ED Thoracotomy for Penetrating Thoracic Trauma

Case Presentation: A 28 yo male presents from the field to the shock room s/p multiple GSW to the chest and extremities. Ten minutes after the call, he arrives tachycardic to the 120s, no BP but palpable carotid and femoral pulse with a GCS of 8. He was intubated and resuscitated with crystalloid and PRBCs with improvement in his tachycardia and SBPs in the 110s. He had two bullet holes in his back, and through-and-through GSWs in both extremities. A right chest tube was inserted with immediate return of 1L of blood. As resuscitation continued, he had another 1L of blood from his chest tube. As he was being prepared to be taken to the OR, he lost another 1L from his chest tube and he lost pulses. CPR was initiated… what next?

The resuscitative (or ED) thoracotomy is probably the coolest procedure that you can perform in the trauma bay. In a surgical era where “less is more,” it’s maximally invasive surgery at it’s finest. I’ve heard surgery attendings talk about how they did so many of these during residency that they let interns do them, but now it seems that we rarely get to perform this procedure. What’s the deal?

Let’s start with some numbers. First of all, the majority of penetrating thoracic injuries can be managed non-operatively (~90%) +/- a chest tube. The remainder require some sort of operative intervention, either in the OR or urgently in the trauma bay. Specifically, of patients who undergo an ED thoracotomy for penetrating trauma, the survival ranges anywhere between 10-40%, with most reports around the 10-20% mark. Survival broken down by stability is as follows1:

●Signs of life in the hospital - 11.5 percent

●Signs of life during transport - 8.9 percent

but not in the hospital

●No signs of life in the field - 1.2 percent

And further broken down by injury:

● Stab wound - 16.8 percent

● Gunshot wound - 4.3 percent

● Blunt trauma - 1.4 percent

● Thoracic injuries - 10.7 percent

● Abdominal injuries - 4.5 percent

● Multiple injuries - 0.7 percent

So as it stands, the best patient to select for and ED Thoracotomy is someone who has a single stab wound and demonstrates vital signs while being resuscitated in the trauma bay. Physiologically speaking, this is because an isolated stab wound (say to the heart) that is significant enough to cause severe hemodynamic instability (or even arrest) can be DIRECTLY treated with maneuvers in an ED thoracotomy. Other more significant thoracic injuries may not directly be treated by an ED thoracotomy, but the maneuvers therein may help with resuscitative efforts en route to the OR.

The current indications for an ED Thoracotomy are as follows2:  

Penetrating Thoracic Trauma	Blunt Thoracic Trauma
Patient manifests signs of life in the field or the hospital	Cardiac Arrest in Hospital
Hemodynamically unstable despite appropriate fluid resuscitation
Has not been pulseless for longer than 15 minutes
A thoracic or trauma surgeon is available within approximately 45 minutes

Indications for ED thoracotomy in Blunt Thoracic Trauma are severely limited secondary to a very low survival rate (0-1%).

So going back to our patient, from a hemodynamic perspective he was a good candidate for the ED Thoracotomy since he had just arrested, but his overall survival following his GSWs was still around 5%. We started with a left thoracotomy at approximately the 5th intercostal space. There was no blood upon entry into the thoracic cavity and his pericardium was entered without any return of blood. Compressions were continued via open cardiac massage and his aorta was clamped. His right chest was opened at this time and he continued to have massive exsanguination coming from what appeared to be injuries to the lung. His right hilum was clamped with some control of the hemorrhage, but his chest cavity continued to fill with blood. The rest of his thoracic cavity was inspected without any other obvious sign of bleeding. Compressions were continued but ROSC was not achieved and was pronounced dead. The Medical Examiner confirmed that his cause of death was massive exsanguination from gun shot wounds to his right lung near the hilum without any other great vessel injury.

Upon reflecting this case, I understand that the odds were stacked against this patient upon arrival - he had already been in profound shock for at least 20 minutes prior to arrival. Furthermore, the patient would have likely required a pneumonectomy, for which the mortality is 60% and upwards. I think that performing the “lung twist” (pictured below) may have helped us with hemorrhage control and getting the patient to the OR if it was performed very early in the resuscitation.

1Rhee, Peter M., et al. "Survival after emergency department thoracotomy: review of published data from the past 25 years." Journal of the American College of Surgeons 190.3 (2000): 288-298.

2Asensio, J. A., et al. "Practice management guidelines for emergency department thoracotomy." Journal of the American College of Surgeons 193.3 (2001): 303-309.

from Moses Kim, MD