Residency · Residency · Cardiothoracic Surgery
Thoracic Trauma: Emergency Department Thoracotomy and Damage Control
Introduction
Thoracic injuries account for approximately 25% of all trauma deaths, and many of these are potentially survivable with rapid intervention. Emergency department thoracotomy (EDT) is a resuscitative procedure performed in extremis for patients with penetrating or blunt thoracic trauma. Damage control thoracic surgery applies abbreviated surgical strategies to control hemorrhage and contamination while deferring definitive repair. Understanding the indications, techniques, and outcomes of these interventions is critical for the cardiothoracic surgeon.
Emergency Department Thoracotomy
Indications
| Injury Mechanism | Survival After EDT | Best Indication | Contraindications |
|---|---|---|---|
| Penetrating cardiac (stab wound) | Up to 35% (with tamponade) | Tamponade + PEA; witnessed loss of vitals | >15 min CPR without signs of life |
| Penetrating thoracic (GSW) | 5-10% | Signs of life present; short downtime | Prolonged CPR without response |
| Penetrating thoracic (stab) | 10-15% | Loss of vitals in ED or field | No signs of life with prolonged transport |
| Blunt thoracic | 1-2% | Witnessed arrest; short transport only | No pulse, no rhythm, prolonged CPR |
| Abdominal hemorrhage | Variable | Aortic cross-clamp to bridge to laparotomy | TBI incompatible with life |
EDT has its best survival outcomes in penetrating thoracic trauma with loss of vital signs in the field or emergency department, achieving approximately 10-15% survival for stab wounds and 5-10% for gunshot wounds with signs of life. Penetrating cardiac trauma with cardiac tamponade and pulseless electrical activity or asystole is a prime indication. Massive hemothorax with hemodynamic collapse unresponsive to resuscitation also warrants EDT. In blunt thoracic trauma, outcomes are much poorer at approximately 1-2% survival, and EDT should be considered only with witnessed cardiac arrest and short transport time. For abdominal trauma with hemorrhagic shock, EDT provides aortic cross-clamping to maintain cerebral and coronary perfusion while laparotomy is prepared.
Contraindications
EDT is contraindicated in blunt trauma with no signs of life in the field and prolonged transport exceeding 10-15 minutes of CPR without response. Penetrating trauma with more than 15 minutes of CPR without signs of life, traumatic brain injury incompatible with life, and multiple blunt trauma with no pulse and no organized cardiac rhythm are also contraindications.
Technique
The procedure uses a left anterolateral thoracotomy in the 5th intercostal space, extending from the sternum to the posterior axillary line. The patient is positioned supine with the left arm abducted. The incision proceeds through skin, subcutaneous tissue, and intercostal muscles to enter the pleural space. Extension across the sternum as a clamshell thoracotomy (bilateral anterolateral with transverse sternotomy) provides bilateral access or addresses right-sided injuries.
Objectives of EDT (Performed in Sequence)
The first objective is to release cardiac tamponade by opening the pericardium anterior and parallel to the phrenic nerve and evacuating blood and clot. The second is to control cardiac hemorrhage using digital pressure, skin staples, or horizontal mattress sutures for cardiac lacerations, with Foley catheter balloon tamponade for larger defects. Third, the descending thoracic aorta is cross-clamped posterior and to the left to provide afterload support and redirect blood flow to the heart and brain. Fourth, pulmonary hemorrhage is controlled by hilum clamping or pulmonary hilar twist for uncontrolled bleeding. Fifth, internal cardiac massage using open bimanual technique is performed, which is more effective than closed-chest CPR. Sixth, air embolism is managed by clamping the pulmonary hilum, aspirating air from the ventricle, and placing the patient in Trendelenburg position.
Damage Control Thoracic Surgery
Principles
Damage control thoracic surgery employs abbreviated surgical techniques to control life-threatening hemorrhage and contamination. Physiologic endpoints guide decision-making, centered on the lethal triad of hypothermia (below 35 degrees C), acidosis (pH below 7.2), and coagulopathy. Definitive repair is deferred until after ICU resuscitation, typically 24-48 hours later. The staged approach consists of a damage control operation, ICU resuscitation, and then a planned return to the operating room.
Hemorrhage Control Techniques
Lung tractotomy involves stapled division of the pulmonary parenchyma overlying a missile track to expose and individually ligate bleeding vessels and bronchi. Pulmonary hilar clamping provides temporary vascular control for massive pulmonary hemorrhage. Non-anatomic stapled lung resection allows rapid control of peripheral parenchymal injuries. Damage control pneumonectomy is a last resort for unreconstructable hilar injuries and carries mortality exceeding 50%. Thoracic packing with laparotomy pads addresses diffuse chest wall or mediastinal bleeding, followed by temporary chest closure.
Temporary Chest Closure
Rapid closure options include towel clip closure or running skin-only suture. Negative pressure wound therapy (VAC) facilitates delayed closure. Chest tubes are left in place for drainage, and a return to the operating room is planned within 24-48 hours for washout, pack removal, and definitive repair or closure.
Specific Injury Patterns
Cardiac Injuries
In penetrating cardiac injury, the right ventricle is the most commonly injured chamber due to its anterior position, and survival is best with stab wounds and tamponade physiology. Repair uses interrupted horizontal mattress sutures with pledgets using non-absorbable 3-0 or 4-0 polypropylene suture, with care to avoid coronary arteries. Atrial injuries may be repaired with a running suture or a partial-occlusion Satinsky clamp. Injuries near coronary arteries require sutures placed deep to the coronary artery to avoid ligation.
Great Vessel Injuries
Aortic injuries are covered in detail in Lecture 70. Innominate, subclavian, and carotid injuries require operative repair or endovascular stenting depending on location and hemodynamic stability. Pulmonary artery and vein injuries present challenging exposure and may require cardiopulmonary bypass for complex repairs.
Tracheobronchial Injuries
Tracheobronchial injuries are rare but life-threatening and should be suspected with massive air leak, subcutaneous emphysema, or pneumomediastinum. Bronchoscopy is the gold standard for diagnosis. Repair involves primary closure with absorbable sutures through a thoracotomy, with a pedicled tissue flap such as intercostal muscle to buttress the repair.
Esophageal Injuries
Esophageal injuries are rare in trauma and more common with penetrating neck or transmediastinal gunshot wounds. Diagnosis relies on esophagoscopy and contrast esophagography, which have a combined sensitivity exceeding 95%. Primary repair within 24 hours uses two-layer closure with drainage and tissue flap reinforcement. Delayed diagnosis beyond 24 hours necessitates wide drainage, diversion, and delayed repair, with significantly higher morbidity.
Massive Hemothorax Management
Massive hemothorax is defined as more than 1500 mL of blood immediately evacuated from the chest tube or more than 200 mL/hr for 2-4 consecutive hours. Indications for thoracotomy include initial output exceeding 1500 mL, ongoing output exceeding 200 mL/hr for 2-4 hours, hemodynamic instability despite resuscitation, or retained hemothorax requiring evacuation. VATS evacuation for retained hemothorax within 3-7 days reduces empyema risk.
Outcomes
EDT survival for penetrating cardiac injuries with tamponade reaches up to 35% for stab wounds. EDT survival for penetrating thoracic injuries with signs of life is 10-15%. For blunt trauma, EDT survival is less than 2%, and most survivors have severe neurological deficits. Damage control thoracic surgery has improved survival for complex multi-system trauma patients.
Key Clinical Pearls
EDT has the best outcomes in penetrating cardiac injuries with tamponade physiology and short down-time, while blunt trauma EDT has dismal outcomes and should be performed only with strict criteria. The pericardium must be opened anterior to the phrenic nerve during EDT to avoid iatrogenic phrenic nerve transection. Lung tractotomy is a key damage control technique that exposes deep parenchymal bleeding vessels for direct control while preserving lung tissue. The lethal triad of hypothermia, acidosis, and coagulopathy should trigger the shift from definitive repair to a damage control strategy. Autotransfusion of shed hemothorax blood is a critical adjunct in the resuscitation of thoracic trauma patients.
References
- Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the EAST. Journal of Trauma and Acute Care Surgery. 2015;79(1):159-173.
- Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. Journal of Trauma and Acute Care Surgery. 2012;73(6):1359-1363.
- Garcia A, Martinez J, Rodriguez J, et al. Damage control techniques in thoracic trauma. European Journal of Trauma and Emergency Surgery. 2020;46(4):719-726.
- Mollberg NM, Tabak BD, Glogowski MM, et al. Emergency department thoracotomy for blunt thoracic trauma: an evidence-based review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2019;27:73.