29 year-old male arrives as a trauma notification. EMS states patient had a single gunshot wound to the mid-chest with vitals as follows: HR 120, BP 90/50, RR 22, SpO2 95%. The patient is mumbling incoherently with spontaneous eye movements and is reacting to pain. As the trauma nurse attempts to hook him up to the monitor, he stops speaking, eyes are closed, and he is no longer moving. The nurse tells you she is unable to obtain vitals. Your intern is in the process of securing the airway.
What is the next step?
This patient needs an emergent thoracotomy. An emergent thoracotomy is done to control bleeding, release cardiac tamponade, identify thoracic/vascular injuries, and/or stabilize penetrating cardiac injury.
What are the indications for an emergent thoracotomy?
Emergent thoracotomies are indicated in penetrating chest injuries with recent, witnessed loss of vitals or cardiac activity or fluid unresponsive hypotension. If a patient presents with blunt trauma and experiences greater than 1.5L of blood return from a chest tube or continue to be hypotensive despite resuscitation, he/she may benefit from a thoracotomy – performing it in the ED vs. OR can be debated. Emergent thoracotomy has low success rates in patients with no pulse prior to arrival in the ED, asystole on monitor, or patients with blunt trauma.
What are the steps in performing an emergent thoracotomy?
Thoracotomy is usually initiated on the left side, which allows for greatest exposure to the heart and aorta.
Positioning: Have patient in supine position with arms above the head. Your initial incision will be on the anterior chest between the fourth or fifth intercostal space. For men, this will be below the nipple line, and for women, this will be inferior to the inframamillary folds.
Incision: Start your incision at the sternum and extend to the mid-axillary line. Cut through all the intercostal musculature. Use mayo scissors to cut and blunt dissect through musculature, periosteum, and pleura.
Retraction: Insert a Finochietto retractor/rib spreader and open the retractor to expose the thorax. Make sure the crank is positioned laterally near to the bed.
Inspection and intervention: Control any noted hemorrhage with pressure, vascular clamps, or sutures. Retract the lungs to get a better view of the heart and pericardium. A tense or distended pericardium usually signifies injury. Make an incision in the pericardium from the cardiac apex to the aorta to inspect the heart. Be careful not to incise the phrenic nerve. Remove any blood clots in the pericardium. If there is a defect in the myocardium, control the bleeding by digital occlusion, staples, sutures, or inserting and inflating the balloon of a Foley catheter (RBC transfusion can be given through this catheter directly into the heart). Perform cardiac massage by compressing the heart between the flat palms of your hands starting at the apex and pushing superiorly.
What is clamshell?
A clamshell is a slang name for a bilateral thoracotomy. It is usually a continuation of a left anterolateral thoracotomy into the right chest. It allows better exposure to the right side of the heart and the right thoracic cavity.
To convert a left anterolateral thoracotomy to the clamshell, incise the right anterior chest the same way as you did the left. To complete the clamshell, the sternum must be split with a Lebsche knife or Gigli saw.
What are the survival rates of a patient who undergoes an emergent thoracotomy?
Survival rates depend largely on how the patient presents to the ED and the mechanism of injury. Different sources report different survival rates, but estimates are usually around 5-10%. Survival rates are higher in patients with penetrating injuries (particularly stab wounds) who present with signs of life (measurable blood pressure, respiratory or cardiac activity, reactive pupils).
Ross, Christopher, and Theresa Schwab. “Cardiac Trauma.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016.
Cothern, Cla. Moore, Ernest. “Emergency department thoracotomy for critically injured patient: Objectives, indications, and outcomes.” World Journal of Emergency Surgery20061:4
Remember, what we do in practice may not always be the right answer on the exam. Frustrating, I know, but are you shocked?
Special thanks to Dr. Silverberg and Dr. deSouza