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ED THORACOTOMY

These pages are excerpted from the Trauma Resident Handbook, Rhode Island Hospital Department of Surgery, Division of Trauma - updated 2001. The policies herein are intended to serve as guidelines only. Individual circumstances need to be considered as there may be times when it is appropriate or desirable to deviate from these guidelines. These educational guidelines will be reviewed and updated routinely.

Emergency department thoracotomy was originally popularized in 1966 as a potentially therapeutic measure for all patients with life-threatening chest injury. Since then, multiple critical analyses of ED thoracotomy (EDT) have prompted a more selective application of the procedure. Patient survival with intact neurologic status (meaningful survival) should be the goal of EDT.

SELECTIVE APPROACH

In deciding whether to perform EDT, the following variables should be considered: Mechanism of injury (blunt vs. gunshot vs. stab); vital signs*, and signs of life**, (both at the scene and on presentation to the trauma room).
The same criteria for performing EDT should apply to children, as their survival closely parallels that of adults. The elderly may be a special population group. In several large series of EDT there are no meaningful survivors over the age of 65. EDT should be used in the over 65 population in only the most favorable circumstances. ED thoracotomy is most productive for life-threatening penetrating cardiac wounds, especially pericardial tamponade. Outcomes for EDT are shown in the following table:

	ED: No sign of life	ED: Signs of life, no vital signs	ED: Vital signs
BLUNT	< 1%	5%	5%
GSW	1%	15%	15%
STAB	5-10%	33%	32%
	1/3 survivors severely neurol. impaired		< 1/10 survivors neurol. impaired

The major goals and potential therapeutic maneuvers that one should bear in mind while performing this procedure are as follows: release pericardial tamponade; control cardiac and/or great vessel bleeding; control hilar bleeding; perform open cardiac massage; redistribute blood to myocardium and brain, and limit sub-diaphragmatic hemorrhage via aortic cross-clamping.

TECHNIQUE

ED thoracotomy is performed through a left antero-lateral incision at the level of the fifth intercostal space, crossing the inferior border of the pectoralis major muscle. The skin, subcutaneous tissue, and chest wall musculature should be incised with one knife pass. The intercostal muscles and pleura should then be incised with heavy Mayo scissors along the superior margin of the rib. A rib spreader is then inserted with the handle toward the axilla. The pericardium is then visualized. If tense, it is opened with a longitudinal incision posterior to the phrenic nerve. Any blood or clot should be evacuated, and attempts made to control intra-cardiac bleeding with digital pressure, foley catheter placement, or perhaps, plegeted sutures. Open cardiac massage can then be performed. Massive bleeding from the lung is controlled with a clamp across the pulmonary hilum. The thoracic aorta is visualized by elevating the left lung anteriorly and superiorly. The aorta is differentiated from the esophagus by palpating the nasogastric tube, and a vascular clamp is placed across the aorta.

RISKS TO TRAUMA TEAM

ED thoracotomy involves the use of sharp instruments and contact with the patient's blood in an often chaotic atmosphere. In this type of situation, universal precautions are often ignored, thus subjecting the trauma team to higher risk than is necessary. In urban trauma populations, the rate of HIV and hepatitis B and C infection range from ten to twenty times that of the general population. This rate may be even higher in the population most likely to require ED thoracotomy, making universal precautions and selective use of the procedure essential.

*Vital signs: Palpable pulse or obtainable BP
**Signs of life: pupillary activity, respiratory effort, or narrow complex QRS.

1. Baxter, B.T., Moore, E.E., Moore, J.B., et al: Emergency department thoracotomy following injury: critical determinants of patient salvage. World J. Surg., 12: 671-675, 1988.
2. Beaver, B.L., Columbani, P.M., Buck, J.R., et al: Efficacy of emergency room thoracotomy in pediatric trauma. J. Pediatric Surg., 22: 19-23, 1987.
3. Biffl, W.L., Moore, E.E., Harken, A.H.: Emergency department thoracotomy. In Trauma, Mattox, Moore, Feliciano, eds., 2000.
4. Branney, S.W., Moore, E.E., Feldhaus, K.M., et al: Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma, 45: 87-94, 1998.
5. Kelen, G.D., DiGiovanna, T., Bisson, L., et al: Human immunodeficiency virus infection in emergency department patients: epidemiology, clinical presentations, and risk to health care workers: the John's Hopkins experience. JAMA, 262: 516-522, 1989.
6. Rothenberg, S.S., Moore, E.E., Moore, F.A., et al: Emergency department thoracotomy in children- a critical analysis. J Trauma, 29: 1322-1325, 1989.
7. Sloan, E.P., McGill, B.A.,Zalenski, R., et al: Human immunodeficiency virus and hepatitis virus seroprevalence in an urban trauma population. J Trauma, 38: 736-741, 1995.

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