Resuscitative thoracotomy

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Resuscitative thoracotomy

A resuscitative thoracotomy is a last-resort surgery in which a left chest opening is made to reach the heart and other organs quickly during severe trauma. It is also called an emergency department thoracotomy (EDT) and is sometimes referred to as “cracking the chest.”

Purpose and what it does
- It gives direct access to the chest to control bleeding, relieve cardiac tamponade (pressure on the heart), repair or control injuries to the heart, lungs, or major vessels, and to perform direct heart massage or defibrillation if needed.
- The procedure is rarely performed and is used only when life support is not possible with other measures.

When it’s considered
- The main indication is penetrating chest trauma with or near cardiac arrest. It may also be considered if a chest tube has drained a very large amount of blood very quickly (more than about 1500 mL in the first hour, or more than 200 mL per hour over several hours) and there are signs of life (electrical activity of the heart, a measurable blood pressure, etc.).
- In blunt trauma, if signs of life are present before reaching the hospital but disappear on arrival, further resuscitation is often not pursued; if life signs are still present on arrival and CPR time has been under about 15 minutes, the procedure may be indicated.
- A focused ultrasound test (FAST) may help determine the need by checking for free fluid in the chest.

How it’s done
- The common approach is a left anterolateral thoracotomy (between the 4th and 5th ribs). The incision goes through the chest wall and intercostal muscles, the pleura is opened, and the ribs are spread to give quick access to the chest.
- If access to both sides or greater exposure is needed, a clamshell thoracotomy is performed, opening both sides of the chest.

Outcomes
- Survival is generally low. About 10% survive after blunt injury and 15–30% survive after penetrating trauma.
- Those with thoracic stab wounds or who arrive with signs of life tend to have the best chances. Overall, patients with multiple injuries or who arrive without signs of life have the lowest chances.

History
- The procedure has roots in the late 1800s, with early uses of open cardiac massage. It evolved alongside defibrillation and CPR, which reduced its role in emergencies over time.