Management of thoracic traumaEmergency Department Thoracotomy
Section snippets
Definition of EDT
Thoracotomy performed in the emergency department for trauma patients in extremis is usually initiated as a left anterolateral incision at the level of the fourth or fifth intercostal space. EDT should not be confused with a thoracotomy undertaken at other stages of the resuscitative process, such as a thoracotomy performed in the operating room or an urgent thoracotomy performed at the intensive care unit within hours after the initial injury.5
The location and the timing of the thoracotomy in
Indications and Contraindications for EDT
In 2001, the American College of Surgeons Committee on Trauma (ACS COT) published a set of guidelines for performing EDT.3 Since EDT itself is not an intervention that lends itself to be studied with prospective randomized controlled trials (Level I data), the guidelines are based on evaluation of some prospective observational studies but mostly are derived from retrospective database investigations.
Rationale for EDT
The objectives of EDT can be summarized as:
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Release of pericardial tamponade
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Control of intrathoracic vascular or cardiac bleeding
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Evacuate bronchovenous air embolism or eliminate a bronchopleural fistula
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Perform open cardiac massage
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Temporarily occlude the descending thoracic aorta
Technical Details of EDT
The technical skills necessary for an EDT include the ability to perform a rapid thoracotomy, pericardiotomy, cardiorrhaphy, and thoracic aortic cross-clamping, as well as knowledge of vascular repair techniques.
To begin an EDT, the patient should remain positioned supine (as the blunt trauma patient would not yet have spine clearance) with the side to be operated on slightly elevated with a towel or wedge under the long board. Both arms should be laid out at right angles to enable peripheral
Clinical Results of EDT
In the last two decades, reported survival rates for EDT after blunt and penetrating trauma range from 1.8% to 27.5%.15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 The largest series (33) included 950 EDTs performed over 23 years and a survival rate of 4.3%. The second largest experience6 described 846 EDTs performed with a survival rate of 5.1%. Survival rates by mechanism show a high degree of variability. Penetrating and blunt injuries range from 2.7% to 38.9% (mean 13%) and 0% to 12%
Conclusions
The general lack of clarity in the medical literature, the severe time constraints involved in the decision as to the need for the procedure, the life and death nature of the decision, and the very low, but finite survival rates account for the significant disagreement among individual surgeons and widely recognized experts on the role of EDT. Although considerable differences in opinion exist, we favor the use of EDT for pulseless trauma patients who have recently lost signs of life. The
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Cited by (17)
Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians
2021, Annals of Emergency MedicineCitation Excerpt :The execution of the resuscitative thoracotomy is critical because any delay in performance rapidly diminishes the chances for survival.3,4 Several studies have demonstrated that prognosis depends on the time between loss of cardiac output and performance of the resuscitative thoracotomy.5-11 Editor’s Capsule Summary
Reanimating Patients After Traumatic Cardiac Arrest: A Practical Approach Informed by Best Evidence
2018, Emergency Medicine Clinics of North AmericaCitation Excerpt :The hospital must identify a priori a process to perform an RT and to provide definitive care if the patient is reanimated. The steps to performing an RT are well described elsewhere.45 Although typically started as a left anterolateral thoracotomy, extension across the sternum into a bilateral thoracotomy or clamshell incision may be required for adequate exposure to the heart, superior mediastinum, or right pulmonary hilum.55
Cardiothoracic surgical emergencies in the intensive care unit
2014, Critical Care ClinicsCitation Excerpt :Generally accepted guidelines include the use of EDT for impending or witnessed cardiac arrest with cardiopulmonary resuscitation less than 15 minutes in the setting of penetrating trauma. The outcomes of EDT for blunt trauma are less favorable and are generally reserved for patients with witnessed cardiac arrest after arrival to the trauma center or with CPR less than 5 minutes.71,74,76,77 Overall survival after EDT is reported at 7.4%, although the survival for patients surviving stab wounds was reported at 16.8% whereas the survival for gunshot wounds was reported at 4.3%.78
Modified emergency department thoracotomy for postablation cardiac tamponade
2012, Annals of Emergency MedicineCitation Excerpt :Classically, the procedure for ED thoracotomy is performed with the left-sided lateral approach and involves making a large opening through the pericardium while being careful not to damage the phrenic nerve. Such techniques as “tearing” the pericardium longitudinally and “delivering the heart” are recommended.9,10,14,15 This technique for penetrating thoracic injuries makes sense because the physician is generally trying to visualize injuries to the high-flow easily accessible left side of the heart.
Emergency thoracotomy. Indications, surgical technique and results
2011, Cirugia EspanolaThoracic Surgical Aspects of Seriously Injured Patients
2020, Zentralblatt fur Chirurgie - Zeitschrift fur Allgemeine, Viszeral- und Gefasschirurgie