Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes

Abstract

In the past three decades there has been a significant clinical shift in the performance of emergency department thoracotomy (EDT), from a nearly obligatory procedure before declaring any trauma patient to select patients undergoing EDT. The value of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable. Its indiscriminate use, however, renders it a low-yield and high-cost procedure. Overall analysis of the available literature indicates that the success of EDT approximates 35% in the patient arriving in shock with a penetrating cardiac wound, and 15% for all penetrating wounds. Conversely, patient outcome is relatively poor when EDT is done for blunt trauma; 2% survival in patients in shock and less than 1% survival with no vital signs. Patients undergoing CPR upon arrival to the emergency department should be stratified based upon injury and transport time to determine the utility of EDT. The optimal application of EDT requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences.

Figure 1

Algorithm directing the use of EDT in the multiply injured trauma patient.

Figure 2

A generous thoracotomy incision is performed through the fourth or fifth intercostal space; the incision should start to the right of the sternum, and begin curving into the axilla at the level of the left nipple. The Finochiettos' rib retractor should be placed with the handle directed inferiorly toward the bed, in case transverse sternal split is warranted.

Figure 3

Cardiorrhaphy of the right ventricle is buttressed with pledgets; ligation of a coronary artery can be avoided by performing vertical mattress sutures.

Figure 4

Internal paddles for defibrillation are positioned on the anterior and posterior aspects of the heart.

Figure 5

Aortic crossclamp is applied with the left lung retracted superiorly, below the inferior pulmonary ligament, just above the diaphragm. The flaccid aorta is identified as the first structure encountered on top of the spine when approached from the left chest.