Editors: Makini Chisholm-Straker MD MPH; Nick Gabinet
What is an Emergency Department thoracotomy
Emergency Department (ED) thoracotomy is a surgical procedure to gain access into the chest cavity. It is meant to allow rapid access to important organs especially the heart and aorta. The main reason to do this procedure is because the person laying on the hospital gurvey is in traumatic cardiac arrest – meaning that their heart has stopped beating because of an injury. In the setting of gunshot injuries, it may be that a bullet, or multiple bullets have pierced the heart or the aorta, causing rapid, life-threatening blood loss.
While we can initiate measures such as massive transfusion protocols to pour large quantities of blood into the body, ultimately the person will not be able to recover unless the injury is found, and the organ repaired.
And because the heart has already stopped beating, there is very little time to save the person’s life. Literally, there are only seconds — maybe minutes — left to try to do something, before death is final. This is why it is performed rapidly within the Emergency Department, rather than in the operating room (OR), which is the more typical area for major life saving surgeries. Such patients would not survive the time required to rush them to the OR under these circumstances.
Why we would do it
It is a serious decision to perform an ED thoracotomy; we do not make it lightly. In medical and surgical societies, clinicians debate about when this procedure is indicated. We study the outcomes in the patients who get ED thoracotomies, and compare the outcomes to similar patients who do not. Here is an example of a publication with guidelines for emergency thoracotomies by the Eastern Association for the Surgery of Trauma.
The decision to perform an ED thoracotomy is serious, because it is an expensive, resource-intensive, high-risk procedure, requiring multiple clinicians, specialized equipment, and a trauma survey team for ultimate reparative surgery. Despite the degree of resources involved, the majority of patients do not survive. However, the team elects to perform the procedure is because they know in that moment, that without the thoracotomy, the injured person’s death is certain. So they ask, Is it worth “cracking open” someone’s chest, for the tiny possibility that they might survive to have a meaningful recovery? Or should we minimize suffering of the person, conserve resources, and accept death?
What we do
A thoracotomy involves cutting open the chest wall, sometimes on just the left side, sometimes through the entire chest. The cutting is intense and requires tools such as bone cutters, saws, and rib spreaders. After that, the heart and aorta are thoroughly examined for injury and bleeding. If the bleeding site can be identified, then it is sewn together, clamped, or plugged to stop bleeding. The entire time, the trauma team waits and hopes for the heart to beat again. In the rare cases in which a thoracotomy is successful, the surgery team emergently arranges for the patient to go to the operating room for a more permanent repair. Even after that, the survivor has a very long road ahead before full recovery.
What is the likelihood of survival
Unfortunately, the likelihood of survival is very low after an ED thoracotomy. Sadly, some look at this procedure as essentially “futile” – because the survival rates are so dismal; only around 9-12% of people will survive after such a penetrating injury. This is because the procedure is only performed after the patient literally dies, meaning that the heart has already stopped beating. This procedure is the ultimate last ditch effort to bring the person back to life, after suffering from the gunshot injury.
And the data is tricky. Survival means that the person is alive, the heart is beating and the brain is somewhat functioning. But it does not speak to quality of life. Would the person who previously had a passion for art continue to be able to create it? Would the young teenager with an academic interest in science ever become a doctor? Or would the person survive in a state of significant weakness, frequent illnesses, and have a life defined through a series of endless doctors appointments, hospitalizations, and back to back surgeries?
What you need to know
- An ED thoracotomy is performed if a person has a penetrating injury, like a gunshot or stab wound, in the chest area and their heart stops beating in the hospital.
- The chest wall is opened up and the heart, aorta, lungs, and other thoracic organs are explored to look for bleeding sites.
- Survival is extremely low.
Where we need more research
- We need to understand how to stop the need for thoracotomies in the first place and how to decrease the number of gunshots that lead to chest injuries. When people die from gun shots to the chest, it is not the medicine that failed them, it is that we failed to prevent the shooting from happening in the first place.
- We need better data to understand why some people are more likely survive this procedure and how to predict survivors in order to avoid unnecessary and futile ED thoracotomies and to maximize survival.
- We need more understanding of the types of bullets that cause different types of chest injury; this would help us to predict who might survive based upon bullet type and gun used, and what their medical and surgical needs will be.
Seamon MJ, Haut ER, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jul;79(1):159-73. PMID: 26091330.