View source for Medicine:Resuscitative thoracotomy

{{Short description|Type of thoracotomy}}
{{Infobox medical intervention
| name         = Resuscitative thoracotomy
| image        = File:Emergency Thoracotomy.png
| caption      = A left-sided thoracotomy incision, allowing direct access to the pericardium, [[Biology:Heart|heart]], left hilum and left [[Medicine:Lung|lung]].
| alt          =
| ICD10        =
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| synonyms  =  Emergency department thoracotomy
| MedlinePlus  =
| eMedicine    = 82584
}}
A '''resuscitative thoracotomy''' (sometimes referred to as an '''emergency department thoracotomy (EDT)''', '''trauma thoracotomy''' or, colloquially, as "'''cracking the chest'''") is a thoracotomy performed to aid in the [[Medicine:Resuscitation|resuscitation]] of a [[Medicine:Major trauma|major trauma]] patient who has sustained severe [[Medicine:Chest injury|thoracic]] or [[Medicine:Abdominal trauma|abdominal trauma]].<ref>{{cite video | url=https://www.youtube.com/watch?v=naUT46aLIDM | title=Resuscitative Thoracotomy | publisher=The Division of Trauma/Surgical Critical Care/Burns is part of the Department of Surgery, UC San Diego Health System | people=November 27, 2012 | location=San Diego}}</ref> The procedure allows immediate direct access to the thoracic cavity, permitting rescuers to control hemorrhage, relieve [[Medicine:Cardiac tamponade|cardiac tamponade]], repair or control major injuries to the heart, lungs or thoracic vasculature, and perform direct cardiac massage or [[Engineering:Defibrillation|defibrillation]]. The procedure is rarely performed and is a procedure of last resort.<ref name = "Moore_2012">{{cite book | vauthors = Feliciano DV, Mattox KL, Moore EJ |title=Trauma | edition = Seventh | location = New York |publisher=McGraw-Hill Professional |year=2012 |isbn=978-0-07-166351-9 }}</ref>{{rp|462}}<ref>{{Cite web | vauthors = Eidt JF, Foreman ML | veditors = Bulger EM, Wolfson AB, Collins KA |title=Resuscitative thoracotomy: Technique |url=https://www.uptodate.com/contents/resuscitative-thoracotomy-technique |access-date=2023-07-16 |website=www.uptodate.com}}</ref>

==Indications==
A resuscitative thoracotomy is indicated when severe injuries within the thoracic cavity (such as hemorrhage) prevent the physiologic functions needed to sustain life. The injury may also affect a specific organ such as the heart, which can develop an [[Medicine:Air embolism|air embolism]] or a [[Medicine:Cardiac tamponade|cardiac tamponade]] (which prevents the heart from beating properly). The primary indication for a resuscitative thoracotomy is a patient with [[Medicine:Penetrating trauma|penetrating]] chest trauma who has entered or is about to enter [[Medicine:Cardiac arrest|cardiac arrest]].<ref>{{cite journal | vauthors = Paulich S, Lockey D | title = Resuscitative thoracotomy | journal = BJA Education | volume = 20 | issue = 7 | pages = 242–248 | date = July 2020 | pmid = 33456957 | pmc = 7807961 | doi = 10.1016/j.bjae.2020.03.005 }}</ref> Other indications for the use of this procedure include the appearance of blood from a [[Medicine:Chest tube|chest tube]] that returns more than 1500&nbsp;mL of blood during the first hour of placement, or ≥200&nbsp;mL of blood per hour two to four hours after placement.<ref>{{cite journal | vauthors = Bertoglio P, Guerrera F, Viti A, Terzi AC, Ruffini E, Lyberis P, Filosso PL | title = Chest drain and thoracotomy for chest trauma | journal = Journal of Thoracic Disease | volume = 11 | issue = Suppl 2 | pages = S186–S191 | date = February 2019 | pmid = 30906584 | pmc = 6389558 | doi = 10.21037/jtd.2019.01.53 | doi-access = free }}</ref>

For resuscitative thoracotomy to be indicated, signs of life must also be present, including [[Medicine:Electrical conduction system of the heart|cardiac electrical activity]] and a systolic blood pressure >70&nbsp;mm Hg.<ref name = "Moore_2012" />{{rp|462}}<ref name="biffl">{{cite journal | vauthors = Biffl WL, Moore EE | title=Resuscitative thoracotomy | journal=Operative Techniques in General Surgery |date=September 2000 | volume=2 | issue=3 | pages=168–175 | doi=10.1053/otgn.2000.17741| s2cid=240245430 }}</ref> In [[Medicine:Blunt trauma|blunt trauma]], if signs of life, such as eye dilatation, are found en route to the hospital by first responders, but not found when the patient arrives, then further resuscitative interventions are contraindicated; however; when first responders find signs of life (respiratory or motor effort, cardiac electrical activity, blood pressure, or pupillary activity)<ref>{{cite journal | vauthors = Cothren CC, Moore EE | title = Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes | journal = World Journal of Emergency Surgery | volume = 1 | issue = 1 | pages = 4 | date = 24 March 2006 | pmid = 16759407 | pmc = 1459269 | doi = 10.1186/1749-7922-1-4 | doi-access = free }}</ref> and cardiopulmonary resuscitation time is under 15 minutes, the procedure is indicated.<ref>{{cite book | vauthors = Peitzman AB, Sabom M, Yealy DM, Fabian TC |title=The trauma manual |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2002 |isbn=0-7817-2641-7 | page = 227 }}</ref>

The use of a [[Medicine:Focused assessment with sonography for trauma|focused assessment with sonography for trauma]] may be performed to determine the need of the procedure by finding free floating fluid in the thoracic cavity.<ref name="Seamon">{{cite journal | vauthors = Seamon MJ, Chovanes J, Fox N, Green R, Manis G, Tsiotsias G, Warta M, Ross SE | display-authors = 6 | title = The use of emergency department thoracotomy for traumatic cardiopulmonary arrest | journal = Injury | volume = 43 | issue = 9 | pages = 1355–1361 | date = September 2012 | pmid = 22560130 | doi = 10.1016/j.injury.2012.04.011 }}</ref>

==Technique==
A left anterolateral thoracotomy is the common method of opening the chest, as it provides rapid access, can be easily extended into the right hemithorax, and provides access to most of the important anatomical structures during resuscitation including the aorta.<ref name="hunt"/> First an incision is made along the fourth or fifth intercostal space (between the ribs), intercostal muscles and the parietal pleura are divided, and then the ribs are retracted to provide visualization.<ref name="biffl"/> When the incision covers both the right and left hemithoraxes it is referred to as a "clamshell" thoracotomy. The clamshell thoracotomy is used when there is a right sided pulmonary or [[Medicine:Vascular|vascular]] injury, or when greater access or visualization is desired.<ref name = "Moore_2012" />{{rp|242}}

==Recovery==
Usually those who undergo resuscitative thoracotomy do not recover—only 10% of those receiving it after sustaining a blunt injury, and 15–30% of those with penetrating trauma survive.<ref name="hunt">{{cite journal | vauthors = Hunt PA, Greaves I, Owens WA | title = Emergency thoracotomy in thoracic trauma-a review | journal = Injury | volume = 37 | issue = 1 | pages = 1–19 | date = January 2006 | pmid = 16410079 | doi = 10.1016/j.injury.2005.02.014 }}</ref><ref>{{cite book | title=ATLS, Advanced Trauma Life Support for Doctors | publisher=American College of Surgeons | author=American College of Surgeons. Committee on Trauma | year=2008 | location=Chicago, IL | isbn=9781880696316 | page = 92 }}</ref><ref name = "Moore_2012" />{{rp|240}} Patients with thoracic stab wounds and patients who arrive at the emergency department with signs of life are associatated with the highest rates of survival. Patients with [[Medicine:Polytrauma|polytrauma]] and patients who present without signs of life are associated with the lowest rates of survival.<ref name="pmid10703853">{{cite journal | vauthors = Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N | title = Survival after emergency department thoracotomy: review of published data from the past 25 years | journal = Journal of the American College of Surgeons | volume = 190 | issue = 3 | pages = 288–98 | date = March 2000 | pmid = 10703853 | doi = 10.1016/s1072-7515(99)00233-1 | url = https://www.ncbi.nlm.nih.gov/books/NBK68160/ }}</ref>

==History==
The procedure was first utilized during the late 1800s by Schiff in conjunction with open cardiac massage. Shortly after it was also used by Block to treat heart lacerations, and the first suture repair performed in 1900.<ref name="trauma.org">{{cite web | url=http://www.trauma.org/archive/thoracic/EDTintro.html | title=Emergency Department Thoracotomy | publisher=Trauma.org | date=6 June 2001 | access-date=January 1, 2013 | vauthors = Brohi K }}</ref> Before external [[Engineering:Defibrillation|defibrillation]] and cardiopulmonary resuscitation came in the 1960s, emergency thoracotomy was the preferred way to treat cardiac arrest.<ref name = "Moore_2012" />{{rp|236}}

== References ==
{{Reflist|2}}

{{Trauma |state=autocollapse}}

[[Category:Cardiac surgery]]

{{Sourceattribution|Resuscitative thoracotomy}}