An emergency department thoracotomy (EDT) is an open chest procedure performed in critically injured patients who are unstable or in cardiac arrest. The key aims of an EDT are to release pericardial tamponade, control cardiac hemorrhage, control intrathoracic bleeding, perform open cardiac massage, and temporarily occlude the descending thoracic aorta. Indications for an EDT include cardiac arrest from penetrating chest trauma or unstable patients with a precordial wound or truncal injury. Outcomes are generally poor with survival rates ranging from 1-35% depending on injury severity and vital signs. The procedure involves a left anterolateral thoracotomy, pericardiotomy, cardiac exposure, and internal

1. Pearls of
Emergency Department Thoracotomy
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2. • Definition
• Relevant Anatomy
• Aims
• Outcomes
• Indications and contraindications: a review
• Techniques: equipment and essential procedures
• complications
• REBOA
• Case scenarios from my experience
• Conclusion

3. Definition
• Terms:
– Emergency department thoracotomy
– Emergency room thoracotomy
– Resuscitative thoracotomy
• Meaning: a thoracotomy performing at ER in
patients who are in extremis
– Salvage procedure

4. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.

5. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.

6. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.

7. Netter’s Atlas of anatomy.

8. Netter’s Atlas of anatomy.

9. Netter’s Atlas of anatomy.

10. Aims of EDT
• release pericardial tamponade
• control cardiac hemorrhage
• Control intrathoracic bleeding
• evacuate massive air embolism
• perform open cardiac massage
• Temporarily occlude the descending thoracic
aorta

11. Release Pericardial Tamponade and
Control Cardiac Hemorrhage
• Cardiac wound especially with cardiac
tamponade: highest survival rate during EDT
• Beck’s triad
• Rising intrapericardial pressure results in both
hemodynamics and cardiac perfusioin

12. Release Pericardial Tamponade and
Control Cardiac Hemorrhage
• Three phases of mechanism when increasing
pericardial pressure:
1. Cardiac output is maintained by compensatory
tachycardia, increased systemic vascular resistance,
and elevated central pressure
2. compromised diastolic filling, stroke volume, and
coronary perfusion result in diminished cardiac
output but BP is still maintained with subtle signs of
shock
3. Intrapericardial pressure approaches ventricular
filling pressure  coronary hypoperfusion  cardiac
arrest

13. • When suspicious: ABCs with volume
resuscitation, investigation (FAST) and
pericardiocentesis
• EDT has a role when SBP < 60 mmHg or third
phase
– Evacuate clot
– Cardiac repair
Release Pericardial Tamponade and
Control Cardiac Hemorrhage

14. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&section
id=45343675

15. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-
15/Pericardiocentesis-in-cardiac-tamponade-indications-and-practical-aspects

16. Control Intrathoracic Hemorrhage
• Penetrating wounds to pulmonary hilum or
great vessels: lack of hemorrhage
containment  high mortality rate
• Less common: frank rupture of torn
descending aorta

17. Mattox KL et al. Trauma. 8th ed.
McGraw-Hill Medical, 2017.

18. Open Cardiac Massage
• External chest compression provides
approximately 20–25% of baseline cardiac
output, with 10–20% of normal cerebral
perfusion: reasonable salvage rate for 15 mins
• So, EDT is the only salvage procedure

19. Temporary
Thoracic Aortic Cross-Clamping
• For 2 benefits:
– Increase perfusion to heart and brain
– Reduce subdiaphragmatic blood loss
• Removal should be performed within 30 mins

20. Evacuate Bronchovenous Air Embolism
• Penetrating chest trauma + profound
hypotension/cardiac arrest + after ETT + PPV
• Produce air emboli to coronary arterial system
• Management:
– Trendelenburg position to trap air in left ventricle
– Thoracotomy to hilar cross clamp
– Air aspiration via left ventricle needle puncture or
coronary a. puncture can be attempted

21. Management

22. • Consider these factors:
– Location and mechanism of injury
– Signs of life at scene and ER
– Cardiac activity at thoracotomy
– SBP response to aortic cross clamping

23. Signs of Life
• Respiratory effort
• Motor effort
• Cardiac electrical activity
• Pupillary activity

24. Outcomes
• Questionable value
• Low-yield, high-cost procedure
• Survival rate
– 35% in penetrating cardiac trauma with shock,
20% without vital signs
– 14% in penetrating torso with vital signs, 8% with
signs of life, 1% without signs of life
– 1-3% in blunt trauma (not catagorized)

25. Mattox KL et al.
Trauma. 8th ed.
McGraw-Hill Medical,
2017.

26. Brunicardi FC et al. Schwartz’s
Principles of Surgery. 10th ed.
McGraw-Hill Education, 2015.

27. Indications from American College of
Surgeons, Committee on Trauma 2004
• Recent prehospital cardiac arrest in a patient
with a precordial wound
• Cardiac arrest in a trauma patient occurring
arrival in ER, during resuscitation or
observation
• SBP < 70 mmHg due to a truncal wound in an
unconscious patient and distant or unavaliable
OR

28. Cothren CC and Moore EE. Emergency department thoracotomy for the critically
injured patient: Objectives, indications, and outcomes. World Journal of Emergency
Surgery 2006, 1:4.

29. The royal Melbourne hospital. Emergency department thoracotomy guideline. Version
2.0, June 2015.

30. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

31. Cessation of EDT
• Irreparable damage
• Massive head injuries
• PEA
• SBP < 70 mmHg after 15-20 mins
• Asystolic arrest

32. Equipment
• In Lampang Hospital:
– EDT set – at ER
– Cutdown set – at ER
– Satinsky clamps – call OR
– Thoracotomy set – you might have to call OR again

33. The royal Melbourne hospital. Emergency department thoracotomy guideline. Version
2.0, June 2015.

34. The royal Melbourne hospital. Emergency department thoracotomy guideline. Version
2.0, June 2015.

35. The royal Melbourne hospital. Emergency department thoracotomy guideline. Version
2.0, June 2015.

36. The royal Melbourne hospital. Emergency department thoracotomy guideline. Version
2.0, June 2015.

37. The royal Melbourne hospital. Emergency department thoracotomy guideline. Version
2.0, June 2015.

38. Techniques
• ABCs: intubation
• Supine position, Left arm abduction above
head
• Prepare the instrument
• Left anterolateral thoracotomy beginning at
– Just below the nipple
– Inframammary fold in women
– Right side of the sternum

39. Techniques
• Intercostal muscles should be dissected at
superior margin with either curved Mayo
scissors or scapel
• Don’t worry about chest wall bleeding, it’s
minimal
• Rib retractor is inserted with handle inferiorly
toward the axilla
• If not adequate exposure, extend to right side

40. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

41. Mattox KL et al. Trauma. 8th ed. McGraw-
Hill Medical, 2017.

42. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.
Figure of eight suture or individual ligation

43. D Wise, G Davies, T Coats, D Lockey, J Hyde, A Good. Emergency thoracotomy “how to
do it”. Emer Med J. www.emjonline.com

44. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

45. Pericardiotomy
Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

46. Pericardiotomy and
Cardiac Hemorrhage Control
• Pericardium is incised:
– Widely
– From apex to sternal notch
– Anterior
– 1 cm Parallel to phrenic nerve
– Picked up with either toothed forceps or clamps
and dissected with scissors

47. • Blood and clots should be completely
evacuated
• Place right hand posterior to heart, encircle
right side, and pull to left chest
• In beating heart:
– Digital pressure for ventricles
– Vascular clamping for atria
– Delay definitive cardiorrhaphy until resuscitation
is completed
Pericardiotomy and
Cardiac Hemorrhage Control

48. • In nonbeating heart: Cardiac repair is done before
defibrillation and massage
• Thinned wall right ventricle: 3-0 nonabsorbable
running or horizontal mattress suture, pledgets
are ideal but not essential
• Left ventricle: stapled when diastole
• Atria: simple running or purse-string suture,
satinsky may be used
• Posterior cardiac wound: require heart elevation,
best at OR
Pericardiotomy and
Cardiac Hemorrhage Control

49. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

50. Mattox KL et al. Trauma. 8th ed.
McGraw-Hill Medical, 2017.
Horizontal mattress for
cut wound closed to
coronary artery

51. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education,
2015.

52. • Destructive or posterior wound: control both
SVC and IVC
• Foley for temporary occlusion but the injury
maybe extent due to traction force
Pericardiotomy and
Cardiac Hemorrhage Control

53. Cardiac Massage and ACLS
• Early defibrillation
• Using amiodarone
• Defibrillation with internal cardiac paddle and
initial energy of 10 Joules
• If not available: close the wound and
conventional external pads
• Bimanual internal cardiac massage: 80 bpm with
milking from apex upward to base of heart
– Single hand against sternum poses perforation with
the thumb

54. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

55. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

56. • Adjuncts:
– Intracardiac epinephrine and vasopressin
– Directly to left ventricle
– Either 1:1,000 or 1:10,000 epinephrine, 0.1-1 mg
– 22G needle
– If used percutaneously: complications include
coronary laceration, pneumothorax, tamponade
Cardiac Massage and ACLS

57. Aortic Cross-Clamp
• Following pericardiotomy, descending aortic
cross clamp should be done inferior to left
pulmonary hilum if SBP < 70 mmHg to
maximize coronary perfusion
• Elevate left lung anteriorly and superiorly
• Taking down inferior pulmonary ligament for
better lung mobilization is unnecessary and
risk injury to inferior pulmonary vein

58. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

59. • Perform first if extrathoracic injury is
suspected
• Contraindication: descending aortic injury
• Isolate aorta by incising mediastinal pleura
and bluntly separate it from esophagus and
prevertebral fascia
• If excessive bleeding, digital pressure against
vertebra
Aortic Cross-Clamp

60. Pulmonary Hilar Control
• 2 indications:
– Present of coronary or systemic air embolism
– Pulmonary hilar injury or lung parenchymal
hemorrhage

61. Mattox KL et al. Trauma. 8th ed.
McGraw-Hill Medical, 2017.

62. Mattox KL et al. Trauma. 8th ed.
McGraw-Hill Medical, 2017.
18G needle and 50 ml
syringe
Use tuberculin syringe
for coronary punture

63. Complications and Consequences
• Procedural complications
• Hemodynamic and metabolic consequences of
aortic cross-clamping

64. Procedural Complications
• Injury to intrathoracic structure, especially
previous thoracotomy with dense pleural
adhesion
• Blood contact: blood-transmitted diseases

65. Hemodynamic and Metabolic
Consequences of Aortic Cross-Clamping
• Decreased blood flow to femoral artery,
visceral organ  tissue acidosis and post-
ischemic organ failure
• Hypoxia to distal organ produces
inflammatory mediators
• Impaired pulmonary function

66. • Declamping associates with
– washout metabolic products to distal torso 
exert cardiac activity
– Fall in coronary perfusion
– Left ventricular dysfunction
Hemodynamic and Metabolic
Consequences of Aortic Cross-Clamping

67. REBOA
• Resuscitative Endovascular Balloon Occlusion
of the Aorta
• Evolving technology that might replace EDT

68. Ribeiro MAF et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA):
an update review. Rev Col Bras Cir. 2018; 45(1):e1709.

69. Conclusion
• EDT is performed at ER in patients in extremis
• ABCs first
• Left anterolateral thoracotomy is the incision
of choice
• Indications and contraindications depend on
salvageability
• REBOA is an alternative option that less
invasive

70. References
คามิน ชินศักดิ์ชัย, ศุภพงษ์ อาวรณ์, อนุชา พาน้อย, บรรณาธิการ. ศัลยศาสตร์หลอดเลือดประยุกต์ เล่ม 3: Surgical
and endovascular techniques for common vascular surgery. กรุงเทพฯ: สานักพิมพ์กรุงเทพเวช
สาร, 2559.
Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.
Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.
Netter’s Atlas of anatomy.
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill
Education, 2015.
Feliciano DV et al. Thoracotomy in the emergency department. American college
of surgeons committee on trauma, 2004.

71. Cothren CC and Moore EE. Emergency department thoracotomy for the
critically injured patient: Objectives, indications, and outcomes. World Journal
of Emergency Surgery 2006, 1:4.
The royal Melbourne hospital. Emergency department thoracotomy
guideline. Version 2.0, June 2015.
D Wise, G Davies, T Coats, D Lockey, J Hyde, A Good. Emergency thoracotomy
“how to do it”. Emer Med J. www.emjonline.com
Lamberg JJ, Malhotra AK, McAlevy ME (2013) Intracardiac Epinephrine
Injection during Open Thoracotomy and Circulatory Arrest. J Anesthe Clinic
Res 4: 341. doi:10.4172/2155-6148.1000341
References

72. References
American College of Surgeons ACS Committee of Trauma. ATLS Student
Course Manual. 10th ed. Chicago: American College of Surgeons, 2017.
Gordy S and Rowell S. Vascular air embolism. Int J Crit Illn Inj Sci. 2013 Jan-
Mar; 3(1): 73–76.
Ribeiro MAF et al. Resuscitative endovascular balloon occlusion of the aorta
(REBOA): an update review. Rev Col Bras Cir. 2018; 45(1):e1709.