Emergency Thoracotomy - Indications and Complications

Introduction:

The vital organs such as the heart, lungs, esophagus (the passage through which food is swallowed and reaches the stomach), and large major blood vessels are present in a space called the pleural cavity in the chest. Thoracotomy is a general surgical procedure to access these vital organs during surgery. During severe trauma to the chest, there is severe bleeding, the organs in the pleural cavity undergo damage, and vital organs such as the heart may stop beating. Therefore, an emergency or resuscitation thoracotomy is performed to save the patient's life. It is an emergency procedure performed by skilled doctors in the emergency department to get direct access to the vital organs in the chest in case of medical emergencies such as road traffic accidents or severe trauma. The goals of emergency thoracotomy are to temporize the wound, stabilize the patient and initiate life-saving interventions.

What Are the Indications of Emergency Thoracotomy?

Thoracotomy is performed in emergencies requiring direct access to the vital organs in the chest (pleural cavity) to initiate life-saving interventions. Emergency thoracotomy is performed for the following reasons:

1. To control severe bleeding due to chest trauma.

2. To relieve fluid build-up around the heart that exerts pressure and prevents it from beating properly.

3. To manage and repair significant injuries to the vital organs of the chest, such as the heart or lungs.

4. To repair injuries of the major large blood vessels of the chest.

5. To directly massage or defibrillate the heart that has stopped beating (during a cardiac arrest after a penetrating chest trauma).

6. To control severe bleeding in the chest tube (a thoracostomy tube inserted into the chest or pleural cavity to drain fluids or air around the lungs).

7. To clamp large blood vessels directly to prevent bleeding.

8. To prevent air embolism (air entrapment in the blood vessels).

What Are the Contraindications of Emergency Thoracotomy?

Emergency thoracotomy is an initial resuscitation procedure performed by trained emergency personnel to save the patient’s life. It is not performed for all trauma patients as it is an invasive surgical procedure. Opening the chest with emergency thoracotomy is contraindicated in the following situations:

1. Definite loss of cardiac output for more than ten minutes (it indicates that the heart has stopped beating and the blood supply to all organs has been deficient for more than ten minutes).

2. The chest should not be opened if the patient’s heart is still beating even with severely low blood pressure.

3. Certain types of blunt injury.

4. No signs of life in the field of trauma.

5. Children below the age of 14 years who have sustained a blunt injury.

6. Elderly patients above the age of 57 years.

7. The chest should not be opened when the necessary equipment is unavailable, such as a manual internal defibrillator that helps to restart the heart.

8. It should not be performed by untrained personnel as it is a temporary procedure before definitive treatment.

9. Severe head injury.

10. Emergency thoracotomy should not be performed in case of severe multiple injuries involving multiple vital organs and blood vessels.

Who Performs Emergency Thoracotomy?

Emergency thoracotomy is a surgical procedure that can be performed only with proper medical training. It is recommended to shift the patients to the operation theatre whenever possible, to open the chest in case of penetrating injuries. However, it is not possible in emergencies such as cardiac arrests. Therefore, trained and skilled emergency personnel perform most of the resuscitation thoracotomies in the emergency department. Apart from that, two qualified personnel are kept dedicated to continuing the standard resuscitation measures, such as advanced cardiac life support. Furthermore, as this is a temporary procedure, the teams to initiate definitive care, such as surgeons, trauma teams, and the operating room personnel, are informed and kept ready to continue treatment after the procedure.

What Are the Tools Used for Emergency Thoracotomy?

As emergency thoracotomy is an emergency procedure, there is not much time to prepare for the procedure. However, arrangement for the necessary tools is essential. Also, the personnel performing the procedure must know how to use the tools properly. The equipment required to perform emergency thoracotomy includes:

1. A sterile tray containing the following:

   1. Sterile drapes and towels.

   2. Special sponges to use inside the body, such as laparotomy sponges.

   3. Blades and scalpel holder.

   4. Scissors.

   5. Rib spreader (instrument to separate the ribs in a chest surgery).

   6. Aortic cross-clamp to stop bleeding from large major blood vessels such as the aorta.

   7. A variety of clamps to stop bleeding.

   8. Tissue forceps, sutures, and needles.

2. Special catheters (tubes) with balloons can be used as an adjunct to stop bleeding.

3. Suction.

4. A manual internal defibrillator (a device to restart the heart during resuscitation)

5. Chest tubes.

6. Gloves, gowns, eye protection, and masks.

How Is an Emergency Thoracotomy Performed?

The patient is made to lie face upwards (supine) and positioned as required for the procedure. Another emergency personnel performs other interventions (such as intubation and intravenous access) to prevent any delay in initiating thoracotomy. It is not essential to fully prepare and drape the patient. Quick skin preparation to prevent infection (asepsis) is usually done. Trained emergency personnel open the chest surgically as per protocol. A special type of incision called a clam-shell incision is recommended when a larger visualization or access to both sides of the chest is needed. Treatment interventions such as clamping large vessels to stop bleeding and the resuscitation procedures to restart the heart are done. The aim is to manage the bleeding and injury and to stabilize the patient to receive definitive treatment.

What Are the Complications of Emergency Thoracotomy?

The common complications of the emergency thoracotomy include:

1. Accidental damage to muscles and bones in the chest during the resuscitation and thoracotomy procedure (iatrogenic injuries).

2. Nerve damage.

3. Due to the cross-clamping of large blood vessels like the aorta, blood supply to some distant organs is affected and leads to organ damage.

4. Recurrent bleeding.

Conclusion:

Emergency thoracotomy is a resuscitative surgical procedure. It is performed in the emergency department on trauma patients who are too unstable to be taken to the operating theatre. The goal of the procedure is to open the chest to control severe bleeding, relieve pressure around the heart, manage the injuries to vital organs and blood vessels temporarily, restart the heart, restore circulation, and stabilize the patient for definitive treatment. Thus, this procedure is used as a last resort to save a patient’s life.