April 29, 2022 - read ≈ 7 min
Sarah A. Brownlee, MD
Department of Surgery, Massachusetts General Hospital, Boston, MA USA
Peter J. Fagenholz, MD
Department of Surgery, Massachusetts General Hospital, Boston, MA USA
Resuscitative thoracotomy, is performed on a patient in circulatory collapse with the objective of addressing reversible causes of cardiovascular collapse from cardiac tamponade or significant hypovolemia [1-5]. The goals are to release pericardial tamponade, control cardiac or intrathoracic hemorrhage, perform open cardiac massage, and temporarily occlude the descending thoracic aorta in the case of persistent hypotension until definitive operative intervention can be performed [1,2,5]. In this article, we detail the indications and contraindications for performing the procedure as well as the necessary equipment, supplies, and preparation; steps of resuscitative thoracotomy; and the anticipated morbidity and mortality.
Outcomes following resuscitative thoracotomy are largely determined by injury type and patient condition at the time of thoracotomy [1,3,5]. The best survival rates are for patients with pericardial tamponade associated with penetrating cardiac injury, who suffer cardiovascular collapse within the hospital or within minutes of arrival [1,4]. It is critical to note that resuscitative thoracotomy is likely a bridge to nowhere unless significant blood and critical care services are available and that the typical indications outlined below may, when resources are constrained, actually be indications to forego resuscitative efforts.
Resuscitative thoracotomy is indicated in the following clinical scenarios (again, with the caveat that sufficient peri- and post-procedure support and supplies are available) [1-3]:
- Penetrating torso trauma with CPR < 15 minutes
- Penetrating non-torso trauma with CPR < 10 minutes
- Blunt trauma with CPR < 10 minutes
Resuscitative thoracotomy is not recommended in the following scenarios, given an extremely low likelihood of meaningful survival [1-3]:
- Penetrating injury with CPR > 15 minutes and no signs of life (pupillary response, respiratory effort, motor activity)
- Blunt injury with CPR > 10 minutes and no signs of life
- Asystole in the absence of pericardial tamponade
Equipment and Supplies
A sterile thoracotomy tray with appropriate instruments and supplies should be prepared and readily available. Instruments include at a minimum: a scalpel, scissors, a self-retaining retractor, vascular clamps, a needle driver, and suture. Additional supplies such as sterile drapes and towels, sterile prep solution (e.g. betadine), sponges and gauze should be available [1-5].
Desirable instruments which are standard in most kits include a Finichetto rib spreader, an instrument for sternal division (sternal saw, Gigli saw, Lebsche knife and mallet, or heavy scissors [“trauma shears”]), vascular sutures, and pledgets.
Personnel involved in the procedure should observe universal precautions by wearing gowns, gloves, and eye protection at all times given the increased risk of exposure to bloodborne pathogens in the emergency setting [1,5]. Standard advantages of the operating room including adequate lighting, suction, and trained procedural personnel are often lacking in the emergency setting, but every effort should be made to obtain adequate lighting.
Resuscitative thoracotamies that succeed in restoring circulation should almost always be followed by transport to an operating room for definitive management of injuries given the usual lack of these resources in the emergency department .
Patient is positioned supine with left arm extended above the head to provide unobstructed access to the left chest.
- Incision and exposure
An anterolateral thoracotomy incision is made in the 4th or 5th intercostal space, just below the nipple. In women, the breast is retracted superiorly, and the incision made at the level of the inframammary fold. The incision starts at the right side of the sternum (which saves time if extension to a clamshell thoracotomy is needed) and curves slightly towards the axilla to follow the curve of the rib. The incision is carried all the way down to the level of the bed. Skin, subcutaneous fat, and muscle is incised with the knife incision. Curved Mayo scissors are then used to divide the intercostal muscles and parietal pleura along the superior portion of the rib to avoid injuring the neurovascular bundle. Once the chest is entered, the rib retractor is placed with the handle directed inferiorly. Once the retractor is fully opened, exposure can often be enhanced by additional division of the intercostals with the scissors.
- Pericardiotomy and cardiorraphy
Since cardiac injury and cardiac tamponade are the injuries most likely to be salvageable, we recommend pericardiotomy as the next step. Toothed pickups are used to grasp and elevate the pericardium. If bulging, this can be nicked with a knife to gain entry. The pericardium is then opened with scissors using a sliding, rather than snipping, motion starting at the cardiac apex in the direction anterior and parallel to the phrenic nerve. Blood and clots, if present, are evacuated. At this point the heart can be delivered from the pericardium for better access to the cardiac chambers for inspection and repair of any injuries present. Hemorrhage is controlled initially with direct digital pressure. Any number of techniques can be used to control cardiac injury, but we recommend interrupted simple sutures for small injuries (<2 cm), or continuous sutures for larger injuries. Wounds near a major coronary vessel should be controlled with a horizontal mattress suture passing underneath the vessel. In the event of asystole in the absence of pericardial tamponade or a reparable cardiac injury, we do not recommend proceeding with ACLS measures such as cardiac massage, epinephrine, or defibrillation.
- Aortic cross-clamping
After thoracotomy, pericardiotomy, and evaluation of the heart for injury, the descending aorta should be occluded to maximize perfusion if hypotension persists. The aorta is palpated directly above the spine. The mediastinal pleura is incised, and the aorta bluntly dissected away from the esophagus superiorly and the prevertebral fascia inferiorly with the surgeon’s thumb and fingertips. Once isolated, the aorta is occluded with a large vascular clamp.
- Hemorrhage control and repair and management of other thoracic injuries
Pulmonary hilar control may be necessary if a pulmonary hilar injury or significant hemorrhage from lung parenchyma is present. The only dissection required to allow for this is division of the inferior pulmonary ligament. Hilar control can then be achieved with digital compression, placement of a large clamp across the hilum, or by twisting the lung into inverted position (hilar twist) if these other maneuvers are not possible. Hilar cross clamping is also indicated in the presence of air embolism. Finally, identification of myriad other thoracic injuries, including lung contusion, blunt cardiac injury, aortic rupture, esophageal disruption, diaphragmatic rupture, hemopneumothorax, and rib fractures are possible during resuscitative thoracotomy and may be important indicators regarding overall morbidity and mortality.
Morbidity and Mortality
Technical complications of resuscitative thoracotomy as well as the hemodynamic and metabolic consequences of aortic cross-clamping are numerous and serious and must be considered prior to the decision to proceed [1,2,5]. Technical complications include, though are not limited to, injuries to nearly every intrathoracic structure, including the heart, lungs, aorta, coronary arteries, and esophagus, as well as injury to the phrenic nerves and avulsion of the aortic branches. In addition, while aortic cross-clamping results in an increase in blood pressure, there are associated reductions in perfusion of the abdominal viscera and lower extremities that may worsen the metabolic consequences of shock and lead to multi-system organ failure . Finally, long-term survival rates and quality of life remain poorly described in survivors of resuscitative thoracotomy, but it is clear that significant resources are required in the form of multidisciplinary therapies both in the hospital and post-discharge setting [1,3,5]. Ultimately, the decision to proceed with resuscitative thoracotomy must be made on a case-by-case basis, particularly in resource-limited settings, by the treating surgeon armed with the knowledge of the risks, potential benefits, and complications.
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