Thoracotomy – Indications



ED Thoracotomy

  • Penetrating chest trauma with signs of life in the field
    • Pulse, BP, pupil reactivity, purposeful movement, organized rhythm, respiratory effort)
  • Blunt chest trauma with signs of life lost in ED
  • Consider for exsanguinating abdominal vascular injuries
Robert’s and Hedges:
The first assessment is made in the prehospital setting, where
determination of the mechanism of injury and the presence or
absence of a pulse is critical. Recommendations from the ACSCOT
guidelines state that EDT has no role in blunt trauma victims who
are apneic and pulseless and lack an organized rhythm. 4 Such
patients do not survive, regardless of the intervention. In one of the
largest EDT series to date, Branney and coworkers 5 reviewed 868
consecutive patients over a 23-year period. They found that no blunt
trauma patients survived EDT when they had no vital signs in the
field but that 2.5% of blunt trauma patients survived EDT when
vital signs were present in the field. Rhee and colleagues 6 examined
4620 cases of EDT from 24 studies over a 25-year period. The overall
survival rate after blunt trauma was just 1.4%, which led to EDT
falling out of favor for this indication. Recent articles, however,
have challenged the idea of limiting EDT to those in cardiac arrest
from penetrating injury only. 7–9 Moore and associates
recommended considering EDT in blunt trauma victims who have
received less than 5 minutes of cardiopulmonary resuscitation
(CPR) and possess signs of life. 7
 The consensus recommendation based
on multiple studies is that any trauma patient who has undergone
CPR for longer than 15 minutes has an exceedingly dismal survival
rate and further resuscitation should be considered
futile. 4,10,11,25–28 
EDT can be considered in
victims of blunt trauma cardiac arrest if CPR has been ongoing for
less than 5 minutes. 7
Perhaps the most critical determinant of the appropriateness of
EDT is whether the patient demonstrates “signs of life.” Signs of life
are objective physiologic parameters that are present in patients
who survive EDT. They include pupillary response, extremity
movement, cardiac electrical activity, measurable or palpable blood
pressure, spontaneous ventilation, or the presence of a carotid
pulse. The presence of one or more of these indicators has been
associated with good neurologic outcomes and increased rates of
survival. 3–9,30
Though supported as a potential lifesaving procedure,
EDT is not a mandated standard of care nor a procedure that is expected to
be performed in most EDs.

Penetrating injury — Resuscitative thoracotomy is justified in patients with penetrating thoracic trauma who are hemodynamically unstable on arrival to the emergency department despite appropriate fluid resuscitation, or in patients who have been pulseless and receiving CPR for less than 15 minutes, but only if appropriate resources (eg, operating room, appropriately trained surgeon) are available for continued resuscitation and definitive repair [7]. 

Contraindications — Resuscitative thoracotomy is likely to be futile in patients with penetrating injury in the following circumstances:

The patient has no signs of life at the scene of injury

Asystole is the presenting rhythm and there is no pericardial tamponade

Prolonged pulselessness (>15 minutes) occurs yat any time

Massive, nonsurvivable injuries have occurred

Blunt injury — The subset of patients with blunt injury who might benefit from resuscitative thoracotomy includes patients who lose vital signs in transit or in the emergency department, and have no obvious non-survivable injury (eg, massive head trauma, multiple severe injuries), or patients with cardiac tamponade rapidly diagnosed by ultrasound, with no obvious non-survivable injury, but only if appropriate resources (eg, operating room, appropriately trained surgeon) are available for continued resuscitation and definitive repair.

From  ATLS Book

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