Chapter 14: Emergency Department Thoracotomy

INTRODUCTION

The number of patients arriving at hospitals in extremis, rather than expiring in the prehospital setting, has increased due to the maturation of regionalized trauma systems (see Chapter 4). Salvage of individuals with imminent cardiac arrest or those already undergoing cardiopulmonary resuscitation (CPR) often requires immediate thoracotomy as an integral component of their initial resuscitation in the emergency department (ED). The optimal application of emergency department thoracotomy (EDT) requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences. Although, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been advocated as a resuscitation maneuver that should replace EDT, there is no objective data to substantiate this proposal and we believe its clear role at this moment is for unstable pelvic fractures with advanced hemorrhagic shock (see Chapter 35). This chapter reviews the features of EDT and highlights the specific clinical indications, all of which are essential for the appropriate use of this potentially life-saving yet costly procedure.

HISTORICAL PERSPECTIVE

Emergent thoracotomy came into use for the treatment of heart wounds and anesthesia-induced cardiac arrest in the late 1800s and early 1900s.¹ The concept of a thoracotomy as a resuscitative measure began with Schiff’s promulgation of open cardiac massage in 1874.¹ Block first suggested the potential application of this technique for penetrating chest wounds and heart lacerations in 1882.² Following use of the technique in animal models, the first successful suture repair of a cardiac wound in a human was performed at the turn of the century.³ Subsequently, Igelsbrud described the successful resuscitation of a patient sustaining cardiac arrest during a surgical procedure using emergent thoracotomy with open cardiac massage.¹ The utility of the emergent thoracotomy was beginning to be tested in a wide range of clinical scenarios in the early 1900s.

With improvement in patient resuscitation and an ongoing evaluation of patient outcomes, the indications for emergent thoracotomy shifted. Initially, cardiovascular collapse from medical causes was the most common reason for thoracotomy in the early 1900s. The demonstrated efficacy of closed-chest compression by Kouwenhoven et al.⁴ in 1960 and the introduction of external defibrillation in 1965 by Zoll et al.⁵ virtually eliminated the practice of open-chest resuscitation for medical cardiac arrest. Indications for emergent thoracotomy following trauma also became more limited. In 1943, Blalock and Ravitch advocated the use of pericardiocentesis rather than thoracotomy as the preferred treatment for postinjury cardiac tamponade.⁶ In the late 1960s, however, refinements in cardiothoracic surgical techniques reestablished the role of immediate thoracotomy for salvaging patients with life-threatening chest wounds.⁷ The use of temporary thoracic aortic occlusion in patients with exsanguinating abdominal hemorrhage further expanded the indications for emergent thoracotomy.^8,9 In the past two decades, critical analyses of patient outcomes following postinjury EDT has tempered the unbridled enthusiasm for this technique, allowing a more selective approach ...