Resuscitative thoracotomy: Technique

INTRODUCTION — Resuscitative thoracotomy is a procedure of last resort that is performed only under specific clinical circumstances. Resuscitative thoracotomy is nearly always performed in the emergency department and involves gaining rapid access to the heart and major thoracic vessels through an anterolateral chest incision to control exsanguinating hemorrhage or other life-threatening chest injuries. The first successful resuscitative thoracotomy was described for the resuscitation of a patient with penetrating cardiac injury, and this indication remains the one associated with the highest rate of survival [1,2].

This topic will briefly review the indications for resuscitative (emergency department) thoracotomy, which are discussed more fully in separate reviews, and discuss the technique of resuscitative thoracotomy.

The initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma is based upon protocols from the Advanced Trauma Life Support (ATLS) program established by the American College of Surgeons Committee on Trauma. The initial evaluation and resuscitation of the patient with blunt or penetrating abdominal or thoracic trauma is discussed elsewhere.

●(See "Initial evaluation and management of blunt thoracic trauma in adults".)

●(See "Initial evaluation and management of blunt abdominal trauma in adults".)

●(See "Initial evaluation and management of abdominal gunshot wounds in adults".)

●(See "Initial evaluation and management of abdominal stab wounds in adults".)

INDICATIONS FOR THORACOTOMY — Resuscitative thoracotomy is a temporizing measure that allows direct control of hemorrhage from exsanguinating thoracic injures or decompression of cardiac tamponade and allows control of the aorta to limit bleeding from infradiaphragmatic injuries to facilitate resuscitation. Resuscitative thoracotomy is discouraged in settings where an appropriately trained surgeon (eg vascular, cardiothoracic, trauma) is not available to provide definitive care. In virtually all survivors, definitive surgical management will subsequently be required. Attempts to transfer patients with an aortic clamp in place are uniformly unsuccessful.

Resuscitative thoracotomy is restricted to patients with specific indications as determined by the patient's clinical status en route and immediately upon arrival to the emergency department, the mechanism of injury, or the need to perform therapeutic maneuvers to manage correctable causes of shock, including decompressing cardiac tamponade, cross-clamping the aorta, managing exsanguinating cardiac or vascular injuries, and evacuating air embolism [3]. (See 'Aortic cross-clamping' below and 'Pericardiotomy' below and 'Hemorrhage control and repair' below and 'Identifying and evacuating air embolism' below.)

Studies that have evaluated adherence to guidelines for these indications have shown compliance rates ranging from 50 to 80 percent [4-6]. Compliance is typically better for penetrating compared with blunt trauma (74 versus 45 percent, in one study [4]).

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 who rapidly deteriorate or arrest during initial resuscitation, or in patients who have been pulseless and receiving cardiopulmonary resuscitation (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]. The rationale for resuscitative thoracotomy in penetrating injury is discussed in detail elsewhere. (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Role of emergency department thoracotomy'.)

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 at 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 nonsurvivable injury (eg, massive head trauma, multiple severe injuries) and patients with cardiac tamponade rapidly diagnosed by ultrasound, with no obvious nonsurvivable injury, but only if appropriate resources (eg, operating room, appropriately trained surgeon) are available for continued resuscitation and definitive repair. These indications are discussed in detail elsewhere (algorithm 1) [8]. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Role of emergency department thoracotomy'.)

It is worth noting that in spite of widespread recommendations against the use of resuscitative thoracotomy following blunt trauma in the absence of signs of life given a lack of efficacy, persistent use of resuscitative thoracotomy in the emergency department was noted in these patients in a review from the American Association for Surgery in Trauma (AAST) Aorta Study Group [9].

Thoracic aortic cross-clamping prior to abdominal exploration may benefit a subset of patients with penetrating abdominal injury and exsanguinating hemorrhage. The management of abdominal vascular injuries is discussed in detail elsewhere. (See "Abdominal vascular injury".)

Retrospective reviews report survival that ranges from 14 to 42 percent in patients with severe penetrating abdominal injuries who underwent thoracic aortic clamping prior to abdominal exploration [10-13]. However, controlled comparisons are lacking. In one of these reviews, hemorrhagic shock was due to major abdominal vascular (75 percent) or severe liver (25 percent) injuries, and all required massive blood transfusion [11]. Sixteen percent of the patients survived hospitalization neurologically intact.

Contraindications — In patients with blunt injury, resuscitative thoracotomy is likely to be futile if:

●The patient requires >10 minutes of prehospital CPR

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

●The patient has massive, nonsurvivable injuries

Also, we do not advocate undertaking resuscitative thoracotomy in any emergency department in which definitive injury management is not immediately available. (See 'Definitive management' below.)

THORACIC ANATOMY — The thorax is the area of the body between the base of the neck superiorly and the diaphragm inferiorly. The thorax contains the heart, lungs, and major vascular structures, including the aorta, arch vessels (brachiocephalic, carotid, and subclavian arteries), and descending thoracic aorta. The descending thoracic aorta is covered by a thin layer of parietal pleura that must be divided to expose the aorta.

The aortic root is a midline structure, and the heart is normally positioned in the left chest with the apex of the left ventricle at the left midclavicular line. The arch of the aorta sweeps from the midline posteriorly to the left, and the descending thoracic aorta lies adjacent to the spine (figure 1). The arch of the aorta and great vessels are located beneath the manubrium of the sternum.

Normal arch anatomy consists of three branches: the brachiocephalic trunk, which gives off the right common carotid and right subclavian arteries; the left common carotid artery; and the left subclavian artery. Variations of the aortic arch (figure 2) occur in approximately 17 percent of individuals [14,15]. The most common variation is a bovine arch with the left common carotid artery arising from a larger than usual brachiocephalic trunk.

The pericardial sac surrounds and protects the heart. The left phrenic and vagus nerves pass anterior to the aortic arch in proximity to the origin of the left subclavian artery. The left phrenic nerve is adherent to the lateral surface of the pericardium (figure 3) and is particularly susceptible to inadvertent injury during resuscitative thoracotomy. The left vagus nerve gives rise to the left recurrent laryngeal nerve, which encircles the aortic arch just medial to the origin of the left subclavian artery. The left vagus nerve travels posterior to the root of the left lung and then adjacent to the esophagus as it descends in the posterior mediastinum. Due to its posterior location, it is less vulnerable to injury compared with the phrenic nerve.

The esophagus is located on the anterior surface of the spine and medial to the aorta. The thoracic duct ascends along the anterolateral surface of the spine, is virtually invisible, and is susceptible to traumatic avulsion that can result in chylothorax.

PREPARATION

General considerations — Once the decision has been made to open the chest, one member of the trauma team should be designated to lead the ongoing resuscitation effort while an experienced member of the trauma team is performing the thoracotomy. The team leader must be easily identified and should present a calm but authoritative demeanor. Personnel not actively engaged in a specific function directed by the team leader should be asked to leave the room. All personnel should be reminded to minimize unnecessary conversations and to remain calm and purposeful. Iatrogenic injury due to haste, inattention, or an overly chaotic environment must be minimized to improve the likelihood of a satisfactory outcome.

While intubation and large-bore intravenous access are underway, patients with penetrating injuries should be completely disrobed and quickly rolled in both directions to locate all entrance and exit wounds [16]. Dual-lumen endotracheal intubation is not recommended in the emergency setting. A nasogastric or orogastric tube should be placed to aid localization when clamping the aorta. (See 'Aortic cross-clamping' below.)

Both the left and the right pleural spaces must be assessed for the presence of blood. A right-sided chest tube or simple "finger thoracotomy" is sufficient to determine the presence of blood in the right chest and can be performed by another member of the trauma team simultaneous with the thoracotomy procedure and should not delay the thoracotomy.

The patient is positioned supine, with the arms placed on arm boards laterally. The skin is prepared using iodine solution poured liberally over the entire thorax. Sterile drapes are applied, but, in practice, a sterile field is rarely achieved.

Equipment and supplies — A sterile thoracotomy tray (picture 1) should be available in the trauma room at all times. The tray should include sterile drapes and towels, laparotomy sponges, and appropriate instruments (table 1). The use of a specific checklist for resuscitative thoracotomy can be used to facilitate rapid deployment of necessary equipment and devices [17]. It is important to limit the number of instruments on the emergency thoracotomy tray to only those instruments that are likely to be used. A comprehensive instrument set may be an impediment to efficient entry into the chest. (See 'Hemorrhage control and repair' below.)

Lighting and suction are frequently inadequate in the emergency setting. Every effort should be made to assure that an overhead surgical light or headlight is available, and that effective wall suction is nearby. Operating room personnel may be helpful if available.

Antibiotics — Antibiotics are recommended prior to cardiothoracic surgery (table 2). However, the procedure should not be delayed for antibiotic administration.

Universal precautions — Resuscitative thoracotomy is associated with significant blood splatter in often unpredictable directions. Given the increased risk of exposure to bloodborne disease in the trauma setting, we agree with ATLS recommendations that all personnel involved in the care of the trauma patient should observe universal precautions wearing gowns, gloves, and eye protection at all times. Any personnel not immediately involved in the thoracotomy procedure should stand away from the table to minimize their risk of exposure. After the procedure is completed, particular care should be exercised with disposal of sharp instruments. (See "Patient safety in the operating room" and "Prevention of hepatitis B virus and hepatitis C virus infection among health care providers", section on 'Epidemiology of bloodborne exposures'.)

The prevalence of bloodborne pathogens (eg, human immunodeficiency virus [HIV] and hepatitis B [Hep B] or hepatitis C [Hep C]) in the trauma population is well known [16,18-25]. The estimated seroprevalence of HIV in injured patients in emergency departments in the United States is between 0.5 and 10 percent [26]. Hep B and C seroprevalence rates may be higher [20,27-29]. In one series evaluating these diseases in penetrating trauma patients, the subset of patients most likely to undergo resuscitative thoracotomy, infection with HIV or hepatitis was present in 9.4 percent. The prevalence of HIV was 1.2 percent, the prevalence of Hep B antigen was 0.6 percent, and the prevalence of Hep C was 7.6 percent [20,28,29]. The risk of infection following occupational exposure to HIV is relatively low (0.3 percent). Hepatitis is more readily transmitted through occupational exposure, with transmission rates for Hep B ranging from 6 to 30 percent and transmission rates for Hep C ranging from 0 to 7 percent [30].

TECHNIQUES — Although the technique of resuscitative thoracotomy is relatively straightforward, the procedure is often performed by those who do not routinely perform elective thoracotomy. A systematic approach can help the practitioner avoid pitfalls and optimize patient outcomes.

General approach — Given the indications for resuscitative thoracotomy (ie, patient in extremis with loss of vital signs), the steps are generally performed in a defined order, which is discussed in more detail below. However, the clinical presentation of the patient or the nature of a specific injury may make one step take precedence over another. As an example, aortic cross-clamping may take precedence over pericardiotomy in the patient with exsanguinating hemorrhage from an aortic rent. In general:

●External chest compressions are stopped prior to thoracotomy. Ongoing chest compressions may delay or complicate the most critical aspects of resuscitation (ie, establishment of intravenous access, endotracheal intubation, sonographic assessment of cardiac activity and presence of pericardial effusion, and lastly chest decompression).

●The incision is made in the left fourth intercostal space, the chest is entered, and a retractor is placed. (See 'Incision' below and 'Opening the chest' below.)

●Damage control maneuvers are used to manage hemorrhage that will impede performance of pericardiotomy or aortic cross-clamping. (See 'Damage control' below.)

●The pericardial sac is opened, and temporizing measures are used to control any cardiac injuries, if present. Air embolism is managed if identified. (See 'Pericardiotomy' below and 'Hemorrhage control and repair' below and 'Identifying and evacuating air embolism' below.)

●The aorta is cross-clamped to allow filling of the heart and facilitate ongoing fluid resuscitation. (See 'Aortic cross-clamping' below.)

●Open cardiac massage is initiated once the heart has filled sufficiently. (See 'Open cardiac massage and internal defibrillation' below.)

●The thoracic structures are systematically explored, looking for any additional bleeding or hematoma formation that might suggest underlying injury. (See 'Hemorrhage control and repair' below.)

Incision — The patient is supine and both arms are extended on armboards. Large-bore intravenous access is essential. The incision extends from the left lateral border of the sternum to the table. The heart, lungs, and descending thoracic aorta are completely exposed. If massive bleeding from a right chest injury is suspected, then an initially right-sided approach may be taken. If needed, the thoracotomy incision can be extended across the sternum to the right (or left) as a clamshell incision, using a Lebsche knife [31,32]. The clamshell incision (figure 4) greatly improves access to the anterior mediastinum, aortic arch, and great vessels. The internal mammary arteries should be controlled after the sternum is divided to prevent iatrogenic hemorrhage. A posterolateral thoracotomy approach is not used in emergency circumstances because of the necessity to position the patient in a lateral decubitus position [33].

For anterolateral thoracotomy, the skin incision is made with a #10 blade from the margin of the sternum along the intercostal space between the 4^th and 5^th ribs (4^th interspace), or 5^th and 6^th ribs (5^th interspace) (figure 5), below the nipple and carried laterally to the left posterior axillary line, following the curve of the rib. In the female patient, the breast should be retracted superiorly. The skin and subcutaneous fat are incised sharply with the scalpel. In thin patients, the initial incision can be carried directly down to one of the ribs.

For patients who arrive in the emergency department with an offending penetrating object (eg, knife blade) in situ, the object should generally be left in place, unless it interferes with performing the thoracotomy [34].

Opening the chest — The thoracic cavity is entered laterally (away from the heart) by making a small (1 to 2 cm) incision along the superior margin of the underlying rib to avoid injury to the intercostal neurovascular bundle, which is located along the inferior margin of the rib (figure 6). The pleura immediately beneath the muscles is likewise divided, taking care to not injure the lung. Once the chest is entered, a curved Mayo scissors (or sterile trauma shears) is placed into the wound and pushed anteriorly toward the sternum to open the interspace by shearing the intercostal muscles from the rib (figure 5). Some surgeons prefer to disrupt the intercostal muscles with a sweeping motion by placing one or two fingers of each hand into the initial defect.

After entering the chest, a rib spreader (Finochietto) is inserted between the ribs with the handle of the retractor directed toward the left axilla, permitting extension of the incision across the sternum for additional exposure, if necessary, without the need to replace the retractor. The retractor should be opened as wide as possible to maximize exposure. To avoid rib fracture, some surgeons intentionally divide one of the ribs near the posterior attachment.

Damage control — Once the chest is opened, the person charged with ventilator management may reduce ventilation to the left lung by intentionally intubating the right main-stem bronchus. The surgeon can facilitate this by manually occluding the left mainstem bronchus. (See "One lung ventilation: General principles".)

Any obvious bleeding source should be controlled with direct pressure initially. Bleeding that will hinder pericardiotomy or aortic cross-clamping needs to be managed first. Bleeding from noncardiac sites can be controlled using a combination of direct pressure using laparotomy pads or sponge sticks. Even for experienced trauma surgeons, blind use of clamps to control bleeding can be hazardous and should only be utilized as a last resort. Significant hemorrhage originating from the pulmonary parenchyma or major pulmonary vasculature can be controlled with direct clamping of the injured lung tissue (Duval clamp) or vessel, clamping the pulmonary hilum, or by using the "pulmonary hilar twist" maneuver (figure 7) [35]. Pulmonary hilar clamping and the "pulmonary hilar twist" also reduce the potential for ongoing air embolism.

To perform hilar clamping or the "pulmonary hilar twist," the injured lung hilum is mobilized by dividing the inferior pulmonary ligament to the level of the inferior pulmonary vein (figure 7). Inadvertent injury to the inferior pulmonary vein represents a major iatrogenic complication that must be avoided, as it is often fatal. The hilum of the lung can be controlled with a large vascular clamp (eg, Crawford or Satinsky) or using a Rommel tourniquet and snares [36]. For the pulmonary twist maneuver, the lower lobe is rotated anteriorly over the upper lobe twisting the lung clockwise 180°, which compresses the main pulmonary artery and vein against the bronchus [35]. It should be noted that the pulmonary hilar twist can result in significant irreversible injury to the lung and great vessels and should be a maneuver of last resort. Care should be taken not to extend or create new injuries by overtwisting. To prevent the lung from untwisting, laparotomy packs are placed at the base and apex of the lung. The maneuver is terminated as quickly as possible after hemorrhage is controlled.

Prolonged hilar control (clamp or twist) can lead to complications such as right heart failure, dysrhythmias, and hypoxemia [37,38]. As such, the duration of time the hilum is clamped or twisted should be minimized, and pulmonary injuries identified and definitively managed as soon as is feasible. For some patients, the ongoing resuscitative effort is prolonged due to hypothermia, coagulopathy, and acidosis. In these patients, prolonged hilar control commits the patient to pneumonectomy. The hilum should remain clamped or twisted until pulmonary resection can be performed.

Pericardiotomy — The next step in a resuscitative thoracotomy is pericardiotomy. If there is no pericardial tamponade and other obvious noncardiac injuries are apparent, the pericardium should be left intact to address these injuries first. Open cardiac massage can be performed with the pericardium intact. Unintentional injury to the myocardium or coronary arteries may be the consequence of unnecessary entry into the pericardial sac.

If there are no other obvious noncardiac injuries, the pericardium should be opened. The phrenic nerve is identified on the anterolateral surface of the pericardium and protected from injury (figure 8). (See 'Thoracic anatomy' above.)

A variety of techniques have been proposed to achieve safe and rapid entry into the pericardium. The Advanced Surgical Skills for Exposure in Trauma (ASSET) course recommends carefully opening the pericardium with a controlled incision using a knife [39]. Others have suggested using toothed forceps, if available, to grasp the pericardium while carefully incising with a knife or scissors (picture 2). The pericardial sac is entered through a small incision anterior to the phrenic nerve and extended parallel (cranial/caudal) to the phrenic nerve from the initial entry point (figure 8) using Metzenbaum scissors to expose the heart and great vessels. Pericardial fluid and any blood clots are evacuated, and the heart and great vessels are inspected. The heart is then delivered from the pericardial sac, inspected on its surface for any wounds, and gently palpated. Any bleeding is controlled initially with digital compression. (See 'Hemorrhage control and repair' below.)

Aortic cross-clamping — The thoracic aorta is typically cross-clamped to redistribute the available intravascular blood volume to the myocardium and brain, which effectively doubles the mean arterial pressure and cardiac output [1,12,13,40-44]. For patients with concomitant abdominal or lower extremity injuries, this maneuver also reduces blood loss.

Digital aortic compression provides a quick means by which to reduce distal blood flow to allow resuscitation while additional dissection for cross clamp placement is done.

To perform aortic cross-clamping, the left lung is retracted superiorly, and the inferior pulmonary ligament is divided. The orogastric or nasogastric tube should be palpated to differentiate the esophagus from the empty descending aorta. Dissection should be performed at the level of an intervertebral space in a plane perpendicular to the aorta to avoid injury to intercostal vessels, which branch from the aorta at the level of the mid-vertebral body (figure 9). The parietal pleura overlying the aorta are incised, and the tissues between the aorta and esophagus, as well as the prevertebral fascia, are separated to create sufficient space to place the aortic clamp without avulsing the intercostal arteries from the posterior surface of the aorta.

The aorta is ideally clamped just above the diaphragm (picture 3) to maximize spinal cord perfusion, but the aorta can also be clamped just below the left pulmonary hilum. For patients with abdominal injuries who survive the initial emergency department resuscitative efforts, the thoracic aortic cross-clamp should be repositioned lower on the abdominal aorta as soon as possible. Prolonged clamping more than 30 minutes proximal to the visceral vessels should be avoided. (See "Surgical and endovascular repair of ruptured abdominal aortic aneurysm", section on 'Aortic control'.)

Open cardiac massage and internal defibrillation — Once the pericardium has been opened, Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) protocols are continued with open cardiac massage and internal defibrillation, as needed.

Cardiac massage should be started immediately after placement of the thoracic aortic clamp and should only be delivered with a two-hand ("clapping") technique (figure 10). The wrists of the caregiver are placed together at the apex of the heart, and the heart is squeezed together between the two open palms in a rhythmic motion. The thumb of each hand is maintained adjacent to the first finger to avoid inadvertent digital penetration into the heart. The pulmonary outflow tract is particularly vulnerable to accidental puncture with the thumb.

Open cardiac massage is superior to closed chest compressions in maintaining cardiac output and providing cerebral and coronary perfusion in animal studies [45-48]. External compressions provide approximately 25 percent of baseline cardiac output, resulting in only 10 percent of normal cerebral and coronary flow, whereas open cardiac massage generates 60 to 70 percent of baseline cardiac output [46,49]. In a small study of 10 patients who all underwent closed chest compressions followed by open chest cardiac massage, coronary perfusion pressures were 400 percent greater with open cardiac massage [50].

For patients in ventricular fibrillation, internal cardiac defibrillation is performed with the defibrillator initially set at 10 joules. Repeat defibrillation is performed, as needed, at 10 to 50 joules. One of the internal paddles is placed on the anterior (ventral) surface of the heart, and the other is placed on the posterior (dorsal) surface of the heart. As with external defibrillation, all personnel should be well away from the patient prior to defibrillation to prevent inadvertent electric shock and avoid blood splatter.

Hemorrhage control and repair — Bleeding is controlled in a systematic fashion first by identifying and controlling bleeding from the heart, followed by controlling bleeding from major vascular structures of the chest and lungs. Temporizing measures are instituted until definitive repair can be undertaken in the operating room in which adequate lighting, proper instrumentation, magnification, supplies, and appropriate nursing and support staff are available.

Patients who are most likely to be saved with a resuscitative thoracotomy are those with stab wounds to the right heart [51,52]. The extent to which repair might be undertaken depends upon the experience of the operator.

Direct surgical repair of cardiac injuries should generally only be undertaken by clinicians with appropriate training and skill. Direct digital pressure is usually effective at controlling hemorrhage while fluid resuscitation takes place and arrangements are being made for definitive repair by a cardiac, vascular, or trauma surgeon. This is preferred to attempting surgical repair under suboptimal conditions. While the successful use of surgical staplers to close cardiac injuries has been reported, in our experience, it is prone to cause further injury. Similarly, while the insertion of a foley catheter into cardiac wounds has been anecdotally reported to be effective at controlling selected cardiac injuries, inadvertent withdrawal of the inflated balloon may only serve to make matters worse.

If there is no alternative, suture repair of ventricular cardiac injuries can be accomplished in the emergency department using double-armed polypropylene (eg, Prolene), preferably on a cardiovascular (CV) needle. Interrupted 3-0 sutures are placed in a horizontal mattress fashion with pledgets. The suture is passed into the cardiac tissue on each side of the hole parallel to the finger that is providing vascular control (z-stitch) (figure 11). As the finger is carefully withdrawn, an assistant gently pulls up on the suture, crossing the ends. Additional sutures are placed, as needed, prior to tying the sutures. Venous and atrial wounds can be repaired in a simple, running fashion using 3-0 or 4-0 sutures. (See "Management of cardiac injury in severely injured patients", section on 'Surgical management'.)

If larger defects are present and prove difficult to control or repair, balloon occlusion can be used to achieve temporary hemostasis. A clamped bladder catheter (5 cc balloon) can be inserted through the cardiac defect, inflated, and then withdrawn to allow the balloon to tamponade the bleeding.

Following evaluation and management of any cardiac injuries, attention should be directed toward any remaining bleeding sites in the chest cavity that have not already been temporarily controlled using damage control techniques. In penetrating trauma, missile or implement trajectories are followed, looking for great vessel, lung parenchyma, chest wall, and diaphragmatic injuries. As discussed above, vascular and pulmonary injuries can be clamped or direct pressure applied to control bleeding. Laparotomy pads that have controlled bleeding should remain in place until definitive repair can be undertaken in the operating room under optimal circumstances. (See 'Damage control' above and "Overview of blunt and penetrating thoracic vascular injury in adults".)

Identifying and evacuating air embolism — After opening the chest and pericardium, the presence of air in the coronary vessels, heart, and possibly the aorta is diagnostic for air embolism.

Initial treatment of air embolism is focused upon preventing any additional air from entering the circulation, reducing the volume of air that is present with aspiration, and ongoing hemodynamic support [53-55]. The most important steps include putting the patient into Trendelenburg position (head down), controlling venous injury (compression, clamping, suture, staples) to prevent additional air entrainment, and providing adequate volume resuscitation. (See "Management of cardiac injury in severely injured patients", section on 'Damage control surgery'.)

When air embolism is thought to be due to lung injury, one-lung ventilation should be instituted and the hilum of the injured lung quickly controlled. (See 'Damage control' above.)

DEFINITIVE MANAGEMENT — If the patient regains signs of life as a result of resuscitative thoracotomy, the next priority should be immediate transfer of the patient to the operating room for definitive management by a multidisciplinary trauma team (trauma surgery, cardiac surgery, thoracic surgery, vascular surgery). The detailed management of specific injuries is beyond the scope of this topic but can be found in separate topic reviews. Given the need for this level of expertise, resuscitative thoracotomy should not be undertaken in any emergency department where definitive injury management is not immediately available. (See 'Indications for thoracotomy' above.)

Once thoracic, abdominal, or other injuries have been adequately addressed in the operating room, the question remains whether to close the chest or to perform temporary closure, as is often performed following damage control laparotomy for trauma. Retrospective reviews have evaluated temporary thoracic closure but have not demonstrated any specific advantage [56,57]. In one small study, initial postoperative peak inspiratory pressures were significantly better with temporary closure compared with definitive closure (20 versus 32.5 cm H₂O) [56]. There were no significant differences in the incidence of infectious complications (24 versus 25 percent), hemorrhagic complications (18 versus 14 percent), or survival (47 versus 57 percent) between the two groups.

Patients who survive the initial operation are transferred to the intensive care unit for ongoing resuscitation to correct acidosis, coagulopathy, and hypothermia. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury".)

MORBIDITY AND MORTALITY — The available data evaluating the outcomes of resuscitative thoracotomy are derived primarily from retrospective reviews and case series [2,7,8,16,27,58-75]. Studies are generally of low quality with heterogeneity in the populations and outcomes studied. A systematic review of 24 nonrandomized studies identified 4620 resuscitative thoracotomies [27]. The overall survival rate was 7.4 percent, ranging from 2.5 to 27.5 percent. The most significant factors associated with survival included mechanism of injury, magnitude and location of the injury, and the presence of signs of life. In a later review that included 10,238 patients who underwent resuscitative thoracotomy, 8.5 percent survived to discharge; 86 percent of survivors were neurologically intact [3].

Mechanism of injury is an important factor determining survival following resuscitative thoracotomy. Reported survival following resuscitative thoracotomy for isolated penetrating trauma is up to 70 percent, whereas survival following resuscitative thoracotomy for blunt trauma is rare. In a meta-analysis performed by the American College of Surgeons Committee on Trauma, which included 7035 patients with emergency department thoracotomy (EDT), the overall survival rate was 7.8 percent [76]. Stratified by mechanism of injury, patients with penetrating injuries had a survival rate of 11.2 percent, compared with 1.6 percent in those with blunt trauma. Among penetrating injuries, survival following resuscitative thoracotomy for stab wounds is two to four times higher than for gunshot wounds [27,51,52,67,77,78].

The location and magnitude of the injuries also plays an important role in determining survival. One study found the highest survival rates for isolated penetrating cardiac injuries (19 percent), followed by penetrating noncardiac thoracic (11 percent), penetrating abdominal (4 percent), and multiple penetrating injuries (less than 1 percent) [27]. Patients with blunt injuries had a survival rate of 1.4 percent. Overall survival for thoracic injuries was 10.7 percent compared with 4.5 percent for abdominal injuries, and much less for multiple injuries at 0.7 percent.

Survival is also closely related to the duration of cardiopulmonary resuscitation (CPR) prior to thoracotomy. Survival is extremely rare if CPR exceeds 15 minutes. Survival is rare in the absence of witnessed vital signs at the scene or in the emergency department (ED). The absence of signs of life, which refers to lack of any evidence of cardiac and cerebral perfusion, is associated with a poor prognosis [68,79]. In one retrospective review, nonreactive pupils were associated with no survival compared with a survival rate of 30 percent for those with reactive pupils. Similarly, one-third of patients with documented spontaneous extremity movement prior to arrival at the hospital survived, whereas none without extremity movement survived [79]. Patients with documented vital signs (blood pressure, pulse) in the field but who arrive to the emergency department in cardiac arrest also have higher survival rates (12 to 19 percent) compared with those without vital signs (0 to 4 percent) [3,27,69-71,80]. In a systematic review involving 10,238 patients who underwent resuscitative thoracotomy in the emergency department, patients presenting pulseless after penetrating thoracic injury had the most favorable outcomes both with and without signs of life (with, survival/neurologically intact: 21.3/11.7 percent; without, survival/neurologically intact: 8.3/3.9 percent) [3]. For patients presenting pulseless after penetrating extrathoracic injury, outcomes were more favorable with signs of life compared to without (with, survival/neurologically intact 15.6/16.5 percent; without, survival/neurologically intact 2.9/5.0 percent). Outcomes after pulseless blunt injury patients were poor. Survival following blunt trauma without neurologic deficit is rare if CPR exceeds 10 minutes. A prior review of resuscitative thoracotomy after blunt trauma identified only two survivors from more than 500 patients without signs of life at the scene, and both had severe neurologic deficits [8]. The survival without neurologic deficit if vital signs were lost during transit was 1.8 percent, and if vital signs were present in the ED, 4.5 percent.

One retrospective review of 102 patients undergoing thoracotomy over a 25-year period identified an overall survival rate of 7.8 percent [69]. The patient population was stratified by the Lorenz Physiologic Status Classification based upon vital signs and signs of life as follows [81]:

●Class I – No signs of life

●Class II – Agonal (ie, pulseless electrical activity, no blood pressure)

●Class III – Profound shock (ie, blood pressure [BP] <60 mmHg)

●Class IV – Mild shock (ie, 60 <BP <90 mmHg)

Survival rates improved significantly with higher physiologic status. Survival was 0.7 percent in class I patients, improving to 44.4 percent in class IV patients [69].

The need for CPR in the field is also associated with low survival rates. Although CPR in the field portends a poor prognosis, CPR in the presence of cardiac tamponade has a more favorable outcome, particularly among patients with stab wounds [82]. For patients with blunt trauma, CPR in the field is associated with no meaningful survival; any survivors are not likely to be neurologically intact [63,82]. For patients with penetrating injuries, survival is possible if the total time for CPR in the field is brief (<5 minutes).

Neurologic outcomes — Approximately one in five survivors of resuscitative thoracotomy suffer significant neurologic injury [16,27,63,64,66,72,83]. In the systematic review discussed above, 7 percent of the patients who survived were neurologically impaired [27]. A later database review from the Western Trauma Association reported that 18 percent of survivors had moderate to severe neurologic deficits requiring long-term care placement [64]. In a study that examined the clinical condition of the patient upon arrival, neurologically intact survival following resuscitative thoracotomy occurred in fewer than 5 percent of those who arrived to the emergency department in shock, was 1 percent for those without vital signs, and 0 percent for those without signs of life in the field [71].

A single-center report from an urban Level I trauma center identified 37 survivors from 448 ED thoracotomies. The report suggests that despite the need for prolonged hospitalization and rehabilitation, many survivors of EDT can expect to return to normal functional lives. The average length of stay was 43±41 days, and one-third of patients required extended treatment in a rehabilitation hospital or skilled nursing facility. Multidisciplinary outpatient assessment after a median of 59 months following resuscitative thoracotomy showed that 75 percent had normal cognition and returned to normal activities, 81 percent were freely mobile and functional, and 75 percent had no evidence of posttraumatic stress disorder [84].

Comparison with REBOA — There have been several reviews comparing the efficacy of resuscitative thoracotomy with endovascular balloon occlusion of the aorta (REBOA) [85,86]. The AAST Aorta Study Group concluded that REBOA offered a survival advantage over resuscitative thoracotomy, particularly in patients not requiring cardiopulmonary resuscitation [86]. However, a nationwide study from Japan found comparable outcomes between REBOA and resuscitative thoracotomy. Additional studies are needed to more clearly define the roles of REBOA and open thoracotomy in severely injured patients [87]. (See "Endovascular methods for aortic control in trauma".)

Long-term outcomes of survivors — Long-term outcomes of survivors of resuscitative thoracotomy are not well known. In one report, of patients admitted to the intensive care unit following successful resuscitative thoracotomy, only 29 percent survived to hospital discharge [88]. In a long-term review, among those that could be contacted, the majority of survivors had no evidence of cognitive functional or psychological long-term impairment over a median 59 months follow-up [84].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Thoracic trauma".)

SUMMARY AND RECOMMENDATIONS

●Resuscitative thoracotomy – Resuscitative thoracotomy is a procedure of last resort in the management of patients with major trauma. It is performed in patients with penetrating or blunt thoracic or exsanguinating abdominal injury who are in extremis, but only under specific clinical circumstances, and only if appropriate resources are available for definitive injury management. (See 'Introduction' above and 'Indications for thoracotomy' above.)

●Preparation – Once the decision has been made to open the chest, one member of the trauma team should be designated to lead the ongoing resuscitation effort while the senior member of the trauma team is performing the thoracotomy. Given the potential for blood splatter and the prevalence of bloodborne disease in the trauma population, all personnel involved in the care of the trauma patient should observe universal precautions wearing gowns, gloves, and eye protection at all times. (See 'Preparation' above.)

●Incision – Resuscitative thoracotomy is performed through an anterolateral incision in the 4^th or 5^th intercostal space in a systematic manner. Given the indications for resuscitative thoracotomy (ie, patient in extremis with loss of vital signs),

●Procedural steps – The procedural steps are generally performed in a defined order; however, the clinical presentation of the patient or the nature of specific injuries may make one step take precedence over another. The typical approach is as follows:

•The incision is made, the chest is entered, and a retractor is placed. (See 'Incision' above and 'Opening the chest' above.)

•Damage control maneuvers are used to manage hemorrhage that will impede performance of pericardiotomy or aortic cross-clamping. (See 'Damage control' above.)

•The pericardial sac is opened and evacuated of any blood or clots, and temporizing measures are used to control cardiac injuries, if present. Signs of air embolism are identified and treated. (See 'Pericardiotomy' above and 'Hemorrhage control and repair' above and 'Identifying and evacuating air embolism' above.)

•The aorta is cross-clamped, which facilitates filling of the heart and ongoing fluid resuscitation. (See 'Aortic cross-clamping' above.)

•Open cardiac massage is initiated once the heart has filled sufficiently. (See 'Open cardiac massage and internal defibrillation' above.)

•The thoracic structures are systematically explored, looking for any active bleeding or hematoma formation that might suggest underlying injury. (See 'Hemorrhage control and repair' above.)

•If the patient regains vital signs, he or she is transferred to the operating room for definitive management of the identified injuries by a multidisciplinary trauma team. (See 'Definitive management' above.)

●Survival – Survival following resuscitative thoracotomy is consistently better in patients with penetrating thoracic injury compared with those who have blunt injury. Survival also depends upon the clinical status of the patient prior to arrival in the emergency department, approaching zero percent for those who do not have signs of life or vital signs in the field. Of those who survive, permanent neurologic deficits occur in 7 to 18 percent of patients. (See 'Morbidity and mortality' above.)