Emergency department (ED) thoracotomy is a resuscitative procedure performed in patients with penetrating chest trauma who have lost signs of life in the presence of prehospital or ED personnel. Thoracotomy in the ED has specific goals once the chest is opened: relief of cardiac tamponade, support of cardiac function (internal cardiac compressions, cross-clamping the aorta to improve coronary perfusion, and internal defibrillation), and control of hemorrhage from the heart, pulmonary vessels, thoracic wall, and great vessels.
Emergency Department Thoracotomy. An unsuccessful resuscitative emergency department thoracotomy with pericardiotomy in a patient with penetrating chest trauma who lost signs of life in the field after the paramedics arrived at the scene. (Photo contributor: Lawrence B. Stack, MD.)
Management and Disposition
Patients with penetrating thoracic trauma who lose their vital signs on arrival or have unstable vital signs despite resuscitation should receive an immediate ED thoracotomy. Survival rates following ED thoracotomy for penetrating trauma are 9%; stab wounds fare much better than gunshot wounds. Patients with blunt trauma who lose their vital signs en route to the ED should not undergo an ED thoracotomy, since they rarely survive. Surgical support should be obtained as soon as possible.
Injuries most likely to be responsive to ED thoracotomy include cardiac tamponade, pulmonary parenchymal and tracheobronchial injuries, large-vessel injuries, air embolism, and penetrating heart injuries.
ED thoracotomy should be performed immediately once the indications have been met, since the likelihood of survival is greater when this is performed earlier in the resuscitation.
Stab wounds and measurable ED vital signs are the best predictors of survival.
Emergency Department Thoracotomy—Ventricular Ballistic Injury. Left ventricular ballistic injury seen after unsuccessful resuscitation and ED thoracotomy. (Photo contributor: Lawrence B. Stack, MD.)