Few major surgical procedures are performed in the emergency department. However, resuscitative thoracotomy is one such procedure. It is an emergent procedure most often performed in the emergency department, involving opening the chest wall to gain rapid access to the heart and major thoracic vessels for patients arriving on the brink of death in an effort to temporize the patient until a definitive repair can be achieved in the operating room. (1-3).

While a resuscitative thoracotomy is one of the most extreme and invasive procedures performed in the emergency department, it can be simplified into five major steps: incision, hemorrhage management, pericardiotomy, aortic cross-clamping, cardiac massage, and repair. (3) There are two primary incision options: a left anterolateral thoracotomy in the fifth intercostal space, typically used for patients in extremis or cardiac arrest, and the clamshell incision, which is preferred for patients suspected of having hemorrhage in the right chest cavity. (4) Once the chest is opened, any bleeding from obvious sources should be controlled. Lungs are a potential source of major bleeding, which can be controlled by directly clamping injured lung tissue, clamping the pulmonary hilum, or using the pulmonary hilar twist maneuver. (3) The pericardiotomy is made anterior and parallel to the phrenic nerve, while gently pushing the lung away from the heart in a posterior direction. Cross-clamping of the descending aorta, just above the diaphragm, helps reduce bleeding from intraabdominal or lower extremity injuries and redirects resuscitative circulation to vital organs, particularly the heart, lung, and brain. Cardiac massage involves using both hands to massage the heart at a rate between 80 and 100 compressions per minute. (4)

While the popularity of the resuscitative thoracotomy has fluctuated over the years, it has become a staple intervention for patients in profound refractory shock and those near death due to blunt or penetrating trauma. (5) The history of the resuscitative thoracotomy dates back to the 19th century and has continually evolved since its inception. In 1874, Schiff first described open cardiac massage, and in 1901, Igelsrud reported the first successful resuscitation of a trauma patient in cardiac arrest undergoing a resuscitative thoracotomy and open heart massage. The procedure took on a familiar form in 1906 when Spangaro described the classic left anterolateral thoracotomy incision used for resuscitative thoracotomies. (4) While this highly invasive procedure fell out of favor for less invasive interventions in the 1940s, it regained traction in the 1960s for resuscitating patients with penetrating cardiovascular injuries. (5)

There has been much controversy surrounding the use of resuscitative thoracotomy given the possibilities of severe anoxic brain injury risk to patients and blood-borne pathogen exposure risk to health care providers but has generally been seen as justified in patients in extremis with loss of vital signs with penetrating thoracic trauma and blunt trauma. (5-7) In the latest edition of the trauma textbook, resuscitative thoracotomy should be performed for the following conditions: penetrating trauma outside of the torso with cardiopulmonary resuscitation (CPR) of less than 5 minutes, blunt trauma with CPR of less than 10 minutes, and penetrating torso trauma with CPR of less than 15 minutes. (1)

More specifically, in patients with penetrating thoracic trauma, a resuscitative thoracotomy is considered appropriate for those who are hemodynamically unstable upon arrival in the emergency department, despite appropriate fluid resuscitation. It is also indicated for those who rapidly deteriorate or experience cardiac arrest during initial resuscitation. Additionally, in patients who have been pulseless and receiving cardiopulmonary resuscitation (CPR) for less than 15 minutes, a resuscitative thoracotomy may be warranted. Furthermore, in cases of blunt trauma injuries, a resuscitative thoracotomy is justified for patients who lose vital signs in transit or the emergency department and do not present obvious non-survivable injuries (e.g., massive head trauma or multiple severe injuries). It is also indicated for patients with rapidly diagnosed cardiac tamponade confirmed by ultrasound, provided there are no apparent non-survivable injuries. Chiefly, this intervention should only be performed if appropriate resources including appropriately trained staff are available for continued resuscitation and definitive repair. (3)

In 2021, Aseni et al. conducted a systematic review of medical literature related to emergency department resuscitative thoracotomies and provided three main categories of indications for resuscitative thoracotomies: a) accepted, b) selective, and c) rare. Accepted indications include patients arriving with penetrating cardiac injuries in the area of the cardiac box (the area that is below the sternal notch, between the nipples and above a transverse line halfway between the xiphoid process and the umbilicus) with profound refractory shock who are hemodynamically unstable but have signs of life such as pupillary reactivity, spontaneous ventilation, presence of a carotid pulse, extremity movement, and cardiac electrical activity.

Selective indications pertain to patients who have sustained penetrating thoracic injuries and arrive without a pulse and without signs of life, as long as CPR has been ongoing for less than 15 minutes, and there is potential for a return to cardiac activity. Rare indications encompass patients who arrive with vital signs but experience a witnessed cardiopulmonary arrest, provided that CPR has been ongoing for less than 10 minutes. (7)

Figure 2: Summary Recommendations for Emergency Department Thoracotomy

Resuscitative thoracotomy is a life-saving procedure in dire situations. It serves multiple critical purposes, including controlling intrathoracic hemorrhage, relieving cardiac tamponade, providing immediate albeit temporary repair of cardiac injuries, enabling open cardiac massage, and facilitating defibrillation to restore cardiac output and circulation. This procedure also aids in controlling both thoracic and abdominal hemorrhage (4, 7). However, there is no consensus on the overall survival rate of resuscitative emergency room thoracotomies. Multiple retrospective studies have reported significant variation in survival rates, ranging from 0% to 56.8%. In cases of penetrating trauma, the survival rate falls between 2.7% and 56.8%, while in instances of blunt trauma, the chances of survival are considerably lower, with rates ranging from 0% to 15.8%. (4)

Eastern Association for the Surgery of Trauma (EAST) evaluated whether emergency department thoracotomy improves outcomes in patients who present to the hospital pulseless after critical injuries by examining survival and neurological intactness rates. EAST used those findings to make corresponding recommendations, see Table 1. They compared patients in six different categories to make these recommendations: Patients presenting pulseless to the emergency department with signs of life after penetrating thoracic injury, without signs of life after penetrating thoracic injury, with signs of life after penetrating extrathoracic injury, without signs of life after penetrating extrathoracic injury, with signs of life after blunt injury, and without signs of life after blunt injury.

It was established that resuscitative thoracotomy significantly enhances both overall survival and the likelihood of achieving neurologically intact survival in patients who arrive pulseless in the emergency department but still exhibit signs of life after experiencing penetrating thoracic injuries. The findings indicated that patients who underwent resuscitative thoracotomy were nearly 7.6 times more likely to survive their hospitalization compared to those who did not receive the procedure (with a survival rate of 21.3% for resuscitative thoracotomy versus 2.8% without it). Furthermore, in terms of neurologically intact survival, patients who received resuscitative thoracotomy were nearly five times more likely to achieve this outcome (with an intact neurologically rate of 11.7% for survivors with resuscitative thoracotomy versus 2.5% for survivors without it).

Resuscitative thoracotomy was found to improve both survival and neurologically intact survival in patients presenting pulseless to the emergency department with absent signs of life after penetrating thoracic injury when resuscitated within 15 minutes of being pulseless. However, both survival and neurologically intact survival are rare after more than 15 minutes of CPR regardless of injury mechanism or anatomic location. Patients presenting pulseless to the emergency department without signs of life after penetrating thoracic injury were 41 times more likely to survive their hospitalization after EDT than without EDT (with a survival rate of 8.3% for resuscitative thoracotomy versus 0.2% without it). In regards to neurologically intactness, patients who underwent a resuscitative thoracotomy were nearly 20 times more likely to survive neurologically intact (with an intact neurologically rate of 3.9% for survivors with resuscitative thoracotomy versus 0.18% for survivors without it).

In the case of patients presenting pulseless to the emergency department with signs of life after penetrating extrathoracic injury, resuscitative thoracotomy was found to improve both hospital survival and neurologically intactness. Patients presenting pulseless to the emergency department with signs of life after penetrating extrathoracic injury were nine times more likely to survive their hospitalization after resuscitative thoracotomy than without (with a survival rate of 15.6% with resuscitative thoracotomy versus 1.7% without). Likewise, patients who underwent a resuscitative thoracotomy were 11 times more likely to survive neurologically intact (with a neurologically intact rate of 16.5% for survivors with resuscitative thoracotomy versus 1.5% for survivors without it).

Regarding patients presenting pulseless to the emergency department without signs of life after penetrating extrathoracic injury, evidence surrounding resuscitative thoracotomy was limited but resuscitative thoracotomy was found to improve both hospital survival and neurologically intactness. For hospital survival there was a 29-fold benefit with resuscitative thoracotomy (with a survival rate of 2.9% with resuscitative thoracotomy versus 0.1% without) and for neurologically intact survival there was a nearly 56-fold benefit (with a neurologically intact rate of 5% for survivors with resuscitative thoracotomy versus 0.09% for survivors without it).

For patients presenting pulseless to the emergency department with signs of life after blunt injury, resuscitative thoracotomy improves hospital survival by nine fold (with a survival rate of 4.6% with resuscitative thoracotomy versus 0.5% without) and neurologically intactness by nearly eight-fold (with a neurologically intact rate of 2.4% for survivors with resuscitative thoracotomy versus 0.3% for survivors without it).

In patients presenting pulseless to the emergency department without signs of life after blunt injury, hospital survival or neurologically intact hospital survival was poor in both groups. Survival in patients with resuscitative thoracotomy was 0.7% compared to 0.001% without. Neurologic outcomes were more grim with only 0.1% of patients surviving with resuscitative thoracotomy compared to an estimated 0.0006% without. (6)

Resuscitative thoracotomies have demonstrated their ability to improve survival and preserve neurological function, especially in cases of penetrating trauma. However, the potential complications associated with this substantial procedure cannot be overlooked in clinical decision-making (6). The complications of resuscitative thoracotomy encompass various issues, including occupational exposure to bloodborne pathogens, accidental ligation of coronary arteries, damage to the phrenic nerve, neurological complications resulting from cerebral hypoperfusion, esophageal damage during aortic cross-clamping, recurrent bleeding from the chest wall or the internal mammary artery, damage to the phrenic nerve, and ischemic damage to distal organs and the spinal cord due to aortic cross-clamping (2), (7). Given the risks to both patients and healthcare providers, coupled with the uncertainty of complication rates, contraindications for resuscitative thoracotomy have been established to minimize potentially futile procedures.

Resuscitative thoracotomy should not be performed when patients have vital signs particularly if the situation appears futile. For instance, where there are no signs of life on scene of injury; asystole as presenting rhythm with no pericardial tamponade; pulseless for greater than 15 minutes; massive, non survivable injuries, pre-hospital penetrating abdominal trauma without cardiac activity, severe head injury, and severe multisystem injury. Because this process is considered to be a temporary stopgap, resuscitative thoracotomy should only be performed when resources to perform the definitive treatment are readily and immediately available. The patient’s age is also taken into consideration, as outcomes for the young and old have been poor. Because of poor outcomes, not performing a resuscitative thoracotomy in patients between ages 0-14 who suffered a blunt thoracic injury and any patient older than 57 years old should be considered (2-3)

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POST BY: ERICA FLEMING-HALL, MS4

FACULTY EDITING BY: COLIN MCCLOSKEY, MD

References

Burlew C, & Moore E.E. (2020). Resuscitative thoracotomy. Feliciano D.V., & Mattox K.L., & Moore E.E.(Eds.), Trauma, 9e. McGraw Hill. https://accesssurgery.mhmedical.com/content.aspx?bookid=2952&sectionid=249118216
Weare S, Gnugnoli DM. Emergency Room Thoracotomy. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560863
Eidt JF, Foreman ML. Resuscitative Thoracotomy: Technique. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on October 16, 2023.)
Pust, G. D., & Namias, N. (2016). Resuscitative thoracotomy. International Journal of Surgery, 33, 202–208. https://doi.org/10.1016/j.ijsu.2016.04.006
Burlew, C. C., Moore, E. E., Moore, F. A., Coimbra, R., McIntyre, R. C., Davis, J. W., Sperry, J. L., & Biffl, W. L. (2012). Western Trauma Association Critical Decisions in Trauma. The Journal of Trauma and Acute Care Surgery, 73(6), 1359–1363. https://doi.org/10.1097/ta.0b013e318270d2df
Mark J. MD; Haut, Elliott R. MD, PhD; Van Arendonk, Kyle MD; Barbosa, Ronald R. MD; Chiu, William C. MD; Dente, Christopher J. MD; Fox, Nicole MD; Jawa, Randeep S. MD; Khwaja, Kosar MD; Lee, J. Kayle MD; Magnotti, Louis J. MD; Mayglothling, Julie A. MD; McDonald, Amy A. MD; Rowell, Susan MD, MCR; To, Kathleen B. MD; Falck-Ytter, Yngve MD; Rhee, Peter MD, MPH. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery 79(1):p 159-173, July 2015. | DOI: 10.1097/TA.0000000000000648
Aseni, P., Rizzetto, F., Grande, A. M., Bini, R., Sammartano, F., Vezzulli, F., & Vertemati, M. (2021). Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review. The American Journal of Surgery, 221(5), 1082–1092. https://doi.org/10.1016/j.amjsurg.2020.09.038

Resuscitative Thoracotomy: When to Crack the Chest

References

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