Thoracotomy (ED & OR)
What the Examiner Expects
Emergency thoracotomy performed either in the ED (resuscitative) or the OR (definitive). ED thoracotomy is a left anterolateral incision in the 5th intercostal space performed for patients with penetrating thoracic trauma who arrive with signs of life but deteriorate or arrest. The goals are: open the pericardium (anterior to the phrenic nerve) to relieve tamponade, perform open cardiac massage, clamp the descending aorta to redistribute blood flow to the coronary and cerebral circulation, and control hemorrhage. The examiner expects you to know survival rates: penetrating cardiac injuries with tamponade have the best outcomes (~35% survival with ED thoracotomy); blunt trauma has < 2% survival.
Key Examiner Focus Points
- ED thoracotomy: left anterolateral in the 5th intercostal space
- Indications for ED thoracotomy: penetrating trauma with witnessed loss of vitals or PEA
- Goals: release tamponade, cross-clamp descending aorta, control cardiac/pulmonary hemorrhage
- Blunt trauma: ED thoracotomy has very poor survival — reserved for witnessed arrest only
- OR thoracotomy: posterolateral for lung, mediastinal, or esophageal injuries
Common Curveballs
You open the pericardium and find a 2 cm laceration on the right ventricle
Control the bleeding immediately with a finger over the hole, then repair with pledgeted horizontal mattress sutures (non-absorbable). The thick muscular right ventricle holds sutures well. For atrial injuries, a Satinsky clamp can be used. For injuries near a coronary artery, use horizontal mattress sutures placed under the vessel.
After ED thoracotomy, the aorta is cross-clamped and there is a massive hemothorax from the left lung hilum
If the hilar bleeding cannot be controlled with clamping, perform a pulmonary hilar cross-clamp (en masse with a large vascular clamp) or pulmonary tractotomy. If the patient stabilizes, transport to OR for definitive repair. Pneumonectomy for trauma has very high mortality but may be the only option for a destroyed lung hilum.
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