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|These pages are excerpted from the Trauma
Resident Handbook, Rhode Island Hospital Department of Surgery,
Division of Trauma - updated 2001. The policies herein are intended
to serve as guidelines only. Individual circumstances need to
be considered as there may be times when it is appropriate or
desirable to deviate from these guidelines. These educational
guidelines will be reviewed and updated routinely.
Emergency department thoracotomy was originally
popularized in 1966 as a potentially therapeutic measure for
all patients with life-threatening chest injury. Since then,
multiple critical analyses of ED thoracotomy (EDT) have prompted
a more selective application of the procedure. Patient survival
with intact neurologic status (meaningful survival) should be
the goal of EDT.
In deciding whether to perform EDT, the following variables should
be considered: Mechanism of injury (blunt vs. gunshot vs. stab);
vital signs*, and signs of life**, (both at the scene and on
presentation to the trauma room).
The same criteria for performing EDT should apply to children,
as their survival closely parallels that of adults. The elderly
may be a special population group. In several large series of
EDT there are no meaningful survivors over the age of 65. EDT
should be used in the over 65 population in only the most favorable
circumstances. ED thoracotomy is most productive for life-threatening
penetrating cardiac wounds, especially pericardial tamponade.
Outcomes for EDT are shown in the following table:
The major goals and potential therapeutic
maneuvers that one should bear in mind while performing this
procedure are as follows: release pericardial tamponade; control
cardiac and/or great vessel bleeding; control hilar bleeding;
perform open cardiac massage; redistribute blood to myocardium
and brain, and limit sub-diaphragmatic hemorrhage via aortic
No sign of life
Signs of life,
no vital signs
1/3 survivors severely neurol. impaired
< 1/10 survivors neurol. impaired
ED thoracotomy is performed through a left antero-lateral
incision at the level of the fifth intercostal space, crossing
the inferior border of the pectoralis major muscle. The skin,
subcutaneous tissue, and chest wall musculature should be incised
with one knife pass. The intercostal muscles and pleura should
then be incised with heavy Mayo scissors along the superior margin
of the rib. A rib spreader is then inserted with the handle toward
the axilla. The pericardium is then visualized. If tense, it
is opened with a longitudinal incision posterior to the phrenic
nerve. Any blood or clot should be evacuated, and attempts made
to control intra-cardiac bleeding with digital pressure, foley
catheter placement, or perhaps, plegeted sutures. Open cardiac
massage can then be performed. Massive bleeding from the lung
is controlled with a clamp across the pulmonary hilum. The thoracic
aorta is visualized by elevating the left lung anteriorly and
superiorly. The aorta is differentiated from the esophagus by
palpating the nasogastric tube, and a vascular clamp is placed
across the aorta.
RISKS TO TRAUMA TEAM
ED thoracotomy involves the use of sharp instruments
and contact with the patient's blood in an often chaotic atmosphere.
In this type of situation, universal precautions are often ignored,
thus subjecting the trauma team to higher risk than is necessary.
In urban trauma populations, the rate of HIV and hepatitis B
and C infection range from ten to twenty times that of the general
population. This rate may be even higher in the population most
likely to require ED thoracotomy, making universal precautions
and selective use of the procedure essential.
*Vital signs: Palpable pulse or obtainable BP
**Signs of life: pupillary activity, respiratory effort, or narrow
- Baxter, B.T., Moore, E.E., Moore, J.B., et
al: Emergency department thoracotomy following injury: critical
determinants of patient salvage. World J. Surg., 12: 671-675,
- Beaver, B.L., Columbani, P.M., Buck, J.R.,
et al: Efficacy of emergency room thoracotomy in pediatric trauma.
J. Pediatric Surg., 22: 19-23, 1987.
- Biffl, W.L., Moore, E.E., Harken, A.H.: Emergency
department thoracotomy. In Trauma, Mattox, Moore, Feliciano,
- Branney, S.W., Moore, E.E., Feldhaus, K.M.,
et al: Critical analysis of two decades of experience with postinjury
emergency department thoracotomy in a regional trauma center.
J Trauma, 45: 87-94, 1998.
- Kelen, G.D., DiGiovanna, T., Bisson, L.,
et al: Human immunodeficiency virus infection in emergency department
patients: epidemiology, clinical presentations, and risk to health
care workers: the John's Hopkins experience. JAMA, 262: 516-522,
- Rothenberg, S.S., Moore, E.E., Moore, F.A.,
et al: Emergency department thoracotomy in children- a critical
analysis. J Trauma, 29: 1322-1325, 1989.
- Sloan, E.P., McGill, B.A.,Zalenski, R., et
al: Human immunodeficiency virus and hepatitis virus seroprevalence
in an urban trauma population. J Trauma, 38: 736-741, 1995.
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