Podcast 1013: Thoracotomy Indications

Contributor; Taylor Lynch, MD

Educational Pearls:

• Thoracotomy 

  • Thoracotomy is used in traumatic cardiac arrest to replace conventional CPR with direct access to the chest.

  • Goals include identifying and controlling reversible causes of bleeding, prioritizing blood flow to the heart and brain, and performing open cardiac massage.

• Trauma categories

  • Penetrating trauma: Gunshot wounds and stab wounds.

    • Has a higher chance of survival because the injury may be localized and directly repairable.

    • Cardiac stab wounds may have the highest survivability because the defect can be visualized, repaired, and treated with blood administration.

  • Blunt trauma: Motor vehicle collisions and falls from height.

    • Has a much lower chance of survival.

• Western guidelines

  • EMS must witness the patient lose pulses.

  • Penetrating trauma: CPR for less than 15 minutes.

  • Blunt trauma: CPR for less than 10 minutes.

  • Survival decreases to essentially zero beyond these time limits.

• Eastern guidelines

  • Focus on the presence of signs of life in blunt or penetrating trauma.

  • Signs of life may include:

    • Pupillary response.

    • Measurable blood pressure.

    • Purposeful movement.

• Patient selection

  • Thoracotomy should only be performed when the patient has a reasonable chance of survival.

  • It is a highly morbid procedure with significant occupational risks, including needlestick injury.

  • Appropriate patient selection and timing are essential.

• Procedure

  • Begin on the left side of the chest.

  • Cross-clamp the aorta to restrict blood flow below the heart and prioritize circulation to the heart and brain.

  • Identify and repair visible sources of bleeding involving structures such as the heart or lungs.

  • Perform open cardiac massage as the equivalent of CPR.

  • ACLS medications may still be administered.

References:

1. Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006;1:4. Published 2006 Mar 24. doi:10.1186/1749-7922-1-4

2. Rhee, Peter M. ; Acosta, Jose ; Bridgeman, Amy et al. / Survival after emergency department thoracotomy : Review of published data from the past 25 years. In: Journal of the American College of Surgeons. 2000 ; Vol. 190, No. 3. pp. 288-298.

3. Nunn, Andrew ; Prakash, Priya ; Inaba, Kenji et al. / Occupational exposure during emergency department thoracotomy : A prospective, multi-institution study. In: Journal of Trauma and Acute Care Surgery. 2018 ; Vol. 85, No. 1. pp. 78-84.

4. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-1363. doi:10.1097/TA.0b013e318270d2df

5. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159-173. doi:10.1097/TA.0000000000000648

Summarized by Steven Fujaros NREMT | Edited by Steven Fujaros & Ahmed Abdel-Hafiz, NREMT-P

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