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With an increase in urban violence, there has been an increase in the number of critically injured patients seen in inner-city Emergency Departments. This increase in violence has been combined with better triage and transport systems, resulting in the arrival of sicker patients at the Emergency Department. Previously, these patients might not have survived long enough to make it to the Emergency Department.1


The majority of individuals with penetrating chest injuries arrive in the Emergency Department in stable condition and are managed without major operative procedures.2 A subset of individuals, however, arrive in extremis and may require a thoracotomy. The purpose of the thoracotomy may be to control hemorrhage within the chest, to relieve a pericardial tamponade that cannot be decompressed by a needle thoracotomy, to redistribute cardiac output to the brain and the heart, or to provide more effective cardiac massage.3


The structures within the chest include the heart, esophagus, lungs, bronchi, pulmonary hilar vessels, and numerous other vascular structures. The heart is located in the anterior mediastinum. The aorta and esophagus are located in the posterior mediastinum. The internal mammary arteries course along the posterior aspect of the anterior chest wall just lateral to the sternum. The intercostal vessels run along the inferior aspect of the ribs. The subclavian vessels are at the very superior aspect of the thorax. They course directly under the clavicles and can be very difficult to visualize via an anterolateral thoracotomy. The azygos vein can be found coursing along the posterior right hemithorax and emptying into the superior vena cava.


The heart is covered by the tough pericardial sac. The phrenic nerves run superiorly to inferiorly on the pericardiac sac bilaterally. They can be visualized as white or yellow strands on either side of the pericardium. Once the pericardial sac is opened, the left anterior descending coronary artery can be visualized on the anterior surface of the heart. It overlies the interventricular septum. Injuries to the left of this artery denote left ventricular damage, while injuries to the right denote right ventricular damage. The majority of the anterior surface of the heart is occupied by the right ventricle.


The posterior mediastinum contains the aorta. It is located posterior to the esophagus and runs lateral to the vertebral bodies. The thoracic aorta gives off the intercostal vessels. If torn during the mobilization of the aorta, the intercostals vessels can cause troublesome bleeding.


Beall et al originally introduced the Emergency Department thoracotomy for penetrating chest wounds.4 This procedure was subsequently used for patients with penetrating abdominal wounds and victims of blunt trauma. In recent years, several studies have shown an abysmal survival rate associated with Emergency Department thoracotomy in victims of blunt trauma. When vital signs are present in the field, the survival rates for such individuals range from 0.6 to 6.0 percent.5,6 Patients who undergo an Emergency Department thoracotomy ...

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