Resuscitative Thoracotomy

Immediate thoracotomy performed for resuscitation of the arrested or peri-arrest trauma patient:

Although the nature of injuries the non-surgeon can effectively deal with are limited, cardiac tamponade and cardiac wounds make up the majority of reversible causes and are reasonably easy to effectively intervene on.

Epidemiology

Survival is:

Essentially survival improves with a less sick patient and a simpler injury pattern.

  • Highly variable; 0-35%
    Substantial change based on indications, patient state, and thresholds for initiation.
  • Related to pathology:
    Good outcomes are associated with:
    • Penetrating trauma
    • Tamponade as mechanism
    • Low-velocity injuries
      Knife wounds more survivable than GSW.
    • Short arrest time
    • Exsanguinating from chest tube

Some centres commence thoracotomy on patients with a parlous (but present) haemodynamic state, and generally report much better outcomes. The significance of this is difficult to tease out, as some patients probably received an “unnecessary” thoracotomy.

Indications

Indications include:

  • Penetrating trauma with cardiac arrest <10 minutes
  • Blunt trauma with witnessed cardiac arrest
    • Can be considered in patients with cardiac arrest <10 minutes, with much lower likelihood of success.
  • Refractory shock with echocardiographic pericardial collection and other causes of traumatic arrest addressed, i.e.:
    • Intubated
    • Bilateral thoracostomies
    • Aggressive blood product resuscitation

Contraindications

Inadequate:

  • Expertise
  • Equipment
  • Environment

Anatomy

Equipment

Essential equipment:

  • Skin preparation
  • Scalpel
  • Heavy scissors
  • Trauma shears
    Sometimes a Gigli saw is used instead.
  • Retractor
    Classically Finochietto.
  • Toothed forceps
  • Vascular clamps
  • Gauze

Technique

This is a high-risk, messy procedure:

  • Blood
  • Sharp injury from rib fractures, sternal fractures, and instruments
  • PPE should include: Double gloves, goggles, gown

Three stages:

  • Gaining access to the chest
  • Dealing with the heart
  • Everything else

Access

Perform bilateral sequential thoracotomy:

If you have two operators the:

  • Primary operator should always perform the left thoracotomy
  • Second operator can perform the right thoracotomy
  • Position supine with arms abducted
  • Skin preparation
    Empty the bottle over the chest. Sterile drapes not applied.
  • Perform bilateral thoracostomies in 4th or 5th ICS in the mid-axillary line
    Often will have already been performed, and so the incision can be extended to the midline from here.
  • Incise with scalpel from the thoracostomy to the midline
    • Cut through skin and fat to muscle with scalpel
      • Don’t cut through muscle to avoid entering pleura injuring lung or diaphragm
  • Place two fingers into thoracostomy wound to hold lung away and use heavy scissors to cut through remaining muscle and pleura to midline
    • The internal mammary artery will be transected, and will bleed when the circulation resumes

Convert to clamshell:

  • Divide sternum
    Using trauma shears or saw.
  • Insert retractor
    Handle down so it doesn’t jam against the arm, and can be opened.
  • Incision may need to be extended posteriorly so that the chest can be opened in a clamshell fashion

The Heart

Open the pericardium:

  • Anterior surface should be opened to avoid the phrenic nerves
    Two approaches:
    • Grab with toothed forceps and open with scissors
      Often very difficult with a tense, full pericardium
    • Small nick with scalpel over collection, and then extend with scissors
  • Extend incision vertically
    Again, to avoid the phrenic nerves.

Interventions:

  • Evacuate tamponade
    Decompression and relief of tamponade is simple and responsible for the largest number of survivors.
  • Close cardiac wounds
    • Staple close
    • Suture close
      Preferable if close to coronary artery to avoid infarction.
    • Occlude with finger
    • Occlude with a Foley catheter
      Balloon inflated inside the heart can also prevent bleeding from larger wounds, however:
      • Balloon may herniate and ↑ size
      • Balloon ↓ EDV and ↓ SV
  • Defibrillation
    • Internal paddles often not available in this setting
    • The retractor must be removed and the chest closed for successful external defibrillation
  • Internal massage
    Much more effective than external compressions and can significantly augment cardiac output. Performance:
    • Ensure heart is not kinked on the vascular pedicle
    • Right hand underneath the heart
    • Left hand on top
    • “Milk” the heart from apex to base

Other Injuries

  • Severe hypovolaemia or control of abdominal bleeding
    • Direct compression of aorta against vertebral column using the hand
    • Clamping possible but is performed blindly and can be difficult to distinguish between aorta and oesophagus when arterial pressure is low
  • Intercostal artery bleeding
    • Can be substantial
    • Oversewing with suture usually effective
  • Mammary artery bleeding
    • Immediate control with vascular clamps
    • Tie off afterwards

Post-Procedure

  • Transfer patient to operating room for washout and definitive management
  • Hot-debrief with team

Complications

  • D
    • Emergence/awareness
      Arrested patients may awaken following resuscitation and require immediate anaesthesia.

References

  1. Paulich S, Lockey D. Resuscitative thoracotomy. BJA Education. 2020 Jul 1;20(7):242–8.
  2. McGonigal, M. ED Thoracotomy Part 1: Getting In. Accessed 8/5/23.
  3. McGonigal, M. ED Thoracotomy Part 2: The Heart. Accessed 8/5/23.
  4. McGonigal, M. ED Thoracotomy Part 3: The Aorta. Accessed 8/5/23.
  5. McGonigal, M. Off-Label Use of the Foley Catheter. Accessed 8/5/23.
  6. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.