A resuscitative thoracotomy (sometimes referred to as an emergency department thoracotomy (EDT), trauma thoracotomy or, colloquially, as "cracking the chest") is a
thoracotomy
A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...
performed to
resuscitate
Resuscitation is the process of correcting physiological disorders (such as lack of breathing or heartbeat) in an acutely ill patient. It is an important part of intensive care medicine, anesthesiology, trauma surgery and emergency medicine. W ...
a
major trauma
Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Dependin ...
patient who has sustained severe
thoracic
The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the crea ...
or
abdominal trauma and who has entered
cardiac arrest
Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and possib ...
because of this. The procedure allows immediate direct access to the
thoracic cavity
The thoracic cavity (or chest cavity) is the chamber of the body of vertebrates that is protected by the thoracic wall (rib cage and associated skin, muscle, and fascia). The central compartment of the thoracic cavity is the mediastinum. There ...
, permitting rescuers to control
hemorrhage
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
, relieve
cardiac tamponade
Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstruct ...
, repair or control major injuries to the heart, lungs or thoracic
vasculature
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
, and perform direct
cardiac massage
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spon ...
or
defibrillation
Defibrillation is a treatment for life-threatening cardiac arrhythmias, specifically ventricular fibrillation (V-Fib) and non-perfusing ventricular tachycardia (V-Tach). A defibrillator delivers a dose of electric current (often called a ''cou ...
. For most persons with thoracic trauma the procedure is not necessary; only 15% of those with thoracic injury require the procedure.
[Moore 2012, p.462]
Indications
A resuscitative thoracotomy is indicated when severe injuries within the thoracic cavity (such as
hemorrhage
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
) prevent the physiologic functions needed to sustain life. The injury may also affect a specific organ such as the heart, which can develop an
air embolism
An air embolism, also known as a gas embolism, is a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system. Air can be introduced into the circulation during surgical procedures, lung over-expansion i ...
or a
cardiac tamponade
Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstruct ...
(which prevents the heart from beating properly). Other indications for the use of this procedure would be the appearance of blood from a
thoracostomy
A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, paramedics, and nurses usually via needle thoracosto ...
tube placed that returns more than 1000-1500 mL of blood, or ≥200 mL of blood per hour.
For resuscitative thoracotomy to be indicated, signs of life must also be present, including
cardiac electrical activity and a
systolic blood pressure
Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
>70 mm Hg.
In
blunt trauma
Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical traumas, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue ...
, if signs of life, such as eye dilatation, are found en route to the hospital by first responders, but not found when the patient arrives, then further resuscitative interventions are contraindicated; however; when first responders find signs of life and
cardiopulmonary resuscitation
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...
time is under 15 minutes, the procedure is indicated.
The use of a
focused assessment with sonography for trauma
Focused assessment with sonography in trauma (commonly abbreviated as FAST) is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart (pericardial effusio ...
may be performed to determine the need of the procedure by finding free floating fluid in the thoracic cavity.
Technique
A left anterolateral thoracotomy is the common method of opening the chest, as it provides rapid access, can be easily extended into the right hemithorax, and provides access to most of the important anatomical structures during resuscitation including the
aorta
The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
.
First an incision is made along the fourth or fifth
intercostal space
The intercostal space (ICS) is the anatomic space between two ribs (Lat. costa). Since there are 12 ribs on each side, there are 11 intercostal spaces, each numbered for the rib superior to it.
Structures in intercostal space
* several kinds ...
(between the ribs), intercostal muscles and the parietal
pleura
The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls.
The inner pleura, called the visceral pleura, covers the surface of each lung and dips bet ...
are divided, and then the ribs are retracted to provide visualization.
When the incision covers both the right and left hemithoraxes it is referred to as a "clamshell" thoracotomy. The clamshell thoracotomy is used when there is a right sided
pulmonary
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of th ...
or
vascular
The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away f ...
injury, or when greater access or visualization is desired.
[Moore 2012, p. 242]
Recovery
Usually those who undergo resuscitative thoracotomy do not recover—only 10% of those receiving it after sustaining a blunt injury and 15–30% of those with penetrating trauma survive.
History
The procedure was first utilized during the late 1800s by Schiff in conjunction with open cardiac massage. Shortly after it was also used by Block to treat heart
lacerations
A wound is a rapid onset of injury that involves lacerated or punctured skin (an ''open'' wound), or a contusion (a ''closed'' wound) from blunt force trauma or compression. In pathology, a ''wound'' is an acute injury that damages the epider ...
, and the first suture repair performed in 1900.
Before external
defibrillation
Defibrillation is a treatment for life-threatening cardiac arrhythmias, specifically ventricular fibrillation (V-Fib) and non-perfusing ventricular tachycardia (V-Tach). A defibrillator delivers a dose of electric current (often called a ''cou ...
and
cardiopulmonary resuscitation
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...
came in the 1960s, emergency thoracotomy was the preferred way to treat cardiac arrest.
[Moore 2012, p. 236]
References
Bibliography
*
*
*
{{Trauma , state=autocollapse
Emergency medical procedures
Cardiac surgery