Overview of Emergency Room Thoracotomy
An emergency thoracotomy is a surgical procedure aimed at managing severe chest wounds. Its main purpose is to stabilize patients, getting direct control of injuries inside the chest, relieving pressure caused by fluid accumulation around the heart (known as pericardial tamponade), and controlling the aorta to avoid excessive bleeding. Though certain conditions require this procedure, it could significantly enhance a patient’s survival chances, allowing them to undergo other required treatments. Here, we will discuss the process and guidelines for when it should or should not be performed urgently.
Emergency thoracotomies performed in the emergency room aim to:
* Control Bleeding
* Reduce the tension around the heart (cardiac tamponade)
They are important for performing a manual heart massage, preventing air from entering the bloodstream (air embolism), gaining access to the descending aorta for stopping blood flow in emergencies (cross-clamping), and repairing injuries to the heart or lungs.
This procedure is usually done in either an emergency room or an operating room. It’s the responsibility of the emergency care provider to inform the surgeon, ensure the procedure goes smoothly, and care for the patient post-surgery.
Anatomy and Physiology of Emergency Room Thoracotomy
The thorax, or chest area, is the part of your body that is situated between your neck and a structure called the diaphragm, which helps with breathing. This area houses essential organs like your lungs and heart, and important blood vessels that distribute blood throughout the body. The major blood vessels include the aortic root, associated arch vessels, and the descending aorta which is near the spine.
Your heart is usually positioned slightly off-center, to the left side of your chest. Starting at the middle of your body, the aorta (the main and largest artery) arches to the back and the left. This aortic arch and the “great vessels” are positioned behind the manubrium, which is the broad upper part of your sternum (breastbone).
The “great vessels” are large arteries that come from the aorta. These are the brachiocephalic artery, which splits into the right common carotid (main artery of the neck) and right subclavian (main artery of the upper chest and arm), and the left subclavian and left common carotid arteries.
A protective layer called the pericardial sac surrounds your heart. Close to this sac is the left phrenic nerve, which is important for diaphragm function, and can be at risk during certain chest surgeries. The left vagus nerve, which helps control heart, lung and digestive functions, runs in front of the aortic arch near the left subclavian artery. Due to its position, this nerve is less likely to be damaged during emergency chest surgery.
The esophagus, which is the tube you swallow food through, runs in front of the spinal column and close to the aorta. The thoracic duct, an essential part of the lymphatic system which helps with immune response, runs towards the front and sides of the spine. However, it’s hard to see because of its location and transparency.
Why do People Need Emergency Room Thoracotomy
If someone has been seriously injured, specifically in the heart or the chest, a procedure called an emergency room thoracotomy might be necessary. This might be the case if the individual has been stabbed or shot in the heart, has a condition called ‘cardiac tamponade’ that was identified in an ultrasound or if they don’t have a pulse and received CPR less than 15 minutes after injuring their chest.
‘Cardiac tamponade’ is a serious condition where blood or fluid fills the space around the heart, which prevents it from beating properly. A temporary but immediate solution to this can be a procedure called ‘pericardiocentesis’ where the fluid is drained via a long needle. This can be done at the scene of the accident or in the emergency room to try and stabilize the patient. However, if the patient’s vital signs continue to worsen, this emergency thoracotomy might be needed until more definitive treatment can be organized.
Another situation where an emergency thoracotomy might be needed is for people who have suffered a serious impact to their chest without suffering other life-threatening injuries. An example of this could be chest injuries from road accidents where the chest has been struck by a steering wheel. Chest/heart surgery in the emergency room might be necessary as it can provide additional time until the patient can be transported to an operating room. Performing this procedure to the right person, can not only save their life but also potentially lead to a good recovery from a usually deadly injury.
It’s important to note that this surgery has a high death rate, largely because it’s usually performed on patients who are critically unwell. Additionally, the outcomes of emergency thoracotomies performed outside of these situations mentioned have been mostly unsuccessful.
When a Person Should Avoid Emergency Room Thoracotomy
An emergency room thoracotomy, which is a surgical procedure to gain access to the organs in the chest, might not be advisable in certain situations. Here’s a simplified explanation:
- Firstly, it’s not recommended if a patient continues to have vital signs, including a low blood pressure.
- Secondly, if it seems like the chances for recovery are low or ‘futile’. For example, if there were no signs of life at the scene of an injury, if the heart is stopped with no pooling of blood in the heart sac, if a pulse is absent for more than 15 minutes, or if injuries are too severe for survival.
In children aged 0-14, who’ve suffered a severe chest injury, it’s usually best to avoid an emergency thoracotomy, particularly if there’s a witnessed loss of pulse but no massive unsurvivable injury – this is due to very poor results. However, the situation may be different for teenagers (age 15-18) who have suffered a similar injury or kids with stab or gunshot wounds to the chest.
Research indicates that as a person grows older, the benefits of such a surgery dwindle. Especially in people older than 57, it might be best to avoid this surgery. Critical support systems and skilled staff, such as an operating room and a trained surgeon, have to be immediately available for this procedure as it is meant to stabilize the patient. To carry out thoracotomy safely and successfully, the right tools must be in place, this includes manual internal defibrillators that help restore normal heart rhythm.
It’s also crucial to mention that in case of severe damage in other parts of the body, or serious head injuries, penetrating injuries to the abdomen with no heart activity before reaching the hospital – these are other reasons why thoracotomy might not be the best solution.
Equipment used for Emergency Room Thoracotomy
To perform a sterile surgical operation on the chest (known as a thoracotomy), we need specific tools and equipment. These include clean surgical drapes and towels, sponges used during surgery, a scalpel holder, scissors, a device to separate the ribs (called a rib spreader), a tool to temporarily stop blood flow in the aorta (aortic cross-clamp), a variety of clamps to stop bleeding, forceps to hold the tissue, sutures for stitching, small patches of Teflon for support (Teflon pledgets), and tools to hold the needles (needle drivers).
An additional option is a 20F Foley catheter, which is a flexible tube used to carry fluids into, or out of, the body. This one has a 30-ml balloon that can be used to control bleeding. Also, adequate lighting and suctioning tools, plus surgical assistants, are extremely useful, but not always immediately available.
In this surgery, a manual internal defibrillator may be needed. This device can deliver an electric shock to the heart to restore normal rhythm, especially useful when the patient is actively being revived. Once the chest is open, regular external defibrillators do not work as well.
Also, a 30F chest tube will be needed. This is a large, flexible tube that doctors insert through the chest wall and into the pleural space (space between the lungs and chest wall) to drain blood, fluid, or air and allow the lungs to fully expand.
Who is needed to perform Emergency Room Thoracotomy?
In a medical emergency, various trained people work together to ensure the patient receives the best possible care. One person will focus on reviving the patient, following advanced protocols designed to support or restore heart function, while others assist. A different person will perform a procedure called a ‘thoracotomy’, which is a surgery to open the chest. If possible, they will have someone to assist them. Finally, a pathway to long-term care needs to be prepared. This means making sure there are surgeons and a trauma care team ready to take over after the procedure is finished, with the right support staff to work in the operating room.
Preparing for Emergency Room Thoracotomy
An emergency room thoracotomy, a type of chest surgery carried out in critical situations, often happens quite suddenly, leaving little time for the doctors to prepare. Most of the groundwork should be done even before the need for the procedure arises. This means that doctors performing the surgery should already be well-equipped and familiar with all the tools they’ll use, and they should have a clear understanding of the steps to take during the surgery.
It’s crucial to gather all necessary staff and equipment — including things like gowns, gloves, and eye protection — before the surgery starts. This preparation helps make sure things move smoothly and quickly, which is key in a critical situation. Though antibiotics are usually recommended before surgery, there’s one case where this doesn’t apply: when a patient needs “resuscitative thoracentesis.” This is a treatment that removes fluid from the chest to help a patient breathe, and it’s so urgent that it can’t wait for antibiotics. During this procedure, it’s just as important for doctors to implement standard safety measures — like wearing protective gear — to protect everyone involved.
How is Emergency Room Thoracotomy performed
The person receiving surgery should lie flat on their back with both arms spread out to 90 degrees. Usually, the doctors work from the left side as this gives them access to the left part of the chest, the heart sack, the heart itself, and the main blood vessel of the body known as the aorta. The doctor will make a cut with a scalpel from the mid-line of the body, across the chest and ribcage, around the lower edge of the nipple, and all the way to the back side of the body. It follows the curve of the ribs. If the patient is a woman, her breasts will be moved upwards slightly for this procedure. This first big cut will go through the skin as well as the layer of body fat right underneath it.
If there’s a possibility of bleeding from the right side of the chest, the cut can be mirrored on the right side. Some medical professionals think that this “clamshell” cut should be the best choice in emergency situations where the full extent of illness or injury isn’t known.
A second, smaller cut should then be made along the top edge of one of the ribs. This cut should be made to one side so as not to damage the heart. It should cut through the muscles between the ribs and the lining of the chest so that the doctor can see inside, but they should take care not to damage the lung tissue underneath. Special scissors are used to extend this cut towards the mid-line of the body, separating these muscles. The cut can then be extended towards the back side of the body.
After the chest has been cut open, a special tool is used to separate the ribs and allow the doctors to see inside the chest. Sometimes, a tube can be put down the windpipe into the right lung to reduce the amount of air going into the left lung, which makes it a bit easier to see.
If it doesn’t look like there’s any fluid around the heart or any damage to the sack around the heart (the pericardium), the doctors may not need to cut open the pericardium just yet. If they can’t clearly see the heart through the pericardium, they should cut open the pericardium and take out the heart.
The pericardium should be held in place with a special kind of forceps while a small cut is made with a scalpel or scissors. They need to take care not to damage the heart or a nerve nearby. They should extend this cut along the line of the nerve, which should expose the big blood vessels and they should remove any blockage, then take a good look at the heart. After all of this, the heart can be moved out from the pericardium.
After any initial bleeding has been controlled, the aorta, the body’s main blood vessel, is usually temporarily squeezed shut. They have to take care not to do this if the person’s blood pressure is normal, because it would make it harder for the heart to pump blood to the body. The left lung is moved upwards, and the aorta is then carefully separated from the esophagus and the back bone.
Once the aorta has been clamped, doctors can carry out other necessary procedures such as open heart massage and internal shock treatment. The aim of the hemorrhage repair is to keep things under control until the patient can be taken to the operating room.
Possible Complications of Emergency Room Thoracotomy
An emergency room thoracotomy is a procedure that can save someone’s life in a critical situation. However, like any medical procedure, it comes with possible complications. This means that it’s important to consider the risks before going ahead with the operation.
One common risk is injury to the person performing the surgery. This could happen if the doctor comes into contact with diseases in the patient’s blood. Wearing the right protective clothing and gear, known as personal protective equipment (PPE), can dramatically reduce this risk.
During the operation, the doctor could accidentally damage the patient’s ribs with a sharp instrument, causing injury to themselves. To avoid this, the doctor follows the shape of the ribs when making an incision. Also, it’s possible for the heart’s protective layer – called the pericardium – and other structures nearby to be damaged. But this risk is lowered if the doctor uses a special kind of scissor, called Mayo scissors, to carefully separate tissues and muscles.
Other important organs like the coronary arteries and phrenic nerve could also get accidentally damaged during the operation. Again, a strong understanding of human anatomy can help avoid this. And to avoid injuring the aorta – the main blood vessel in your body, it’s crucial to fully expose it during the operation.
Other risks include not getting enough blood to organs below the aorta if it’s clamped incorrectly, ongoing bleeding from the chest wall or a blood vessel called the internal mammary artery, and damage to the phrenic nerve. The phrenic nerve controls an important muscle called the diaphragm, which helps us breathe.
What Else Should I Know About Emergency Room Thoracotomy?
In the last 40 years, the reasons for performing immediate chest surgery have been improved because of better data and medical results. Now, this surgery has been very effective at reducing deaths in certain circumstances when performed on the right patients. However, it’s important to note that the procedure still carries significant risks. The survival rate is on average between 7.4% to 8.5%, depending on the type of injury.
Several factors can affect these risk levels. These include the type and severity of the injury, the exact place where the injury is located, and the patient’s vital signs. Survival rates may be lower in children and in cases of blunt chest trauma compared to penetrating injuries like gunshot wounds.
At this point, medical professionals don’t fully agree on whether immediate chest surgery should be attempted in most cases of blunt trauma (injuries caused by impact) because of the low rates of survival. Staying updated with information about when to use this surgery, how to perform it, and when it should be avoided could lead to a better use of medical resources and fewer unnecessary procedures.
