Resuscitative

Thoracotomy
Andrew J. Hopwood, MSIII
Saint Louis University School of
Medicine

Question #1
A call is received in your trauma unit stating that a victim of a motor vehicle
collision is en route to your ER with no vital signs. The ambulance is 3 minutes
away. As you formulate your plan, which of the following situations would
constitute an indication for ER thoracotomy?
a.
b.
c.
d.

Massive hemothorax following blunt trauma to the chest

Blunt trauma to multiple organ systems with obtainable vital signs in the
field, but none on arrival in the ER
Rapidly deteriorating patient with cardiac tamponade from penetrating
thoracic trauma
Penetrating thoracic trauma and no signs of life in the field

Question #1
A call is received in your trauma unit stating that a victim of a motor vehicle
collision is en route to your ER with no vital signs. The ambulance is 3 minutes
away. As you formulate your plan, which of the following situations would
constitute an indication for ER thoracotomy?
a.
b.
c.
d.

Massive hemothorax following blunt trauma to the chest - indication for

thoracoStomy
Blunt trauma to multiple organ systems with obtainable vital signs in the
field, but none on arrival in the ER - futile procedure
Rapidly deteriorating patient with cardiac tamponade from penetrating
thoracic trauma
Penetrating thoracic trauma with no signs of life in the field

Indications for Resuscitative Thoracotomy

Rapid exsanguination
from chest tube (1500
mL)

Indications/Contraindications for
Resuscitative Thoracotomy
Although indications for thoracotomy in the ER are controversial, the procedure appears to be most
beneficial when it is employed to:
(1) release cardiac tamponade in patients with penetrating thoracic trauma who are deteriorating too
rapidly for a subxiphoid pericardial window to be created
(2) allow cross-clamping of the descending aorta in patients with intra-abdominal bleeding for whom
other measures are not effective in maintaining blood pressure
(3) allow effective internal cardiac massage in patients who arrive in the ER with faint or absent pulses
and distant heart sounds, and for whom other resuscitative efforts are unsuccessful.
By contrast, existing evidence suggests that patients who are unsalvageable and do not benefit from ER
thoracotomy include:
(1) those with no vital signs (pulse, pupillary reaction, spontaneous respiration) in the field, especially
lack of pulse for > 15 minutes at any time
(2) those with blunt trauma to multiple organ systems and absent vital signs on arrival in the ER
(3) nontraumatic cardiac arrest
(4) severe head injury

Question #2
A 25 yo male is brought to the ED after suffering a stab wound just to the left of
the sternum. Upon arrival, he becomes pulseless. Which of the following is a
component of a resuscitative thoracotomy?
a.
b.
c.
d.

Right thoracotomy in the fifth intercostal space

Ultrasound of the left chest
Incision in the pericardium anterior to the phrenic nerves
Cross-clamp of the abdominal aorta

Question #2
A 25 yo male is brought to the ED after suffering a stab wound just to the left of
the sternum. Upon arrival, he becomes pulseless. Which of the following is a
component of a resuscitative thoracotomy?
a.
b.
c.
d.

Right Left thoracotomy in the fifth/fourth intercostal space

Ultrasound of the left chest - important for abdominal trauma
Incision in the pericardium anterior to the phrenic nerves
Cross-clamp of the abdominal thoracic aorta

Thoracic Anatomy

Resuscitative Thoracotomy
Technique

Aggressive hydration and blood product transfusion

Incision - left anterolateral approach, exposing
heart, lungs, descending aorta, and esophagus
Damage control - initial bleeding control to allow for
next 2 steps
Pericardiotomy - small incision through pericardial
sac anterior to phrenic nerve to decompress
tamponade (1)
Cross clamping of thoracic descending aorta to
prevent exsanguinating hemorrhage in abdomen
and increase brain and heart perfusion
Cardiac massage (2)
Hemorrhage control and repair (3)

Question #3

Of the following patients, which has the greatest likelihood of 30 day survival
after undergoing emergent thoracotomy?
a.
b.
c.
d.
e.

32-year-old male with isolated penetrating cardiac injury

35-year-old male with isolated penetrating non-cardiac thoracic injury
32-year-old male with isolated penetrating abdominal injury
38-year-old male with blunt thoracic injury
35-year-old male with multiple penetrating injuries

Question #3
Of the following patients, which has the greatest likelihood of 30 day survival
after undergoing emergent thoracotomy?
a.
b.
c.
d.
e.

32-year-old male with isolated penetrating cardiac injury

19%
35-year-old male with isolated penetrating non-cardiac thoracic injury 11%
32-year-old male with isolated penetrating abdominal injury
4%
38-year-old male with blunt thoracic injury
1.4%
35-year-old male with multiple penetrating injuries
< 1%

Outcomes

Mechanism of injury

Location of major injury

Penetrating - 8.4%
Stab - 16.8%
Gunshot - 4.3%
Blunt - 1.4%
Thoracic - 10.7%
Abdominal - 4.5%
Multiple areas - 0.7%
Heart - 19.4%

Signs of life

Present on arrival - 11.5%

Absent on arrival - 2.6%
Absent in field - 1.2%

Question #4

If the patient survives emergent thoracotomy and regains signs of life as a result
of the procedure, what is the most appropriate next step?
a.
b.
c.
d.

Air evacuation to Level I trauma center

Discharge home and follow-up in 1 week with trauma team
Transfer to the ICU for ongoing resuscitation and observation to correct
acidosis, coagulopathy, and hypothermia
Immediate transfer of the patient to the OR for definitive management by
trauma team

Question #4
If the patient survives emergent thoracotomy and regains signs of life as a result
of the procedure, what is the most appropriate next step?
a.
b.
c.

d.

Air evacuation to Level I trauma center - resuscitative thoracotomy must

occur where definitive injury management is available within 45 minutes
Discharge home and follow-up in 1 week with trauma team - not appropriate
Transfer to the ICU for ongoing resuscitation and observation to correct
acidosis, coagulopathy, and hypothermia - must adequately address injuries
in OR
Immediate transfer of the patient to the OR for definitive management by
trauma team

Summary

Indications

Technique - Big 3

Pericardiotomy, cardiac massage, hemorrhage control and repair

Outcomes

Penetrating thoracic trauma with signs of life and severe hypotension (unresponsive to
fluids)

Best in isolated penetrating cardiac injuries

Post-op

Get to multidisciplinary trauma team in OR

Topics Not Covered

Details on specific situations in which thoracotomy is performed

Details of performing the procedure
Survival rates for more specific types of injuries
Specific complications from procedure
More on post-op management
Details on studies included in presentation
Link to video of procedure:
https://www.youtube.com/watch?v=EVVltPdABCc

Is Resuscitative Thoracotomy the First Step

of Autopsy?

References
Kao, Lillian S. and Lee, T. (2009). PreTest Self-assessment and Review. New York: McGraw-Hill Medical.
Klingensmith, M. E. (2008). The Washington manual of surgery. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Rhee PM, Acosta J. Bridgeman A, et al. Survival after emergency department thoracotomy: review of
published data from the past 25 years. J Am Coll Surg 2000; 190:288.
Seamon MJ, Shiroff AM, Franco M, et al. Emergency department thoracotomy for penetrating injuries of
the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. J
Trauma 2009; 67:1250.