint seemed toconfer no real advantages with side impact. Severityof injury was also shown to be directly related toimpact velocity, with significant injury commonlyoccurring at impact speeds of around 10—20 mph inunrestrained persons, compared to at least 30 mphin restrained individuals.64 Severity of thoracicinjury can be predicted from the type of impact,speed of impact and adequacy of restraint.

During sudden profound deceleration, the heartswings on the aorta, tearing the great vessels–—theso-called intrathoracic ‘bell clanger’ effect. Thiscommonly occurs at the ligamentous attachmentof the descending aorta to the left pulmonaryartery. Shear forces may also disrupt the bronchi,leading to immediate pneumothorax and not infre-quently tension or ‘massive’ pneumothorax, which

nsequences of penetrating thoracic trauma.

Emergency thoracotomy in thoracic trauma–—a review 5

Figure 2 Summary of the pathophysiological consequences of blunt thoracic trauma.

may be challenging to manage with simple chestdrainage alone. Crush injury compresses the myo-cardium between the sternum and the vertebrae,resulting in contusion, or rupture, of the myocar-dium and possible great vessel disruption. Suddensevere crush injury of the abdomen and extremitiesmay also cause a dramatic increase in intrathoracicvenous pressures, leading to right atrial, or ventri-cular, rupture. Cardiac valve injuries occur as aconsequence of shearing, or crushing, forces tothe heart and can easily be overlooked.

Penetrating trauma results in localised anatomi-cal disruption, significantly to blood vessels,depending on the location and angle of entry andthe type of object, or projectile, involved. In pene-trating ballistic trauma, the track of the projectilemay be erratic and very difficult to predict, despiteobvious entry and exit wounds. High velocity trans-fer projectiles may produce far more profound tis-sue damage, due to laceration and cavitation, and

Table 2 Mechanisms and patterns of blunt thoracic traum

Mechanism of injury Chest wall injury

High velocity(deceleration)

Chest wall often intact � sternumfracture � bilateral rib fractureswith anterior flail

Low velocity(direct blow)

Lateral: unilateralrib fractures; anterior:fractured sternum

Crush injury Anteroposterior: bilateral ribfractures � anterior flail;lateral: ipsilateral fractures � flail;possible contralateral fractures

few victims survive high velocity wounds to theheart, great vessels, or pulmonary hila.

The major physiological consequence of pene-trating trauma is usually haemorrhage. Arterialbleeding is often rapid, although vessel retractionand vasoconstriction can arrest haemorrhage.Venous bleeding may be arrested by tamponade,as intravenous pressure falls. Laceration to themyocardium, or coronary vessels, may lead to peri-cardial tamponade, most often occurring with amediastinal entry site.87 Penetrating thoracictrauma generally results in an open pneumothorax.When the chest wound is smaller in diameter thanthe glottis, the pneumothorax is usually small andpulmonary ventilation is preserved. However, whenthe wound is larger in diameter than the glottis, thepneumothorax will increase due to preferential airpassage through the chest wall defect.

Direct communication may occur between bloodvessels and air passages, or lung parenchyma, sec-

a87

Possible thoracicvisceral injuries

Common associatedinjuries

Ruptured aorta;cardiac contusion;tracheo-bronchialdisruption;ruptured diaphragm

Head and Max-Fax injuries;C-spine fracture;lacerated liver/spleen;long bone fractures

Pulmonary contusion;cardiac contusion

Lacerated liver/spleen if lowerribs involved Max-Fax injuries

Ruptured bronchus;cardiac contusion;pulmonary contusion

Fractured thoracic spine;lacerated liver/spleen;lacerated liver/spleen

6 P.A. Hunt et al.

ondary to trauma involving these structures. Sys-temic air embolism will occur if air enters pulmon-ary veins as a result of low pulmonary venouspressure, increased airways pressure, or both. Theconsequences may be catastrophic if pulmonaryvenous gas embolises to the coronary vessels, heartchambers or cerebral arteries. The incidence ofsystemic air embolism has been estimated to be4—14%, with two thirds resulting from penetratinginjury and one third from blunt trauma.80,88

Haemorrhage

Bleeding may be obvious if it reaches the exterior,especially in penetrating trauma. Death from exsan-guination is not just limited to penetrating thoracictrauma. Bodai et al. noted that, in their series of 38patients undergoing emergency thoracotomy forblunt trauma, 19 (50%) deaths could be attributedto massive haemorrhage.12 The only sign of severeintrathoracic haemorrhage may be the clinical fea-tures of shock, including restlessness, agitation,tachycardia, sweating, pallor and peripheral venos-pasm, with reduced capillary circulation. Signs ofshock may be apparent with respiratory distress, aswell as with significant haemorrhage. The volume ofblood lost into the pleural cavity is difficult to assesswithout drainage by tube thorocostomy. Each hemi-thorax can rapidly accommodate more than half of apatient’s total blood volume before physical signsbecome obvious.9

The question of when to perform a chest radio-graph is also controversial. Bokhari et al. demon-strated that in blunt trauma, patients who arehaemodynamically stable, with normal physical find-ings on examination, do not require a routine chestradiograph. By contrast, they found that all victims ofpenetrating trauma require chest radiographs,because many will have haemopneumothorax with-out overt clinical findings.15 For unstable patientswith physical findings of thoracic trauma, immediatetreatment is required, such as needle thoracostomyfor tension pneumothorax, and careful physicalexamination to elucidate a significant haemothorax.

Tube thoracostomy drainage serves to relievedyspnoea and to improve gas transfer and ventila-tion/perfusion mismatch, as well as identify con-tinued bleeding and the need for thoracotomy. It hasbeen suggested that surgical exploration is indi-cated when initial drain insertion yields more than1500 ml of blood, or if the rate of drainage is morethan 250 ml/h.84 However, the response to fluidresuscitation, the nature of the trauma (blunt versuspenetrating) and, if available, specialist advicemust also be taken into account.

Pericardial tamponade

The presentation of pericardial tamponade dependson the underlying cause. Myocardial rupture, orcoronary artery laceration, will result in the abruptappearance of tamponade, while minor lacerations,or contusions, with slow extravasation result in agradual rise in intrapericardial pressure. This clin-ical appearance may well be confused with pulmon-ary embolism in the early stages, due to its effectson diastolic right atrioventricular filling.81

Often, patients with penetrating cardiac woundsreaching hospital alive do so because of the arrest ofbleeding by pericardial tamponade. The combina-tion of a praecordial entrance wound with profoundsystemic hypotension, tachycardia and distendedneck veins is pathognomonic.

Elevated intrapericardial pressure restricts car-diac filling, thereby leading to diminished cardiacoutput.86 Cardiac arrest occurs later due to coron-ary hypoperfusion, as the intrapericardial pressureapproaches ventricular filling pressure. In the earlystages of pericardial tamponade, blood pressuremay be maintained deceptively well, complicatedby the fact that aggressive fluid resuscitation willtemporarily elevate filling pressures and overcome,to an extent, the effect of the tamponade. However,clinical signs of systemic shock will soon becomeapparent. In the later stages of tamponade, pre-cipitous and profound hypotension occurs as thephysiological compensatory mechanisms fail.75,85

Systemic air embolism

Despite being a subtle clinical entity, systemic airembolus should be considered in any major thoracicinjury resulting from either penetrating or blunttrauma. It is often diagnosed only when suddencirculatory collapse occurs immediately aftertracheal intubation and the initiation of positivepressure ventilation. This collapse is typically unre-sponsive to conventional resuscitation. The unex-plained development of a neurological deficit, orseizures, in the absence of a head injury impliescerebral air embolism unless proven otherwise.81

The current recommendation for treatment ofsystemic air embolus associated, with unilaterallung injury, is immediate thoracotomy, in the emer-gency department if necessary, in order to clampthe hilum of the injured lung so as to arrest thepassage of air into the systemic circulation.88 Bub-bles may be noted in the vasculature on thoracot-omy. Selective ventilation of the uninjured lung maybe a life-saving alternative procedure in unilateralinjuries.41 Saada et al. demonstrated that there is

Emergency thoracotomy in thoracic trauma–—a review 7

an observed decrease in emboli when ventilatorypressures and volumes are reduced.71

Junctional trauma

Blunt trauma rarely presents with thoracic injuryin isolation. It often involves the so-called ‘junc-tional zones’, above and below the anatomicallydefined boundaries of the thorax. Such zonesinclude the root of the neck, the thoracic spineand the upper abdomen/diaphragm. When there issuspicion of an abdominal cause for haemorrhageit has been recommended that the patient undergolaparatomy before thoracotomy, given both thevulnerability of abdominal viscera to blunt traumaand early availability of appropriate surgicalexpertise.

Junctional zones may also be implicated inpenetrating thoracic trauma. Projectiles and otherobjects may enter the thorax from below, via theabdominal cavity (through the diaphragm), fromabove via the neck, or through the thoracic spine.As a result, intrathoracic injury may not be sus-pected initially due to the more distant location ofthe entrance wound. However, significant thoracictrauma should always be considered in the case ofjunctional zone trauma, especially when the clin-ical signs cannot be explained by the expectedmechanism of injury. Associated diaphragmaticrupture can also complicate the clinical presenta-tion; the combination of abdominal visceral rup-ture and a diaphragmatic tear may lead toapparently excessive drainage from a thoracost-omy tube. Although the volume of such drainagemay suggest the presence of significant intrathor-acic trauma, an initial thoracotomy may be rela-tively unhelpful and, if anything, delay thenecessary laparotomy.

Physiological status at presentation

The physiological status of the patient will affectclinical decision-making with respect to emergency

Table 3 Physiological status classification54

Class I: no signs of life Class II: agonal

No electrical activity:described as asystoleor ventricular standstill.Absent pupillary,corneal and gag reflexes

Electromechanical dissociation(EMD) or pulseless electricalactivity (PEA)Any electrical activity on ECGwithout palpable pulse ormeasurable blood pressureGCS 3

thoracotomy. Survival rates are directly correlatedwith the patient’s physiological status in the pre-hospital and hospital setting.26,54,68 Hendersonet al. demonstrated that the physiological indexwas the most significant independent factor pre-dicting patient survival following emergency thor-acotomy.40 Importantly, exclusion criteria for theprocedure, in many guidelines and recommenda-tions, include the absence of ‘signs of life’. There-fore, an accurate and reproducible categorisation ofphysiological status is required. Table 3 shows amodified version of the classification recommendedby Lorenz et al.

Hospital clinicians vary greatly in their definitionof ‘signs of life’. Miglietta et al. showed that apalpable pulse and spontaneous movements werethe most commonly acknowledged, though even themore straightforward indicators (such as pupillaryreflex and electrical cardiac activity) were far fromuniformly agreed.62 Emphasis is needed on clearlydefining the physiological status of the patient,ideally at scene and/or in transit. However, theproblems of deciding on the presence, or absence,of signs of life are even more difficult in a pre-hospital setting.

Prognosis following thoracic trauma

In patients presenting with vital signs after apenetrating thoracic injury, survival from emer-gency thoracotomy may be as high as 38%.4 TheAmerican College of Surgeons Committee onTrauma carried out a major review of the litera-ture from 1966 to 1999, in order to evaluate themany reports dealing with emergency departmentthoracotomy.1 A strict selection was carried outand 92 articles were referenced. Sixty-three werebased on retrospectively collected data, while 29were clinical studies, only 3 of which were pro-spective. They reported that of 7035 emergencythoracotomies there were a total of 551 survivors(7.8%). Stratification by mechanism of injuryrevealed a survival rate of 11.2% for penetratingtrauma and 1.6% for blunt trauma. Importantly, of

Class III: profound shock Class IV: mild shock

Systolic blood pressureless than 60 mmHg

Systolic blood pressurebetween 60 and 90 mmHg

Transient responder orunresponsive to fluidresuscitation

Stable response tofluid resuscitation

8 P.A. Hunt et al.

14 series reporting accurately on neurological out-comes, 4520 patients underwent emergency thor-acotomy with a survival rate of 226 (5%) and ofthese 34 (15%) survived with neurological impair-ment. Penetrating cardiac injuries were shown tohave the highest survival rate with 46 series (1165cases) yielding an overall survival rate of 31.1%following emergency thoracotomy.

It has already been shown that physiologicalstatus correlates well with survival rate. In an ana-lysis of 251 cases of cardiac injury following emer-gency thoracotomy, Henderson et al. showed thatsurvival rates diminished significantly with higherphysiological indices: the overall survival rate in thisstudy was 18.7%. The findings suggested that emer-gency thoracotomy is most helpful for patients withlimited penetrating cardiac injuries who have sig-nificant physiological impairment secondary to peri-cardial tamponade.40

Significant differences in survival rates followingemergency thoracotomy are noted when comparingblunt and penetrating thoracic trauma. Over thepast few decades a number of studies has shown nosurvival in cases of blunt trauma.12,36,44 In theirreview, Biffl et al. showed that an overall survivalrate following emergency department thoracotomyin blunt thoracic trauma is 1.1%, compared to 9.1%for penetrating cardiac trauma.9

Indications and contraindications foremergency thoracotomy

The major difficulty with attempting to standar-dise the indications for emergency thoracotomy isthat the main body of evidence in the literature islargely derived from retrospective data. Emer-gency thoracotomy is not a procedure that lendsitself to randomised, prospective trials and henceit remains a highly controversial procedure. Thereis also significant variation in nomenclature ofemergency thoracotomy in the available litera-ture, making statistical analysis and comparisons

Table 4 The physiological rationale for emergency thorac

Procedure Physi

Release of pericardial tamponade ImproControl of intrathoracic vascular or

cardiac haemorrhageFaciliImpro

Control of massive air embolism orbronchopleural fistula

Resolcontr

Permit open cardiac massage Improperfu

Occlusion of descending aorta(cross-clamping)

Redisbrain

between relevant studies difficult. In this review,the definition of emergency thoracotomy is, aspreviously discussed, that which is required as partof the immediate resuscitation of the traumapatient.

It is first of all important to discuss the clinicalgrounds and theoretical justifications for perform-ing a thoracotomy. The primary physiological objec-tives of emergency thoracotomy are listed inTable 4.

Since its introduction into clinical practice, therecommended indications for emergency thoracot-omy have become increasingly selective. ATLSguidelines offer specific recommendations for car-rying out thoracotomy in the setting of penetratingchest trauma with electrical cardiac activity, butnot for blunt trauma with electrical cardiac activityin a pulseless patient. Other indications, such aspenetrating abdominal, or extremity, trauma, arenot addressed. Several studies have concludedthat there is no value in performing emergencythoracotomy in moribund patients with blunttrauma.13,22,54,61 The primary indication for thora-cotomy is generally accepted to be a penetratinginjury of the thorax in patients on the point ofarresting, or who have just arrested, or in thosewho are in profound shock.65 Brown et al. concludedthat emergency thoracotomy should be limited topatients with penetrating thoracic trauma withsigns of life, a pulse and measurable blood pressure.They also concluded that patients with no signs oflife, or an agonal physiological status, do not surviveemergency thoracotomy and that, therefore, theuse of this procedure in these patients should beabandoned.22

Bleetman et al. noted in their series of 25patients, in a UK Accident & Emergency Depart-ment, that the best results were seen in thosepatients stable enough to undergo thoracotomy inthe operating theatre. Of the 18 emergency roomthoracotomies, only 1 survived to discharge, whileall 7 of the operating department thoracotomypatients survived to discharge. It was noted,

otomy

ological benefit

ve cardiac output and control of cardiac haemorrhagetate fluid resuscitation–—‘turning off the tap’.ve cardiac output and myocardial perfusionve myocardial ischaemia and hence myocardialactility as well as prevent neurological injuryved resuscitative cardiac output and coronarysion especially with limited ventricular filling pressurestribution of limited blood volume to myocardium andas well as limiting subdiaphragmatic losses.

Emergency thoracotomy in thoracic trauma–—a review 9

however, that the majority of patients who under-went emergency department, rather than operatingroom,thoracotomy had the worst survival probabil-ities of the series.11 Balkan et al. also notedimproved survival rates amongst those undergoingoperating room emergency thoracotomy, acceptingthat a stable physiological status was the significantfactor.3

In a careful review of the literature, Danne et al.noted that in most cases blunt trauma to the thoraxresulted in very poor survival after emergencydepartment thoracotomy, while penetrating thor-acic wounds were associated with the best survivalrates following the procedure. Importantly, it wasshown that all survivors in the study had some vitalsigns at the scene.27 Isolated reports exist in whichgroups of patients with blunt thoracic trauma hadhigh survival rates after emergency thoracot-omy.38,58 However, the authors noted that thesecases could have been explained by differences inpatient selection, criteria, or physiological status,on admission and it was also noted that the deter-mination of ‘survival’ was not consistent acrossarticles.

Kish et al. noted that the majority of emergencythoracotomies performed in their series wereundertaken for haemorrhage as a result of penetrat-ing trauma, manifest either as direct external lossesvia thoracostomy tube, or indirectly by noting phy-siological changes and fluid resuscitation demands.Survival in this group was significantly higher thanfor blunt trauma. However, they noted that patientssustaining blunt trauma commonly had extensivemultiple system injuries and other sources of hae-morrhage.48

Lewis and Knottenbelt, in a series of 45 cases,suggested that the primary indication for resuscita-tive emergency thoracotomy was an observablepericardial tamponade, and that results were shownto be good for this single indication. However, theynoted that emergency thoracotomy was justifiablefor all patients with cardiac arrest, or persistingsevere hypotension, following penetrating thoracictrauma, as not all cases of tamponade are clinicallyobvious on admission. They also concluded that thecase for emergency thoracotomy in blunt traumaremained debatable.52 In a detailed literaturereview, the American College of Surgeons Commit-tee on Trauma recommended that emergency thor-acotomy be performed rarely in blunt thoracictrauma with cardiopulmonary arrest, due to lowsurvival rates and poor neurological outcomes.1

Grove et al. repeated these conclusions, reportingno survivors at all from a total of 19 cases, over a 2-year period, of blunt multisystem trauma, includingthoracic injury requiring emergency thoracotomy.36

Miglietta et al. assessed the opinions and atti-tudes of trauma specialists in America, demonstrat-ing a wide variety of indications for emergencythoracotomy over a diverse selection of clinicalscenarios in many different institutions. Most ofthe reported indications were liberal, especiallyfor blunt trauma scenarios. However, in the main,indications were determined by clinical parameters,such as the existence of signs of life and themechan-ism of injury, rather than physician associated, orinstitutional, factors.62

As discussed previously, wide variation exists inthe definition of signs of life, which, in turn, has anotable effect on uniformity and selectivity foremergency thoracotomy in different institutions.Generally, however, most respondents agreed thatemergency thoracotomy was more appropriate inthe setting of penetrating thoracic trauma thanother mechanisms.

Cardiopulmonary arrest ‘in transit’, or in the pre-hospital setting, is almost uniformly fatal followingtrauma.36 Such patients arriving in the emergencydepartment in asystole invariably die, despite allresuscitative attempts.29,38 Emergency thoracot-omy in these cases is not considered to be anappropriate procedure.

When considering the definitive indications foremergency thoracotomy, the decision to proceeddepends greatly on many local circumstances,including availability and preparedness of correctsurgical equipment and trained personnel, depart-mental policies and protocols, and the experience ofthe unit in carrying out the procedure. The indica-tions and contraindications set out in Table 5 havebeen summarised on the basis of the available pub-lished evidence. These may serve as a guide onwhich to base local policy and protocols, taking intoaccount those factors discussed above.

Whilst physiological status is held to be the mostappropriate indication for performing emergencythoracotomy, most authors also recommend thatthe specific application of any guidelines must,where possible, include consideration of the indivi-dual patient’s circumstances, such as age, quality oflife, or pre-existing disease. In addition, logisticalissues, such as availability of specialist personneland accessibility, and proximity to appropriate oper-ating facilities and equipment, should also be con-sidered.

Emergency thoracotomy in children

Trauma is the leading cause of death and morbidityin children over 1 year of age.37 The majority ofpaediatric trauma patients who require emergency

10 P.A. Hunt et al.

Table 5 Suggested indications and contraindications for emergency thoracotomy

Indications Relative indications Contraindications

Cardiorespiratory arrest following isolatedpenetrating thoracic trauma, with evidenceof signs of life before arrival inemergency department

Post traumatic refractory hypotension,transiently responsive with evidenceof intrathoracic haemorrhage

Absence of signs of life orpatient in asystole onarrival in the emergencydepartment, followingblunt thoracic trauma

Post traumatic persistenthypotension due tointrathoracic haemorrhage,unresponsive to fluid resuscitation

Post traumatic persistent hypotension,due to extrathoracic haemorrhageunresponsive, or transiently responsiveto fluid resuscitation

Absence of signs of lifeat scene and on arrival,following cardiopulmonaryresuscitation for morethan 5 min

Persistent severe hypotension,with evidence ofsystemic air embolism orpericardial tamponade

Presence of signs of life on arrivalin emergency department,independent of mechanism

Associated severe head injuryor thoracic injury as part ofsevere multisystem trauma

thoracotomy do so following blunt trauma andusually have sustained multisystem injuries.35 Justas in adult trauma, improved transportation ofinjured children to hospital has resulted in thearrival and treatment of patients who may other-wise have been pronounced dead at the scene.Standardisation and regionalisation of the traumacare of children have led to new problems, includingthe need to define the role of emergency resusci-tative thoracotomy in injured children, otherwiseunresponsive to conventional resuscitation.

Although the role of emergency thoracotomy hasbeen reviewed extensively in the adult literature,there are comparatively little experience and datafor paediatric cases. Anecdotal reports and theimpression that children may tolerate more readilyischaemia and the physiological stress of severetrauma, have led to the expectation that aggressiveresuscitation, including thoracotomy, should havean improved outcome in this group of patients.30 Asa result, selection criteria for emergency thoracot-omy in children are uncommon in most centres,including those which have defined protocols foradult thoracotomy.

Unfortunately, the hope that children may have amore favourable outcome than adults followingemergency thoracotomy, has not been borne outby published evidence. Although there is limitedexperience with emergency thoracotomy in chil-dren, comparison of adult and paediatric survivalrates show remarkable similarities. Overall survivalrates in children following emergency thoracotomyfor penetrating thoracic trauma are around 11—12%and for blunt trauma around 1—2%.1,9 Again, thehighest survival rates were noted in cases of thor-acotomy following single penetrating wounds to thethorax.

As in adults, the data support the selective appli-cation of emergency thoracotomy in children based

on injury mechanism and physiological status atpresentation. General consensus is derived fromrecent literature that the indications for emergencythoracotomy in children should be the same as thosecurrently accepted for adult trauma victims.7,70,74

Pre-hospital care considerations

In their study, Sugg et al. found that <20% ofpatients with penetrating wounds of the heartreached hospital alive.78 Presently, with improvedemergency transport systems, more patients arebeing seen in emergency departments for treatmentfollowing thoracic trauma. The chances of survivalare greater if time from injury to definitive surgeryis kept to a minimum. Survival rates after emer-gency department thoracotomy have been corre-lated with field and transport times.24 Survival frompenetrating thoracic trauma has been shown todecrease sharply if patients reach hospital morethan 25 min after injury.34 Branas et al. showed thatthere was no observed effect on patient survival as aresult of the use of non-medical personnel to trans-port trauma patients to hospital. This offeredfurther support to the concept of ‘scoop and run’,although it is possible that a confounding factor isintroduced by at-scene triage by attending crews.18

Minimizing the use of field stabilisation manoeuvreshas also been shown to improve survival of criticallyinjured patients.77

On-scene thoracotomy

Experience of on-scene thoracotomies has lead tothe abandonment of this practice by some.66 It isnoted that the best outcomes are achieved inpatients who have signs of life at the scene and

Emergency thoracotomy in thoracic trauma–—a review 11

Table 6 Guidelines for carrying out prehospital thoracotomy25

Evidence of penetrating thoracic traumaPatient is found to lose pulse at scenePatient is to be intubated immediately

Nearest surgical intervention is:More than 10 min away (following loss of pulse) Less than 10 min away (following loss of pulse)

On-scene thoracotomy Immediate transport

reach hospital within 10 min of injury.34 The limitedefficacy of on-scene thoracotomy tends to support a‘scoop and run’ policy, as delay due to the proceduremay be detrimental to the overall management ofthe patient. Also, it is far more advantageous tocarry out the procedure with a trained, multi-dis-ciplinary team using suitable facilities and equip-ment. A solo doctor attempting the procedure at thescene may additionally be required to maintain adifficult airway, or provide assistance to othertrauma victims. However, a few series have beenpublished which show benefit to some patients fol-lowing prehospital thoracotomy, most notably theresults from the London Helicopter Emergency Med-ical Service (HEMS). In their series of 39 cases, therewere 4 survivors (10%), 1 with long-term disability.The conclusion of the team is that prehospital thor-acotomy should be considered if there is an appro-

Figure 3 Decision making process flow

priately experienced, trained and equipped doctorpresent, who is acting within a trauma system withcontinuing training and quality assurance. Theguidelines used by the HEMS team are shown inTable 6.25 In their case report and review of pre-hospital thoracotomy, Wall et al. suggested a similardecision-making process.83

Other measures

In the study by Durham et al. the duration of pre-hospital cardio-pulmonary resuscitation (CPR)before thoracotomy was evaluated as a prognosticfactor. A significant difference was noted betweensurvivors and non-survivors with the data suggestingthat 5 min of prehospital CPR approaches the limitsof viability in non-intubated patients. However, the

chart for emergency thoracotomy.

12 P.A. Hunt et al.

average time of CPR tolerated by intubated survi-vors was shown to be doubled, compared to non-intubated survivors (9.4 min versus 4.2 min).29 It istherefore essential to record accurate informationrelating to prehospital resuscitation efforts, so thatthe decision to carry out emergency thoracotomycan be made appropriately, once the patient arrivesin the emergency department.

Protocols

Several studies, original articles and reviews suggestprotocols, or decision-making flow charts, for emer-gency thoracotomy.9,10,17,36,82 These, and the gen-eral recommendations found in the relatedliterature, vary in their complexity and differ intheir suggested indications and contraindications.Most of the guidelines rely on a mixture of generalphysiological observations and observer informationregarding mechanism of injury and response toinitial resuscitation. One of the major issues regard-ing protocols is that while proscriptive, or highlyselective, guidelines may result in improved survivalrates from emergency thoracotomy, the risk is that apotentially salvageable patient may be excluded.

A comprehensive protocol that includes specificphysiological indicators and consideration of themechanism of injury, as well as relevant associatedclinical factors, such as age and secondary trauma,may prove to be a useful tool when consideringperforming emergency thoracotomy. However, thisis unlikely to be of practical use when dealing withsuch a critically ill patient. Fig. 3 aims to summarisethe current evidence utilising a simple flowchart as aguide for the decision-making process. The mainelements of this are the presence or absence of life

Table 7 Instrument and equipment list for emergency tho

Instrument

Scalpel–—no. 10 bladeSuitable retractor, such as Finochietto’s rib spreader,or Balfour abdominal retractorLebschke’s knife and mallet, or Gigli sawCurved Mayo’s scissorsToothed forcepsLarge vascular clamps, such as SatinskyDeBakey aortic clampMosquito/Dunhill artery forcepsFoley catheterLong and short needle holdersInternal defibrillator paddlesSutures, Teflon pledgets, sternal wires

Skin preparation materials and swabsGood lighting and high volume suction

signs on presentation and the major secondary prog-nostic indicators associated with highest survivalrates, or, conversely, those associated with a gen-erally poor outcome.

Technique of thoracotomy and adjunctmanoeuvres

Equipment

For a formal (elective) thoracotomy the range ofequipment and number of instruments is far inexcess of that required for emergency thoracotomy.Table 7 illustrates the typical emergency thoracot-omy instrument list.9,14,21

Approach and access to the thorax

Ideally, venous and arterial access should be estab-lished before thoracotomy is performed. However,excessive time should not be wasted on this asvenous and arterial access can be obtained rapidlyonce the thorax is open; potential sites includingdirect insertion into the right atrium, or superiorvena cava. Arterial cannulae may also be placeddirectly into the aorta, or left ventricle, for pressuremonitoring. The patient should be positionedsupine, with the side to be operated on elevatedslightly (about 158) by a wedge, or pillow. Both armsshould be laid out at right angles to enable periph-eral vascular access. Surgical draping is not essentialfor resuscitative thoracotomy.

Arguably, the best incision for use in emergencythoracotomy should be determined on the basis ofthe anticipated injury, as suggested by the clinicalexamination. The left anterolateral thoracotomy is

racotomy

Role/comments

Incision of skin and soft tissuesOpening up the rib space

Cutting through sternumGeneral dissectionExploration and suturingMajor vessel haemorrhageAortic cross-clampingHaemorrhage controlTemporary cardiac wound sealSuturing/placing tiesIntrathoracic defibrillationTo include 3/0 non-absorbable suturesand 2/0 absorbable tiesFor example, a laparotomy packEssential both in- and pre-hospital

Emergency thoracotomy in thoracic trauma–—a review 13

frequently utilised for resuscitation and in acutedeterioration, or cardiac arrest.32 The advantagesof this incision are rapid access with simple instru-mentation, its appropriateness for a supine patient,and easy extension to the contralateral hemithoraxwith exposure of pleural, anterior and mediastinalstructures.9 This approach also allows for aorticcross-clamping and open cardiac massage. In isola-tion, however, it affords relatively limited access,particularly for injuries to the heart, lungs or greatvessels necessitating direct surgical repair. It can beargued that this is best regarded as an initialapproach, facilitating the relief of cardiac tampo-nade, or enabling massage, prior to extension into abilateral anterior thoracotomy (clamshell incision)which, although an aggressive approach, facilitatesaccess to pleural and pericardial cavities, as well asextension into the neck or abdomen.

An initial right anterolateral incision should bereserved for cases involving penetrating injuries tothe right side of the chest. When an associatedcardiac wound is noted, or further resuscitativemeasures are required, this incision should beextended trans-sternally. A median sternotomyallows for exposure of the anterior and middlemediastinum and is advocated particularly for pene-trating wounds of the upper anterior thorax, but, inthe emergency setting, its applicability is typicallylimited by the availability of the equipmentrequired to divide the sternum longitudinally. Itsapplicability is also questionable for injuries invol-ving the lungs, or pulmonary hila.

The left anterolateral thoracotomy is made inthe 5th or 6th intercostal space, starting from the

Figure 4 Left anterolateral thoracotomy. Copyright TheRoyal College of Surgeons of England. Reproduced withpermission from Botha A et al. (2002) Definitive SurgicalTrauma Skills.

costochondral junction anteriorly and passing tothe mid-axillary line laterally, following the upperborder of the rib (Figure 4). In women, the breastwill need to be retracted superiorly to expose thisinterspace and the infra-mammary fold may beused as a guideline. The skin and subcutaneouslayer are first incised with a scalpel and then themuscle, periosteum and parietal pleura aredivided in one layer with scissors and blunt dissec-tion. Chest wall bleeding is generally minimal inthese patients, though the internal thoracicarteries will need to be ligated. Once the incisionis completed and the pleural cavity exposed, asuitable retractor should be inserted, the handlepointing towards the axilla, for ease of instrumen-tation and visibility. The superior, or inferior,costal cartilages of the opened interspace maybe incised in order to achieve additional exposure.When sternal transection is required, the internalmammary vessels must be ligated.

Pericardiotomy

The phrenic nerve can be identified anterior to thehilar vessels by retracting the lung posteriorly(Figure 5). The pericardium can be inspected at thisstage and, in the case of a significant tamponade,will be tense, with the absence of visible pulsations.To release a pericardial tamponade, an openingshould be made parallel to, and at least 1-cm ante-rior to, the phrenic nerve, started with a blade, orsharp point of scissors. Blood clots can then beevacuated and any cardiac bleeding points identi-fied and controlled, initially by digital pressure. It isnot essential to close the pericardium after thisprocedure. In patients who do not have tamponade,but have arrested, internal cardiac massage is indi-cated.

Figure 5 Identification of the phrenic nerve. CopyrightThe Royal College of England. Reproducedwith permissionfrom Botha A et al. (2002) Definitive Surgical TraumaSkills.

14 P.A. Hunt et al.

Haemorrhage control

Partially occluding vascular clamps should be usedto control major vessel and atrial bleeds. In thecase of significant lung laceration, or widespreadparencyhmal destruction, the hilum of theaffected lung should be occluded with a vascularclamp, such as a Satinsky clamp, until a definitivesurgical procedure can be performed. Air embo-lism can also be managed initially in this way andair evacuated from the left ventricle by needleaspiration.14 With a beating heart, any attempt atrepair should be delayed until initial resuscitativemeasures are completed. In the case of a non-beating heart, suturing may be performed beforeresuscitation and defibrillation.9,14 In cardiac inju-ries, the whole heart should be examined to loca-lise all sources of bleeding.

For temporary control of cardiac wound hae-morrhage a Foley catheter may be inserteddirectly into the cardiac wound, after which theballoon can be inflated to control bleeding. Thecatheter may also be utilised for fluid infusion.63

The tube of the catheter must be clamped andgreat care must be taken not to exert too muchtraction as this may pull the balloon out of thecardiac wound and, in so doing, increase the size ofthe hole.

Temporary control of haemorrhage from cardiacwounds can be achieved either by suturing with 3/0 non-absorbable vertical, or horizontal, mattresssutures, or the use of a stapling device. Suturerepair of ventricular lacerations requires consider-able dexterity and control of bleeding while pla-cing multiple sutures, which exposes the surgeonto the risk of a contaminated needle stick injury.79

The use of a standard skin stapler was assessedclinically by Macho et al. and was shown to be aneffective and rapid technique in simple, single ormultiple, cardiac wounds whilst eliminating therisk of a needle stick injury. However, the authorsrecommended that stapling must be considered atemporary measure and that staples be removedafter definitive cardiorraphy in the operating thea-tre.55 Great care must be taken to avoid inadver-tent occlusion of, or trauma to, coronary vesselsand horizontal mattress sutures placed under avessel should prevent this occurring. Closure ofposterior cardiac wounds may necessitate eleva-tion of the heart for exposure and this is bestaccomplished in an operating theatre, where opti-mal lighting and equipment are available.9 Tem-porary inflow occlusion of the superior and inferiorvenae cavae may be necessary to facilitate repair.Low pressure venous and atrial lacerations can berepaired with simple continuous sutures.

Adjunctive manoeuvres

Internal cardiac massage

Internal cardiac massage has been shown to producean improved cardiac index, compared to externalcardiac massage.28 The technique for this has beendescribed as a hinged clapping motion of the handswith the wrists apposed, resulting in ventricularcompression proceeding from the apex to the baseof the heart.9 A one-handed massage technique isalso possible though this is known to pose a small riskof myocardial perforation.

Internal defibrillation may be required to restorecardiac output, despite adequate filling pressures,especially in the event of ventricular fibrillation, ortachycardia. The energy settings are reduced to 15—30 J.

Aortic cross-clamping

Cross-clamping of the descending aorta leads to atemporary increase in the proximal arterial pressureand hence preservation of perfusion of the brain andheart. It is also used in attempts to limit subdiaph-ragmatic haemorrhage in both blunt and penetrat-ing trauma. The descending thoracic aorta isoccluded inferior to the left pulmonary hilum, whichis best exposed by elevation of the left lung ante-riorly and superiorly. The aorta must be separatedfrom the oesophagus anteriorly and the pre-verteb-ral fascia posteriorly by blunt dissection, beforeoccluding using a large vascular clamp, such as aDeBakey’s. Care must be taken when clamping theaorta, in order to avoid avulsion of vital branches.This risk is minimised by incompletely encircling theaorta.

Overzealous fluid volume loading during cross-clamping may lead to cardiac failure as a result ofacute ventricular dilatation and caution must alsobe exercised when releasing the clamp, in order toavoid a precipitous drop in blood pressure as flow isresumed. It should be noted that aortic cross-clamp-ing has been shown to be a significant predictor ofpoor outcome during emergency thoracotomy, mostprobably related to the degree of haemodynamiccompromise that necessitated the procedure.2

Measures following successfulthoracotomy

Once haemorrhage has been arrested and cardiacoutput is returning, the patient requires rapid trans-fer to the formal operating theatre. Definitiveexploration, repair and appropriate closure of the

Emergency thoracotomy in thoracic trauma–—a review 15

original access procedure are best performed by aspecialist surgeon in a controlled environment withsuitable resources. Hypotensive resuscitation (sus-taining systolic blood pressure at around 90 mmHg)should be employed, aiming for critical organ perfu-sion, whilst minimizing additional haemorrhage.Once effective cardiac function returns, the priorityof further treatment shifts from the repair of injuryand prevention of haemorrhage to maximisation ofcardiac output and delivery of oxygen to the tissues.The penalty of aortic cross-clamping increasesmarkedly when occlusion time exceeds 30 min.Therefore, the aortic clamp must be removed onceeffective cardiac function and systemic arterialpressures have been achieved.9 Aortic declampingis associated with a sudden reperfusion of distalischaemic tissues and subsequent release of inflam-matory mediators into the cardiopulmonary system;therefore, careful monitoring is required in theimmediate post-thoracotomy period. The oxygencarrying capacity can be enhanced by optimisationof cardiac contractility, by adequate filling and themaintenance of haemoglobin levels (above 10 mg/dL). Inotropic agents may also be utilised in order toimprove myocardial function.

Discontinuation of resuscitation

The discontinuation of all resuscitative effortsrequires careful judgement, having regard to themethod of injury, a knowledge of the physiologicalindicators, both in the prehospital environment andon arrival in the emergency department, and anunderstanding of the factors predictive of a pooroutcome following emergency thoracotomy. Speci-fic endpoints need to be set to prevent undueprolongation of futile resuscitation efforts.

Termination of emergency thoracotomy shouldcertainly be considered on the discovery of irrepar-able heart, or lung, injuries, asystolic arrest and thepresence of other lethal trauma, such as a massive

Table 8 Factors suggesting discontinuation of resus-citation during thoracotomy

Systolic blood pressure remains <70 mmHg after15 min despite fluid volume resuscitation

Self-sustaining rhythm is not achieved within 15 minof start of thoracotomy

Need for aortic cross-clamping in an attemptto restore myocardial and cerebral perfusion

Absence of a pericardial effusion without cardiacactivity on opening of the chest

Emergence of signs of secondary devastating injurieswith an independently poor outcome

head injury. Table 8 outlines the factors predictive ofapoor outcome,andwhich suggest discontinuationofresuscitation efforts involving thoracotomy.14,65

Risks to medical staff

Several studies indicate that patients who sustainpenetrating cardiac trauma are also at an increasedrisk of having infectious viral diseases, such ashepatitis and HIV infection.31,46,76 This figure canbe as high as 20% among the subgroup of patientsrequiring emergency department thoracotomy.Whilst on the whole this reflects the experienceof emergency departments in the USA, considera-tion must be given to avoiding potentially high-riskactivities in departments anywhere in the world.Emergency thoracotomy involves the rapid use ofmultiple surgical instruments and exposure topatients’ blood is certain. As a result, the possibilityof sustaining a significant HIV-seropositive exposureduring emergency thoracotomy must be a matter ofconcern. Fortunately, the overall number of cases ofoccupation-related HIV seroconversion, as a resultof patient contact, remains very low. Nevertheless,the application of appropriate guidelines and aselective approach to the use of emergency thor-acotomy will minimise the risk of exposure to blood-borne pathogens.

Other options for management

Pericardiocentesis and subxiphoidpericardiotomy

Any patient who is physiologically unstable enough torequire an emergency thoracotomy is unlikely to besuitable foreitherpericardiocentesis, or a subxiphoidpericardiotomy. However, pericardiocentesis maystill have aplace in themanagement of somepatientswith thoracic trauma,who are stable enough tomoveto the operating theatre for an urgent thoracotomy.Such patientsmay gain somebenefit fromat least thepartial relief of an acute pericardial tamponade.Pericardiocentesis, or subxiphoid pericardiotomy,may also prove to be useful in cases of delayedpericardial effusion following recent thoracictrauma. The incidence of this condition is not known,althoughat least one series has beenpublishedon thesubject.39 Its conclusion was that subxiphoid pericar-diotomy was an adequate form of therapy followingdiagnosis by ultrasound investigation.

However, the use of pericardiocentesis in thoracictrauma is a controversial subject. One of the majorlimitations is that it is not possible to evacuate

16 P.A. Hunt et al.

clotted pericardial haemorrhage by pericardiocent-esis. The literature includes many series of cases inwhich pericardiocentesis is discussed as both a diag-nostic and a therapeutic procedure. In one suchreview of 33 patients seen with penetrating cardiacinjuries over a 7-year period, McFarlane and Brandayconcluded that pericardiocentesis was not helpful inmaking the diagnosis and was only performed as aresuscitative measure in unstable patients prior tothoracotomy. They also concluded that a high indexof suspicion in patients with penetrating thoracictrauma, leading to expeditious thoracotomy, wouldresult in the greatest salvage rate.60 In their reviewofrecent advances in the diagnostic tools used in themanagement of chest injuries, Mattox and Wall con-cluded that abdominal (FAST) ultrasound, performedby surgeons in the emergency department, makesdiagnostic pericardiocentesis and subxiphoid peri-cardiotomy obsolete.59 Similarly, in their series of64patientswith penetrating cardiac injuries, Tavareset al. noted that performance of a subxiphoid peri-cardiotomy wastes valuable resuscitative time andrisks releasing a tamponade without allowing ade-quate control of the bleeding source.79 Overall, peri-cardiocentesis and subxiphoid pericardiotomy werenot shown to be appropriate in the management ofcases of thoracic trauma, unless the patient wasphysiologically stable, in which case they might beappropriate as temporary measures to improve car-diac output before urgent (operating department)thoracotomy, or to drain a delayed, or septic, peri-cardial effusion presenting late following trauma.They may also be appropriate diagnostic proceduresfor cases of suspected cardiac injury, where symp-toms and signs are questionable.

Digital thoracotomy

The pleural space may be entered by the examiningdoctor’s finger in order to feel for for conditions that

Table 9 Findings with digital thoracotomy examina-tion

Positive finding Differential diagnosis

Tense pericardiumwith reducedcardiac pulsation

Suggestive of apericardialeffusion/tamponade

Evidence of pleuralsymphysis

Likely secondary toprevious traumaor disease

Palpable holes inpericardium ordiaphragm

Traumatic injury tothoracic structures

Palpable abdominalorgans

Evidence ofdiaphragmaticrupture

might require further diagnostic, or therapeutic,measures. Examples of these are show inTable 9.84 This procedure should not delay resusci-tative efforts in an obviously moribund, or physio-logically unstable, patient and must be followed bythe placement of an intercostal chest drain.

Thoracoscopy

Thoracoscopy has been utilised mainly for theassessment and examination of thoracic structuresduring elective procedures.89 The procedure canalso be applied to the removal of clotted hae-mothoraces, to visualise the diaphragm for trau-matic ruptures, to examine the pericardium, forthe removal of foreign bodies and for the controlof chest wall, or intrathoracic, bleeding.45,51,57 Itsuse in cases where emergency thoracotomy isrequired has not been investigated.

FAST examination

The Focused Assessment with Sonography forTrauma (FAST) examination of the pericardiumand abdomen has been a significant advance inthe care of the trauma patient.73 In one study of238 victims of penetrating torso injury, the routineuse of FAST was noted to be beneficial, with thedetection of pericardial, or peritoneal, fluid beingthe most clinically useful gain, facilitating expedi-tious surgical care.16

By avoiding ionizing radiation, this examinationhas also the advantage of being able to be repeatedas many times as required during the continuedassessment and management of a trauma victim,and reduces collateral exposure of the treatingteam to ionising radiation in the emergency setting.

Summary

The term emergency thoracotomy has been appliedto thoracotomy carried out in different environ-ments, leading to a wide variation in its use in muchof the literature. The term emergency departmentthoracotomy is that most commonly used in caseswhere thoracotomy was carried out as a resuscita-tive measure. The nomenclature should be clarifiedso that emergency thoracotomy is the term for anythoracotomy carried out as part of the resuscitativeprocess, whether carried out on-scene, in the emer-gency department, or in the operating theatre.

Emergency thoracotomy may well be under-uti-lised in the specific group of patients who are likelyto benefit the most from the procedure. Experiencehas shown that there is approximately a 10% salvage

Emergency thoracotomy in thoracic trauma–—a review 17

rate following emergency thoracotomy in a popula-tion of patients that would otherwise have a 100%mortality rate and, therefore, this procedure shouldbe carried out immediately, when indicated.Patients who have an isolated penetrating cardiacinjury have the best prognosis, while moribundpatients who have suffered blunt trauma, especiallyassociated with extrathoracic injuries (in particular,severe head or spinal injuries), will generally have adismal prognosis.

The keys to successful resuscitation of the trau-matized heart are a high index of clinical suspicion,early recognition and rapid intervention. Depart-mental training, with moulage practice during reg-ular education sessions, will aid in the recognition ofclinical signs and speed appropriate intervention incases where emergency thoracotomy is indicated.

Finally, routine and robust audit, as well asefforts to collect data prospectively, will help toimprove upon and clarify the information on thisfortunately uncommonly needed procedure.

References

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