EMERGENCY DEPARTMENT THORACOTOMY

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CHAPTER 19 EMERGENCY DEPARTMENT THORACOTOMY

Juan A. Asensio, Patrizio Petrone, Luis Manuel Garcí-a-Núñez, Dan L. Deckelbaum, Dominic Duran, Donald Robinson, Kenneth D. Stahl, Michael F. Ksycki, Francisco A. Ruiz Zelaya, Alexander D. Vara, John S. Weston, Allan Capin, Carl Schulman

Emergency department thoracotomy (EDT) remains a formidable tool within the trauma surgeon’s armamentarium. Since its introduction during the 1960s, the use of this procedure has ranged from sparing to liberal.¹ At many urban trauma centers, this procedure has found a niche as part of the resuscitative process.¹ Because of improvements in emergency medical services systems (EMS), many critically injured patients now arrive in extremis prompting trauma surgeons to perform this procedure to attempt saving their lives. This technically complex procedure should only be performed by surgeons familiar with the management of penetrating cardiothoracic injuries.

Indications for the use of EDT appearing in the literature range from vague to quite specific.¹ It has been used in a variety of settings including penetrating and blunt thoracic and/or thoracoabdominal injuries, cardiac and exsanguinating abdominal vascular injuries.¹^–⁴ It has also been used rarely in exsanguinating peripheral vascular injuries arriving in cardiopulmonary arrest and also in pediatric trauma. Many studies in the literature have also reported its use in patients presenting in cardiopulmonary arrest secondary to blunt trauma.

HISTORIC PERSPECTIVE

In 1874, Schift ⁵ was first to promote the concept of open cardiac massage. Rehn⁶ in 1896 reported the first successful repair of a cardiac injury, a stab wound of the right ventricle. In 1897, Duval⁷ described the median sternotomy incision widely used today. Igelsbrud⁵ in 1901 was the first to report successful resuscitation of a patient, sustaining a post-traumatic cardiac arrest patient with a thoracotomy and open cardiac massage. Spangaro ⁸ in 1906 described the left anterolateral thoracotomy widely used today for resuscitation as an intercostocondral thoracotomy.

Zolls ⁵ in 1956 was the first to introduce the concept of external defibrillation, and Kouwenhoven⁵ in 1960 described closed cardiopulmonary resuscitation. Beall⁹ et al. in 1961 was the first to propose that patients experiencing cessation of cardiac action should undergo immediate resuscitative thoracotomy and cardiac massage, whether in the ED, operating room (OR), or recovery ward, and was first to attempt this procedure. Similarly, in 1966, he advocated the use of immediate cardiorrhaphy in the emergency room and setting up an instrument tray; he was also the first to successfully perform this procedure.¹⁰

OBJECTIVES

Objectives of the EDT procedure include the following:

Resuscitation of agonal patients with penetrating cardiothoracic injuries (Figure 1A and B)

Evacuation of pericardial blood and clot to relieve cardiac tamponade

Control of thoracic hemorrhage

Perform open cardiac massage, which can produce up to 60% of the normal ejection fraction (EF)

Repair of cardiac injuries

Cross-clamp the pulmonary hilum to control pulmonary vessel hemorrhage

Cross-clamp the descending thoracic aorta (Figures 2 and 3)

Cross-clamp the pulmonary hilum and aspirate both the right and left ventricles to prevent and/or treat pulmonary embolism

Figure 1 (A) Suturing a stab wound to the heart, after emergency department thoracotomy. (B) Same patient with the suture completed (arrow).

Figure 2 The descendent aorta when entering the aortic hiatus. The aorta was dissected prior to being clamped. Note the esophagus superiorly.

Figure 3 Aortic cross-clamp in place. Note the size of the left hemithorax cavity, which can hold the entire patient’s volemia during exsanguinated injuries.

INDICATIONS

Indications for EDT can be subdivided into three categories: accepted, selective, and rare.¹^–⁴

Accepted Indications

Emergency department thoracotomy is best applied to patients sustaining penetrating cardiac injuries who arrive in trauma centers after a short scene and transport time with witnessed or objectively measured physiological parameters (signs of life), pupillary reactivity, spontaneous ventilation even if agonal, presence of a carotid pulse, measurable or palpable blood pressure, extremity movement, and cardiac electrical activity.

Selective Indications

Emergency department thoracotomy should be performed selectively in patients sustaining penetrating noncardiac thoracic injuries due to its very low survival rate. Because it is difficult to ascertain whether injuries are noncardiac thoracic versus cardiac this procedure may be employed to establish a diagnosis.

EDT should be performed selectively in patients sustaining exsanguinating abdominal vascular injuries due to its very low survival rate. Meticulous selection of patients should be exercised. This procedure should be used as an adjunct to definitive repair of abdominal vascular injuries.

Rare Indications

Emergency department thoracotomy should be performed rarely in patients sustaining cardiopulmonary arrest secondary to blunt trauma due to its very low survival rate and poor neurological outcomes. Extreme caution should be exercised in selecting patients for this procedure. It should be strictly limited to those who arrive with vital signs at the trauma center and experience a witnessed cardiopulmonary arrest. Most authors would caution against this indication.

TECHNIQUES FOR CARDIAC INJURY REPAIR

Incisions

There are two main incisions that are used in the management of penetrating cardiac injuries. Trauma surgeons should be aware that injuries caused by missiles can be unpredictable in their trajectory and that a missile injury that penetrates a hemithoracic cavity may not remain confined in the original area of entrance and may produce injury to the contralateral cavity. This will require the trauma surgeon to access the contralateral hemithoracic cavity.^67,^68,^70,^74,⁷⁷

Median sternotomy described by Duval ³⁷ is the incision of choice for patients admitted with penetrating precordial injuries that arrive with some degree of hemodynamic instability and may either undergo preoperative investigation with FAST and/or chest x-ray. It is also the incision of choice or those that are thought to harbor occult cardiac injuries. The left anterolateral thoracotomy is the incision of choice in the management of patients who arrive in extremis. This incision is used in the ED for resuscitative purposes.^67,^68,^70,^74,⁷⁷

The left anterolateral thoracotomy described by Spangaro ⁴¹ can also be extended across the sternum as bilateral anterolateral thoracotomies, if it is determined during the resuscitative period that the patient’s injury extends into the right hemithoracic cavity (Table 1). Extension into bilateral anterolateral thoracotomies is also is the incision of choice for patients that are hemodynamically unstable after incurring mediastinal traversing injuries. This incision allows full exposure of the anterior mediastinum and pericardium as well as both hemithoracic cavities. It is important to note that upon transection of the sternum both internal mammary arteries are also transected and must be ligated after restoration of perfusion pressure. Uncontrolled, they can serve as a significant source of blood loss. This is a frequent pitfall during the institution of damage control; as trauma surgeons may forget to ligate these vessels prompting return to the operating room for a patient that can ill afford it. For patients that sustain thoracoabdominal injuries, the left anterolateral thoracotomy is also the incision of choice if patients deteriorate in the OR while undergoing a laparotomy.^67,^68,^70,^74,⁷⁷

Table 1 Algorithm for Emergency Department Thoracotomy

Operator	Well-trained surgeon
Initial assessment and resuscitation	Endotracheal intubation
	Immediate venous access
	Rapid infusion
Position	Supine with left arm elevated
Incision	Left anterolateral incision
Incision	Fifth intercostal space from left sternocostal junction to latissimus dorsi m.
Procedure	Incision as above
	Sharp transection of intercostal m.
	Open pleura
	Place a Finnochietto retractor
	Open cardiac massage
	Elevate left lung medially
	Locate and dissect descending aorta
	Cross clamp aorta by Crafoord-Debakey clamp
If cardiac injury (bluish and tense pericardium)	Open pericardium longitudinally with preserving phrenic n.
	Evacuate blood clot
	Repair cardiac injury (mattress sutures of Halsted with Prolene 2/0)
If active bleeding at pulmonary hilum	Cross-clamp pulmonary hilum with Crafoord-Debakey clamp
If pulmonary parenchymal laceration	Clamp with Duval clamp
If associated injury in contralateral thoracic cavity	Extend incision to the contralateral side
	Transect sternum sharply
	Convert to bilateral anterolateral thoracotomy
If air embolism is suspected (air in coronary v)	Aspirate left ventricle
Miscellaneous	Ligate internal mammary a.
	Systemic or intraventricular epinephrine administration
	Internal defibrillation 10–50 joules
	Temporary pacemaker
Immediately transport to operating room after successful resuscitation

Adjunct Maneuvers

Trauma surgeons must possess several maneuvers in their armamentarium to deal with penetrating cardiothoracic injuries. The first adjunct maneuver dealing with these injuries was described by Sauerbuch ⁴² in 1907, as quoted by Brantigan. This maneuver entailed controlling blood flow to the heart by compression of the base. This maneuver is difficult to perform via a left anterolateral thoracotomy, has been abandoned, and is only mentioned because of historical interest only.

Total inflow occlusion to the heart is a complex maneuver that entails cross-clamping both the superior (SVC) and inferior vena cava (IVC) in their intrapericardial location to arrest total blood flow to the heart. Crafoord-DeBakey cross-clamps are employed, resulting in the immediate emptying of the heart. The trauma surgeon must recognize that cross-clamping the inferior vena cava intrapericardially at the space of Gibbons can be quite treacherous, as it is often fused with the posterior aspect of the pericardium. Inexperienced trauma surgeons will often force the cross-clamp in an attempt to rapidly achieve total occlusion leading to an iatrogenic injury of the intrapericardial IVC. Similarly, circumferentially dissecting this delicate vessel can also lead to iatrogenic injury. The clamp must be placed carefully and sometimes at an angle so as to totally occlude the intrapericardial IVC.^70,⁷⁷

Total inflow occlusion of the heart is indicated for the management of injuries in the lateral-most aspect of the right atrium and/or the superior or inferior atriocaval junction. Total inflow occlusion will lead to immediate emptying of the heart and allow the injury to be visualized and thus repaired. Frequently this procedure results in cardiopulmonary arrest, as tolerance by the injured, acidotic, hypothermic and ischemic heart is very limited. The safe period for this maneuver is unknown, although a 1–3 minute range is often quoted in the literature as the period of time after which clamps must be released. As the clamps are released, venous return fills the right-sided cardiac chambers and forward cardiac pumping motion will begin. More often than not, the heart will fibrillate requiring immediate direct defibrillation along with pharmacologic manipulation. This may be unsuccessful, particularly if a period of 3 minutes has been exceeded. Restoration of a normal sinus rhythm is often impossible.^70,⁷⁷

Cross-clamping of the pulmonary hilum is another valuable maneuver indicated for the management of associated pulmonary injuries, particularly those that have hilar central hematomas and/or active bleeding. This maneuver arrests bleeding from the lung and prevents air emboli from reaching the systemic circulation. However, one of its negative effects is responsible for significantly increasing the afterload of the right ventricle, as half of the pulmonary circulation is no longer available for perfusion. We recommend sequential de-clamping of the hilum to be carried out as expediently as possible along with a direct approach by stapled pulmonary tractotomy ^70,⁷⁴ for identification and control of hemorrhaging intraparenchymal pulmonary vessels. This will promptly unload the right ventricle. In the presence of acidosis, hypothermia, and ischemia, the right ventricle may not be able to tolerate this maneuver leading to fibrillation and arrest.^70,⁷⁴

Grabowski ¹ recently described a maneuver to facilitate exposure of posterior cardiac wounds by placing a Satinsky clamp at the right ventricular angle, which is formed at the acute anteroinferior margin of the right ventricle as it reflects on the right diaphragm. Grabowski¹ recommends that the clamp only grasp a small portion of the right ventricle. He recommends this maneuver for elevating the heart out of the pericardium to repair posterior injuries. We have no experience with this maneuver and cannot recommend it. We strongly feel that if used inappropriately, it will lead to the development of significant cardiac dysrhythmias.^70,⁷⁴

Maneuvers such as venting either the right or left ventricle postcardiorrhaphy are recommended to provide an avenue of egress for air emboli trapped in these chambers. This is usually accomplished by placing 16-gauge intravenous catheters. Theoretically, air should eject out of the repair chambers, thus preventing air emboli. Although the authors have used this maneuver successfully, little has been written in the literature describing its outcome.^70,⁷⁴

At times a trauma surgeon will need to elevate the heart out of the pericardium in order to repair certain injuries. Rapid and injudicious manipulation of the heart will often result in complex dysrhythmias that might include ventricular fibrillation and even cardiopulmonary arrest. Occasionally, given the degree of exsanguinating hemorrhage the heart must be extracted rapidly from pericardium in order to perform cardiorrhaphy. The trauma surgeon must communicate with the anesthesiologists whenever this maneuver is performed. If hemorrhage can be digitally controlled, gradual elevation of the heart by placing multiple laparotomy packs will allow better tolerance of this maneuver while decreasing the chances for the development of dysrhythmias.^70,⁷⁴

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