Emergency Department Thoracotomy

Anatomy and Physiology

The thorax is anatomically situated between the neck superiorly and the diaphragm inferiorly. Critical organs within the thorax include the bronchi, lungs, heart, and major vascular structures, including the ascending aorta, aortic arch, and descending thoracic aorta. The heart lies just left of the midline, with the aortic root centrally positioned. The aortic arch curves posterolaterally to the left, transitioning into the descending aorta, which courses adjacent to the thoracic spine. The aortic arch gives rise to 3 primary branches: the brachiocephalic trunk, the left common carotid artery, and the left subclavian artery. The brachiocephalic trunk divides into the right common carotid artery and the right subclavian artery. All aortic arch branches lie posterior to the manubrium.

The pericardial sac surrounds the heart and covers the myocardium. The left phrenic nerve courses along the lateral pericardium and supplies motor innervation to the diaphragm, enabling spontaneous respiration. The left phrenic nerve is particularly vulnerable to injury during pericardiotomy, as visualization often remains difficult for novices performing this procedure. Anterior to the aortic arch and near the left subclavian artery, the left vagus nerve gives rise to the recurrent laryngeal nerve, which innervates the vocal cord muscles responsible for phonation, before traveling posteriorly around the root of the left lung and continuing adjacent to the esophagus into the posterior mediastinum. The esophagus runs anterior to the spinal column and medial to the aorta. Placement of an orogastric tube within the esophagus can provide tactile confirmation. The thoracic duct courses anterolaterally to the spine and is often challenging to visualize. Awareness of these anatomical relationships and physiological significance is essential to prevent iatrogenic injury and improve postoperative outcomes.

Indications

According to the 2015 Practice Management Guidelines from the Eastern Association for the Surgery of Trauma (EAST), EDT is a high-acuity, last-resort intervention performed in select trauma patients presenting in extremis. Decision-making to proceed with EDT is based on mechanism of injury, duration of cardiopulmonary resuscitation (CPR), and presence of signs of life (SOL). The reported success remains exceedingly rare outside these indications, particularly in cases of blunt trauma and prolonged CPR.[9] The Western Trauma Association (WTA) further identifies profound refractory shock as an additional indication for EDT.

Strong indications for EDT include penetrating thoracic trauma with SOL, such as pupillary response, spontaneous movement, cardiac electrical activity, or respiratory effort, in the absence of a palpable pulse. Cardiac tamponade in the setting of penetrating chest trauma is also a strong indication, particularly when suspected on clinical examination or confirmed by focused assessment with sonography for trauma (FAST) ultrasound. Conditional indications include penetrating thoracic or extrathoracic trauma without SOL when CPR duration is less than 15 minutes; blunt trauma with SOL and less than 10 minutes of CPR; and witnessed traumatic arrest (penetrating or blunt) with brief prehospital downtime and SOL on emergency department arrival.

In addition to the EAST and WTA recommendations, the European Resuscitation Council guidelines outline 4 essential conditions for successful resuscitative thoracotomy, summarized as the “4 E’s”: expertise, equipment, environment, and elapsed time. The procedure should be performed by trained providers (expertise), using appropriate surgical instruments (equipment), in a resuscitation-ready setting (environment), and ideally within 10 minutes of cardiac arrest (elapsed time), as survival declines significantly beyond this window. According to these guidelines, failure to meet any of the 4 criteria constitutes a contraindication to resuscitative thoracotomy, as performance of the procedure under such conditions is considered futile and exposes the clinical team to unnecessary risk.[10]

Contraindications

EDT should not be performed in patients who continue to have vital signs, including those with hypotension but measurable blood pressure.[11] The procedure is also considered inappropriate in clearly futile clinical circumstances, such as when SOL are absent at the scene of injury, asystole presents without pericardial tamponade, pulselessness exceeds 15 minutes, or injuries are massive and nonsurvivable. Blunt trauma without signs of life is a contraindication to EDT.[12]

In the pediatric population, available evidence indicates that patients aged 0 to 14 years with blunt thoracic injury and otherwise qualifying criteria, such as witnessed loss of pulse and absence of nonsurvivable injuries, should generally not undergo EDT due to extremely poor outcomes. Patients younger than 15 to 18 years with blunt thoracic injury, as well as pediatric patients with penetrating thoracic trauma, are not considered to have a relative contraindication based on age alone.[13][14][15]

Age over 57 years may be a relative contraindication to EDT.[16][17] However, more recent data in penetrating trauma indicate that age alone does not reliably predict failure to rescue and should not exclude patients who otherwise meet favorable criteria for intervention.[18]

EDT should not be performed in the absence of immediately available resources, including operating room capability and appropriately trained surgical personnel, as the procedure functions as a temporizing measure intended to facilitate rapid transfer to definitive surgical care. [Source: American College of Surgeons. ATLS®: Advanced Trauma Life Support® Student Course Manual, 10th Edition. 2018] EDT is also contraindicated when essential equipment is unavailable, including capability for internal cardiac defibrillation. Additional contraindications include severe head injury and severe multisystem injury.[19]

Equipment

Personal protective equipment (PPE) includes sterile gloves, a gown, a mask, and a face shield or eye protection. Skin preparation requires an antiseptic solution, such as chlorhexidine gluconate (Chloraprep). Incision and dissection instruments include a scalpel with a #10 or #22 blade, trauma shears or heavy-duty scissors, and a Gigli saw, which may be used for sternal division when indicated. Hemorrhage control and repair instruments include a rib spreader (such as a Finochietto retractor), tissue forceps (such as Spencer-Wells artery forceps), needle holders in long and short configurations, non-absorbable sutures such as 2-0 silk, vascular clamps including Satinsky clamps, and an aortic cross-clamp (see Image. Emergency Department Thoracotomy Clinical Field). Additional supplies include sterile drapes and towels, laparotomy sponges, a high-volume suction device, chest tubes (typically 30F), internal defibrillator paddles, a 20F Foley catheter with a 30-mL balloon, and a skin stapler.

These items are essential for executing EDT successfully and managing the complex challenges associated with traumatic thoracic injury. Failure to secure essential equipment before the procedure should prompt reconsideration of whether EDT is appropriate.

Personnel

EDT requires a highly coordinated interprofessional team. Clear role delineation is essential to ensure efficiency under time-critical conditions. Effective communication and teamwork among physicians, nurses, and ancillary staff are essential to maximize the likelihood of successful outcomes in these high-acuity scenarios.

Resuscitation Lead

One clinician should serve as the resuscitation lead, coordinating ongoing resuscitative efforts, including Advanced Cardiovascular Life Support measures, such as airway management and blood product administration. This clinician should work alongside a nurse responsible for preparing and administering medications, setting up defibrillation equipment when indicated, and documenting interventions in real time.

Procedural Team

A second clinician, ideally the most experienced available provider, should perform the thoracotomy. A dedicated assistant should support the procedure by facilitating exposure, passing instruments, managing suction, and assisting with key steps, such as pericardiotomy, aortic cross-clamping, and cardiac repair. A circulating nurse or scrub nurse should assist by maintaining sterility, preparing instruments, and anticipating procedural needs.

Nursing Support

Additional nursing personnel should be assigned to maintain intravenous access, manage fluid and blood product administration, coordinate with the blood bank, and ensure availability of surgical supplies and medications. One nurse should also assist with preparation for transport to the operating room if return of spontaneous circulation is achieved.

Surgical Coordination

Surgical coordination should simultaneously activate a pathway to definitive care, including immediate notification of the trauma surgeon, operating room team, and intensive care unit staff. Preparations should ensure that surgical instruments, transfusion support, and postoperative critical care resources are readily available.

Preparation

EDT is an emergent procedure that allows little time for preparation once indicated. Most preparation should occur in advance of the need for intervention, including familiarization with equipment location and proper use. Providers should be well-versed in procedural steps and indications for EDT. All personnel and equipment should ideally be assembled and immediately available prior to initiation of the procedure.

Antibiotics are recommended before cardiothoracic surgery. However, EDT should not be delayed for antibiotic administration. All personnel involved in resuscitative efforts should follow universal precautions by using gowns, gloves, and eye protection.

Technique or Treatment

The patient should be positioned supine with both arms abducted to 90° and extended. A left-sided approach is generally used, as it provides access to the left thorax, pericardium, heart, and aorta (see Image. Surgical Incision Pathways for Thoracotomy Procedures). A skin incision is made with a #10 blade scalpel from the sternum through the 4th or 5th intercostal space below the nipple and extended laterally to the posterior midaxillary line following the curvature of the ribs. Breast tissue should be retracted superiorly. The initial incision passes through skin and subcutaneous fat and may extend to the ribs in lean patients.

A right-sided approach may be used when right thoracic bleeding is suspected. Extension of the incision from left to right inferior to the sternum creates a clamshell incision, which exposes the anterior mediastinum, aortic arch, and great vessels. Ongoing debate exists regarding the optimal approach, with some authors suggesting that, for emergency providers with limited procedural familiarity and incomplete injury information, the clamshell incision should be preferred.[20]

A 1- to 2-inch incision should be made laterally to avoid cardiac injury, along the superior margin of the inferior rib to avoid the intercostal neurovascular bundle (see Image. Dissection of the Left Posterior Thoracic Wall Showing Intercostal Spaces 3 and 4). The incision should penetrate and separate the intercostal muscles and parietal pleura, with care taken to avoid injury to the underlying lung tissue. Mayo scissors or sterile trauma shears are then used to extend the incision from the initial defect anteriorly toward the sternum, separating the intercostal muscles. The incision is completed by extending posteriorly toward the posterior midaxillary line.

After entry into the chest, a rib spreader is inserted between the ribs with the arm directed toward the axilla and the ratchet bar oriented inferiorly. The rib spreader is then expanded maximally to optimize exposure.

Optional right mainstem bronchus intubation may reduce left lung ventilation and further improve exposure after entry into the chest. Visible bleeding should be controlled with direct pressure or laparotomy sponges. Vascular clamps should be reserved for last-resort use. Bleeding from major pulmonary vasculature may be controlled by direct clamping of injured lung tissue or vessel, clamping of the pulmonary hilum, or using the “pulmonary hilar twist” maneuver to reduce the risk of air embolism.

Further damage control measures are reasonable prior to pericardiotomy if no pericardial effusion or apparent pericardial injury is present. Open cardiac massage may be performed with the pericardium intact.

Pericardiotomy should be performed if the myocardium cannot be visualized through the pericardium, and the heart should be delivered from the pericardial sac. The phrenic nerve should be identified along the lateral pericardium and protected from injury during pericardiectomy. The pericardium should be grasped with toothed forceps, and a small incision should be made with a scalpel or scissors, avoiding injury to the myocardium and phrenic nerve. This incision is extended parallel to the phrenic nerve in a superior direction and should expose the great vessels. Pericardial fluid and clot should be removed, followed by evaluation of the great vessels. The heart should then be delivered from the pericardial sac.

The heart should be palpated for injury and inspected for bleeding or hemorrhage. Bleeding should initially be controlled with direct pressure. If direct pressure proves insufficient or hemorrhage is too brisk, further interventions that may be considered include ligation with suture, closure of the laceration with staples, or insertion of the tip of a Foley catheter with balloon inflation followed by gentle traction to achieve internal compression. The Foley catheter technique is most effective for ventricular puncture injuries, where the catheter tip is inserted into the defect, and the balloon is inflated to tamponade bleeding.

Superficial myocardial lacerations or cardiac vessel injuries may be managed with temporary repair using sutures or staples to control hemorrhage until definitive surgical repair in the operating theater. Care should be taken to avoid tamponade or ligation of a coronary vessel.

Next, the aorta is typically cross-clamped to improve cerebral perfusion. Aortic cross-clamping should be avoided in normotensive patients due to increased afterload and reduced cardiac perfusion.[21]

The left lung is retracted superiorly, and the pulmonary ligament is divided. The esophagus may be differentiated from the aorta by palpation of a nasogastric or orogastric tube within the esophageal lumen. The overlying pleura is then separated, and the aorta is mobilized from the esophagus and the vertebral column posteriorly, creating sufficient space for cross-clamping. Aortic cross-clamping should be performed within an intervertebral space to reduce the risk of intercostal vessel injury. Optimal clamp placement is just above the diaphragm, although placement just below the left pulmonary hilum may also be used when required.

Advanced Cardiovascular Life Support and Advanced Trauma Life Support resuscitative measures may continue following aortic cross-clamping. Open cardiac massage and internal defibrillation may be performed as indicated.

Complications

EDT is a lifesaving procedure. However, potential benefits must be weighed against the risk of complications before administering this intervention.

Operator injury is a frequent complication, and appropriate use of PPE is the primary preventive measure. Occupational exposure to blood-borne pathogens, such as HIV, is slightly higher than baseline risk, although strict adherence to PPE use significantly reduces exposure risk.[22]

Rib transection may occur during the primary incision, creating sharp edges capable of injuring the operator. A curvilinear incision following the rib contour is essential to minimize this risk. Use of a scalpel for deep thoracic entry may also cause inadvertent injury to the pericardium and underlying structures. Such iatrogenic injury is most effectively avoided by using Mayo scissors to divide intercostal muscles and soft tissues under controlled dissection.

Pericardiotomy carries a risk of phrenic nerve damage. Coronary artery injury may occur during cardiac exposure and manipulation. A functional understanding of thoracic anatomy and operative technique is essential to minimize inadvertent structural injury.

Complete exposure of the aorta is required to prevent incomplete cross-clamping, inadvertent clamping of the esophagus, or simultaneous clamping of the esophagus with the aorta. Additional complications include phrenic nerve injury, distal organ ischemia secondary to aortic cross-clamping, and recurrent hemorrhage from the chest wall or internal mammary artery.[23]

Clinical Significance

Indications for EDT have evolved significantly over the past 6 decades based on increasing clinical experience and more robust outcome data.[24] The procedure may be lifesaving when performed in appropriately selected patients, particularly those with penetrating thoracic injuries and SOL, with measurable reductions in mortality in select clinical scenarios.

Despite these potential benefits, overall morbidity and mortality associated with EDT remain high. Reported survival rates range from less than 1% to 35%, depending on mechanism of injury, location of major injury, and presence of physiologic SOL at presentation.[25] Outcomes are notably improved in penetrating trauma, with survivability approaching 8.8%, and, in isolated cardiac injuries, survival approximating 20%. Presence of SOL on hospital arrival is associated with approximately 11.5% survival. The survival rate after EDT for blunt trauma is extremely low, particularly in the absence of witnessed SOL in the hospital, with even poorer outcomes when SOL are absent in the field.

At present, no strong consensus supports the routine use of EDT in blunt trauma, and most guidelines recommend its administration only in cases with clearly defined indications and SOL present on arrival to the emergency department. Inappropriately performed thoracotomies contribute to resource overutilization, increased occupational risk, and reduced likelihood of favorable outcomes. Up-to-date knowledge of EDT indications, contraindications, and techniques remains critical for appropriate application. Continued education, review of cases, and adherence to institutional protocols may reduce futile interventions and improve decision-making in the emergency department.

Enhancing Healthcare Team Outcomes

EDT is a last-resort intervention for lifesaving treatment in a narrowly defined patient population. Resuscitation of patients undergoing EDT requires an interprofessional team, including an emergency medicine physician, nurses, and, potentially, assistants, technicians, or other available staff. EDT cannot be performed in isolation, and coordinated team function improves efficiency and outcomes. A trauma surgeon and supporting staff are often present during the procedure. When not immediately available, the surgical team should be activated without delay to provide definitive operative management.

Clear identification of appropriate candidates for EDT may improve outcomes by reducing futile intervention in patients with unsurvivable injuries. Review of procedural steps and anticipated next actions may further enhance interprofessional communication and workflow efficiency during time-critical resuscitation.[26]