World J Surg DOI 10.1007/s00268-014-2829-z
SURGICAL SYMPOSIUM CONTRIBUTION
Resuscitative Thoracotomy in Penetrating Trauma Lindsay M. Fairfax • Li Hsee • Ian D. Civil
Ó Socie´te´ Internationale de Chirurgie 2014
Abstract: The resuscitative thoracotomy (RT) is an important procedure in the management of penetrating trauma. As it is performed only in patients with peri-arrest physiology or overt cardiac arrest, survival is low. Experience is also quite variable depending on volume of penetrating trauma in a particular region. Survival ranges from 0 % to as high as 89 % depending on patient selection, available resources, and location of RT (operating or emergency rooms). In this article, published guidelines are reviewed as well as outcomes. Technical considerations of RT and well as proper training, personnel, and location are also discussed.
Introduction Performing an emergent resuscitative thoracotomy can be a dramatic and life-saving procedure. As the procedure is only performed on patients with cardiac arrest or peri-arrest physiology, the survival rate is low. In addition, experience varies widely depending on the amount of penetrating trauma in a particular region. This article will review the literature surrounding resuscitative thoracotomy as well as discuss important points such as training and scope of practice. History Emergency resuscitative thoracotomy (ERT) is an important life-saving procedure; however, specific indications are often the subject of debate. From the 1960s to the present day, considerable world-wide experience has been accumulated in ERT. Boyd published a meta-analysis in the 1992 with a total of 2,294 patients and 14 % survival for penetrating trauma . By the end of the twentieth L. M. Fairfax L. Hsee I. D. Civil (&) Auckland City Hospital Trauma Services, Park Road Grafton, Auckland 1023, New Zealand e-mail: [email protected]
century, three large scale review papers were produced, all yielding similar results. Branney and colleagues in Denver reviewed 868 cases performed at their institution from 1974 to 1997. Survival was 7 % for penetrating trauma, with 14 % for stab wounds and only 4 % for gun shot wounds. Regarding timing of loss of vital signs, for penetrating trauma patients survival was 3 % if vital signs not present at the scene, 16 % if lost in transit, and 24 % if still present upon arrival . Rhee et al. published a 25-year review of ERT performed through 1998. This paper encompassed 24 studies with 4,620 cases. The overall survival was 7.4 %, with highest survival in patients with penetrating trauma (8.8 %), specifically stab wounds (16.8 %). Patients with signs of life on arrival had an overall survival rate of 11.5 % compared to only 1.2 % if no signs of life at the scene . The American College of Surgeons Committee on Trauma (ACSCOT) guidelines were produced from a review of 7035 cases from 1966 to 1999, reporting an overall survival of 11.2 % for penetrating trauma and only 1.6 % for blunt injuries. This led to the recommendation of ERT for penetrating trauma with signs of life and short transport times, and for blunt trauma only in cases of witnessed arrest . These three papers have influenced a few common approaches, summarized well by Hall and colleagues in
World J Surg Table 1 Comparison of guidelines regarding indications for ERT American College of Surgeons Committee on Trauma, 2001 
Cothren and Moore, 2006 
Western Trauma Association, 2012 
Blunt trauma: limited to patients with witnessed arrest at the trauma center
Blunt trauma: \5 min of CPR
Blunt trauma: \10 min of CPR
Penetrating trauma: patients with a short scene and transport time, with witnessed signs of life*
Penetrating trauma: \15 min CPR
Penetrating trauma: \15 min CPR
Abdominal trauma: ‘‘judicious selection of patient’’
Also used in patients with SBP \ 60 with suspected cardiac tamponade, air embolism, or hemorrhage (thoracic, abdominal, extremity or cervical)
Not recommended if no cardiac activity and no tamponade
* Signs of life defined as pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, and cardiac electrical activity
2005 . ERT is markedly more successful in penetrating trauma, specifically thoracic trauma from a stab wound. ERT should be considered in gun shot wounds, abdominal, or multiple site penetrating injuries, but may have less success. In addition, most universally DO NOT recommend ERT for those who are found in the field to have no signs of life, and DO recommend the procedure in those who have witnessed arrest in the emergency department. Those penetrating trauma patients who lose vital signs en route to the hospital represent more of a gray area of optimal management. Cothren et al. published recommendations based on their single institution data, encompassing 959 patients . The Western Trauma Association reviewed the publish data and, combined with expert opinion, published further guidelines in 2012 . The prominent guidelines are summarized in Table 1. Indications and timing The majority of studies relating to ERT have been retrospective and/or single institution in nature. This has produced a wide range of survival rates over the past 14 years, detailed in Table 2. Common factors found to effect survival include prehospital signs of life, injury mechanism and anatomic location, as well as cardiac activity. The Western Trauma Association (WTA) produced a prospective multicenter review of ERT, with 56 survivors in the 6 year time period. There were no survivors of penetrating trauma with CPR [ 15 min and no survivors who presented in asystole without cardiac tamponade . In 2012, WTA then produced a comprehensive annotated algorithm regarding performance of ERT, shown in Fig. 1. To summarize the algorithm, ERT should be considered for patients undergoing CPR \ 15 min with penetrating injuries. In those found to have no cardiac activity without tamponade, efforts should be terminated. For patients with cardiac activity and/or tamponade to release, efforts should be made to control hemorrhage.
This may include cardiac repair, hilar cross-clamping if pulmonary injuries, and consideration of aortic cross-clamp to redistribute blood flow and control distal hemorrhage. Once these maneuvers are performed, viability is assessed to determine utility of formal operative intervention . While penetrating cardiac injuries have been shown to have the most success after ERT, this is not universal. Limiting their study to only this injury pattern, Molina et al. demonstrated a survival rate of only 8 %. However, this was in an urban trauma center in which gunshot wounds predominated. Stab wound survival was much higher at 33 % . In Philadelphia, Seamon and colleagues reviewed a series of 283 ERTs for penetrating trauma, 250 of which were from gunshot wounds. Survival was 11 times more likely for stab wound victims. Only 1 of 133 patients with multiple gunshot injuries survived, suggesting possible futility in this population . As in many aspects of trauma care, the experiences in Iraq and Afghanistan have contributed new literature on the subject of ERT in penetrating trauma. In contrast to civilian gunshot wound data, military groups have higher ERT success rates. A series of 110 patients from 2003 to 2007 had a survival rate of 12 % . A more recent study looking at patients from 2006 to 2011 found a markedly higher survival rate of 21.5 %. However, distribution of success still depends on the location of the patient when vital signs were lost. This series had a success rate of 0 % for vital signs lost in the field, 10.3 % when they were lost en route and 42.3 % at the field hospital . The United States military guidelines recommend ERT only if this can be performed within 10 min of loss of vital signs. The United Kingdom guidelines limit the time to 5 min . In 2011, Mollberg et al. showed that the guideline of ERT only for penetrating trauma with CPR \ 15 min was a good predictor of survival. Looking at 120 ERTs for penetrating trauma, the management of 70 patients fell within the guidelines and 50 outside of guidelines. The first
World J Surg Table 2 Summary of outcomes for ERT in penetrating trauma since 2000 First author
Survival to discharge
9 (18 %)
Single surgeon series. Implementation of a protocol in 2002 improved survival as ERT was no longer performed on patients with no signs of life
3 (3 %)
1 (8 %)
Concerned that inappropriate ERT resulted in no survivors, and costs including financial, blood products, and exposure to blood borne pathogens Additional survivor of the procedure died in ICU due to lack of blood products available. No patients transported by EMS.
Seamon [10, 39, 40]
7 (70 %)
RT performed in emergency department
25 (89 %)
RT performed in operating room
8 (8 %)
Stab wound (SW), prehospital transport by police, higher GCS, sinus tachycardia, and vital signs in the emergency department associated with survival
15 (5 %)
Multiple cardiac great vessel gunshot wounds (GSW) are essentially unsalvageable. 250 patients suffered GSW, with 3 % survival in this population and 24 % for SW.
23 (13 %)
Higher survival if brought in by police, supporting ‘‘scoop and run’’
8 (16 %)
All patients with hemorrhagic shock from abdominal injuries, but underwent prelaparotomy ERT for vascular control
37 (8 %)
Penetrating vs. blunt ERT not specified; 98 % of survivors had penetrating trauma. Long-term follow-up of survivors showed majority had no impairment
0 (0 %)
High volume trauma center, but low volume ERT
10 (37 %)
Prospective & retrospective
12 (13 %)
Sharp contrast to other Scandanavian studies, recommended a ‘‘liberal attitude’’ toward ERT given high survival rate All survivors neurologically normal. Recommend ERT following penetrating trauma from combat injuries when signs of life present.
WTA Study Group. 30 SW and 21GSW, only patients who survived ERT were reported. ERT considered futile when prehospital CPR exceeds 15 min and/or asystole is the presenting rhythm with no cardiac tamponade
7 (6 %)
No survivors in the group of ERT performed outside the ACSCOT guidelines
11 (19 %)
3.5 times increase in mortality and 5 times decrease in adherence to guidelines when performed by emergency physicians compared to surgeons
3 (50 %)
Small sample size, all patients with vitals signs in the emergency department
4 (2 %)
6 nonsurvivors were potential organ donors
8 (8 %)
All patients with transmediastinal GSW
14 (22 %)
Combat injuries. No patients who lost vitals in the field survived.
135 (9.8 %)
Range 0–70 %
* Not included in total count
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Fig. 1 Western Trauma Association ERT Algorithm 
group had a survival of 8.7 %, all neurologically intact. In the latter group, there was only one survivor, who was neurologically compromised . Despite the existence of evidence-based guidelines, what happens in practice often differs widely. In 2001, Miglietta et al. surveyed members of Eastern Association for the Surgery of Trauma (EAST) and American Association for the Surgery of Trauma (AAST) to determine the situation in which they would perform ERT. In contrast to the guidelines, 29 % reported they would perform ERT for blunt traumatic arrest greater than 5 min and 48 % for penetrating trauma with arrest in the field. 83 % would perform ERT for penetrating abdominal trauma with arrest less than 5 min, and 58 % for penetrating extremity trauma .
Risk versus benefit The factors to weigh when considering an ERT for penetrating trauma include not only benefit to the patient, but also risk to the health care providers, and utilization of resources. Passos et al. examined 123 ERTs over 17 years, divided into 60 appropriate (penetrating trauma, \15 min since arrest and signs of life or blunt trauma with arrest in the emergency department) and 63 inappropriate cases. The
former group had a 5 % survival rate and the latter 0 %. There were no cases of organ donation. The rate of needle stick injury was 6 % in the inappropriate cases with 335 units of blood products used, 6 trips to the operating room, and an average of 8 ICU days. The authors argue this is a high societal cost for a futile procedure. The appropriate group, however, had only 3 survivors to discharge with 21 trips to room and 850 units of blood products used . Regarding occupational exposure during ERT, Sikka et al. created a model for likelihood of both exposure and seroconversion. This resulted in a 0.004 % chance for HIV seroconversion and 0.27 % chance of hepatitis C seroconversion for the health care provider. This added a cost of $1377 to each ERT, not to mention the social and emotional cost of such infection . In addition, this study used literature estimates of overall patient prevalence of these diseases. Penetrating trauma patients may in fact have a higher incidence of HIV and Hepatitis C. Several studies have examined the financial cost of ERT. Esposito et al. found hospital charges nearly $60000 greater than that reimbursed for ERT in 1991 . Mazzorana and colleagues in 1994 calculated an overall cost of $93175 per survivor, but this number dropped to $20137 when only considering patients with penetrating trauma presenting with signs of life . Other groups found much
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higher numbers from $100800 to $109025 per survivor [1, 19]. Branney et al. provided a detailed cost-benefit analysis considering factors such as care of the neurologically impaired patient to age 65 as well as survivors contribution to society, finding a 1.8:1 benefit in favor of ERT . In 2007, Brown performed an updated analysis including the risk to providers and the expense of caring for neurologically devastated patients. For penetrating trauma, the procedure was deemed cost-effective at $16125 per quality-adjusted life year . Those arguing futility in ERT point to questionable neurologic status after a period of traumatic arrest. Contradicting this, however, Keller et al. in a mean 61 month follow-up of 21 ERT, survivors showed 75 % with normal cognition and only 13 % with severe impairment. 81 % were freely mobile and only 25 % suffered PTSD, all in line with other populations of major trauma patients . In Rhee’s meta-analysis in 2000, 92 % of survivors had normal neurologic function . Another potential societal benefit of ERT is organ donation. Schnuriger et al. published their series of ERT in 2010, with 1.9 % survival and 4.2 % of patients surviving to possible organ donation, of which 3 of 11 patients were able to donate. Of note, at this center, all trauma patients arriving without a pulse received ERT, regardless of mechanism of injury. Of the organ donors, two suffered blunt trauma and one penetrating . When performed for proper indications, ERT can be a cost-effective procedure and result in neurologically intact survivors as well as possible benefits of organ donation. When making the emergent decision on whether or not to perform ERT, it is difficult to put a price on any possible life saved.
Technical considerations Objectives that may be achieved during ERT include release of pericardial tamponade, control of cardiac or intrathoracic hemorrhage, evacuation of air embolus, aortic cross-clamping, and open cardiac massage . The most successful outcomes occur in patients with isolated cardiac injuries and pericardial tamponade as the primary physiologic derangement [3, 23]. Practical considerations during ERT include having adequate equipment and exposure. The incision is carried from the sternum along the 4th or 5th intercostal space below the nipple/inframammary fold, curving along the rib cage toward the axilla. This is carried through the intercostal muscles with the knife to enter the chest. The rib spreader is placed to enlarge the cavity, ensuring the handle is on the left side of the patient in the event the thoracotomy requires extension to the right chest. The pericardium
Fig. 2 Cardiac tamponade as viewed immediately upon entering the thoracic cavity. 180 9 135 mm (180 9 180 DPI)
is incised with scissors (with the scalpel if it is quite tense), in a longitudinal fashion to avoid the phrenic nerve. Figure 2 demonstrates a tense pericardium upon entrance into the chest. Clot is evacuated and the heart is quickly evaluated for injury and any signs of contractility. If there is concern for right-sided pulmonary injury, or to facilitate better exposure to the heart a great vessels, the thoracotomy may be extended across in a ‘‘clamshell’’ fashion. The sternum is divided using heavy scissors or a gigli saw if needed, and a thoracotomy is performed on the right using the same landmarks as on the left. Figure 3 demonstrates repair of the right atrium via a clamshell incision. Ventricular wounds are controlled with direct pressure, and clamps may be used for atrial injuries. On the thicker left ventricle, wounds may be temporized with a stapling device. Ventricular wounds should be repaired with 3-0 nonabsorbable suture, ensuring the coronary vessels are not incorporated in the repair. Once there is adequate temporary control of bleeding, open cardiac massage, internal defibrillation, and pharmacologic treatment of dysrhythmias are used to restore output prior to definitive repair. If hypotension is still present after the above, or if no injuries to the heart are found, the thoracic aorta may be cross-clamped to increase coronary and cerebral perfusion. The aorta is located with blunt dissection, and the aid of a nasogastric tube if present in the esophagus which will lie anterior. The aorta may be digitally compressed against the spine or clamp applied. If air embolus is suspected immediate pulmonary hilar cross-clamping is performed on entry into the chest. Following this, air may be aspirated from the chambers of the heart and aorta, with the patient in trendelenburg to trap air at the apices. On entering the chest, if there is no evidence of cardiac injury, other intrathoracic injuries are sought and clamped as able for damage control. This may include
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Fig. 3 A clamshell thoracotomy has been performed to provide access to the right atrial injury. 180 9 135 mm (180 9 180 DPI)
extending to a clamshell incision to evaluate the right chest. As previously noted, the survival rate is much lower for non-cardiac injuries found on ERT.
Personnel and location Initially, the Emergency Department was inevitably the location for a resuscitative thoracotomy for a patient with arrest or peri-arrest physiology. However, improved inhospital systems of care have meant that ERT is not necessarily performed there. With patients who present in cardiac arrest or lose vital signs on arrival, the thoracotomy, if indicated, will usually still take place in the Emergency Department (EDT). However, in some hospitals, it is possible to transport the patient very rapidly to the operating room and undertake the resuscitative thoracotomy in more controlled circumstances (ORT). Lustenberger, et al. showed a higher survival rating for ORT compared to EDT (89 vs. 70 % for penetrating injuries). ORT was not performed unless the patient had vitals signs in the emergency department, therefore ORT patients had lower severity of injury . Expanding the scope even farther, ERT has been undertaken in the prehospital environment. Although this environment is the most challenging of all, with good equipment, good training ,and the ability to rapidly transport a responder to hospital, some successes have been recorded . Survival following thoracotomy in the operating room as opposed to the emergency room would be expected to be higher, as these patients were able to survive long enough for transport to the operating room. To eliminate this selection bias, Karmy-Jones et al. compared ERT performed in an emergency department resuscitation room
versus an adjacent specialized resuscitation room, with a setup similar to the operating room. Patients were brought directly to this room, eliminating delay or selection bias. For patients suffering gunshot wounds, thoracotomy performed in such a room rather than in the emergency department was an independent predictor for survival. There was no such difference for stab wounds, which follows with the improved success of treating cardiac tamponade from a single ventricle wound, regardless of location and personnel . Another topic of debate is who is best qualified to perform ERT. There is little doubt that surgery is best performed by those who do it most often, specifically surgeons regularly involved in time-critical decision-making who undertake thoracic surgery. Trauma surgeons, general surgeons, and thoracic surgeons all fall into this category. However, in many parts of the world these surgeons are unlikely to be in the ED when a patient who might benefit from ERT arrives. Even a few minutes delay in undertaking ERT will make the procedure futile. Therefore, some argue that emergency physicians, who are likely to be in the ED when a suitable patient presents, should be trained to perform the procedure independently . Mollberg et al. suggested a possible survival advantage when cardiothoracic surgeons perform the procedure. (37.5 vs. 5.9 %, p = 0.039) . However, these thoracotomies all occurred in the operating room. Jurkovich et al. suggested a similar advantage with trauma surgeons performing ORT having a survival rate of 38 % for penetrating trauma, suggesting it is location rather than additional thoracic training that increases survival . At the other end of the spectrum is prehospital ERT. In the United Kingdom, on-scene thoracotomy for penetrating trauma is recommended if transport time will be greater than 10 min after loss of pulses. The on-scene doctor is a specialist surgical trainee, PGY5-10, of anesthesia, emergency medicine, or surgery. Of 39 patients who met these criteria over 6 years, the survival rate was 10 %, with 3 of the 4 survivors neurologically intact. The only survivors were those with cardiac tamponade due to single ventricle injury . In a second series of 71 such patients, there were 13 (18 %) survivors, 11 of whom were neurologically intact . Once again, the thoracotomies were performed by mostly non-surgical trainees. This data supports the idea that emergency physicians should be trained to perform ERT. The counter argument involves what is to be done if return of spontaneous circulation is achieved? In a system such as London HEMS, survivors are able to be promptly transported to a waiting surgeon for room. However, in a system in which an emergency physician does not have proper surgical back-up, performing ERT would not be appropriate. Unfortunately, systems such as London HEMS and the fully stocked and staffed resuscitation rooms described by
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Karmy-Jones are not available at the majority of hospitals. In more austere environments, ERT should be performed more selectively for those patients who have a chance at survival—specifically penetrating thoracic trauma with recent loss of vital signs. It is also apparent that injuries from stab wounds are far more likely to be survivable after ERT with a more lenient combination of location and personnel compared to gunshot wounds.
traumatic cardiopulmonary arrest when compared to adults, outcomes are worse for the trauma population. This is attributed to children requiring a more severe injury to cause cardiopulmonary collapse . However, the spectrum of injury is wide, and children suffering penetrating trauma to the thorax should proceed with the same indications as adults until further studies may be performed. Future directions
Training As ERT is relatively rarely performed, it is difficult to ensure adequate training. This becomes of particular concern when discussing expanding the performance of ERT to non-surgeons, who are not trained in any elective thoracic surgery. For the prehospital physicians performing ERT, training is provided prior to deployment in the field and involves a simplified surgery kit and instructions. All patients receive a bilateral 5th interspace incision, and the kit is comprised of a scalpel, large scissors, silk suture, and forceps. In this circumstance, the doctors are only expected to save patients with cardiac tamponade as the cause of arrest and a single ventricle injury. Definitive repair is performed on arrival to the trauma center . While performing a non-indicated ERT simply for ‘‘teaching purposes’’ is inappropriate, the development of simulation centers may fill this void. Simulation has been shown to be effective in many areas of surgical education including trauma [29, 30]. In 1996 Chapman and colleagues in Sacramento showed a pig model to be superior to computer and paper models for thoracotomy assessment among emergency medicine residents . However, as simulation techniques have improved, in 2009 Carter et al. reported a trial of simulation training for open lobectomy. The student volunteers showed significant improvements in subjective and objective measures . With work hour restrictions in place across the globe, trainees have less opportunity for exposure to relatively rare procedures such as ERT. In addition, North American trauma populations have a much higher proportion of penetrating injuries seen compared to those in Europe and Australasia. However, a time-critical response such as ERT does not afford the luxury of on-the-job-training. For this reason, increases in simulation for learning and assessment as an integral part of trauma training have been called for . Special population: pediatrics Trauma is the leading cause of death for patients 1–21 years of age. Therefore, several groups including the ACSCOT recently reviewed traumatic out-of-hospital pediatric arrests. While children fare better after non-
Given the difficulties and risks associated with ERT, and relatively low survival rate, novel ways to treat penetrating thoracic trauma have been sought. One such concept is resuscitative endovascular balloon aortic occlusion (REBOA) in place of the aortic cross-clamp. White et al. investigated this technique in a porcine model of hemorrhagic shock, showing improved physiologic response in the balloon occlusion group . Brenner et al. published a series of 6 patients undergoing REBOA for hemorrhagic end stage shock, 2 of whom had suffered penetrating trauma. All patients had signs of life, and there was an improvement in blood pressure and no hemorrhage-related deaths . This technique requires further study and training, however, may be a promising alternative, particularly in non-cardiac injuries.
Summary ERT is clearly indicated in cases of penetrating thoracic trauma and witnessed arrest in the emergency department. It is not indicated in patients with no signs of life at the scene. Patients who lose vital signs en route must be decided upon based on signs of life that were present and length of time of CPR. ERT is most successful for cardiac tamponade caused by a single cardiac wound. More complex injuries, as often occur with gunshot wounds, have lower success rates, and require treatment by more experienced personnel. When considering ERT, the risks to healthcare workers as well as societal costs of utilization of resources, as well as care for neurologically devastated patients, must be taken into account. Trauma surgeons should be performing the majority of ERT, as they are then able to operatively manage any injuries found. The inclusion of a cardiothoracic surgeon into the emergency response for penetrating chest trauma may allow a more comprehensive approach in the ED including median sternotomy. However, in systems in which the trauma surgeon is still en route on patient arrival, properly trained emergency physicians may be able to begin the procedure to release tamponade and/or perform aortic clamping.
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Systems with prehospital physician presence may consider incorporating on-scene thoracotomy to their algorithm for penetrating thoracic trauma with no pulse. Simulation training should be incorporated into the trauma curriculum to allow practice of this uncommon but important procedure.
Conflicts of interest
No conflicts of interest.
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