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An emergency room thoracotomy is performed in selected cases of direct thoracic injury concurrently with ACLS/ATLS resuscitation. Survival rates are low; however, this is because it is a life-saving measure aimed at temporizing a critical patient until a definitive repair can be achieved in the operating room. This activity reviews the evaluation and management of patients who undergo emergency room thoracotomy and highlights the role of the interprofessional team in evaluating and improving the care of such patients. Objectives: Review the indications for emergency room thoracotomy. Describe the equipment, personnel, preparation, and technique in regards to emergency room thoracotomy. Summarize the expected outcomes of emergency room thoracotomy. Discuss interprofessional team strategies among emergency room providers, personnel, and surgical teams, to improve care coordination and communication to advance emergency room thoracotomy and improve outcomes. Access free multiple choice questions on this topic.

Emergent thoracotomy is a procedure that is intended to temporize wounds and stabilize a patient via direct control of intrathoracic injuries, decompression of pericardial tamponade, and control of the aorta to prevent exsanguination. There are particular situations when an emergent thoracotomy is indicated. However, in those instances, this procedure could very well be life-saving, allowing the patient to survive to definitive interventions. We will review the procedure below, as well as the criteria for when you should and should not consider performing a thoracotomy emergently. The primary goals of emergency room thoracotomy are following:[1] Hemorrhage control Release of cardiac tamponade[2][3] For open cardiac massage[4][5] Prevention of air embolism Exposure of descending thoracic aorta for cross-clamping Repair cardiac or pulmonary injury Emergent thoracotomy is typically performed in an emergency room or operating room. The emergency provider needs to inform the surgeon and facilitate the procedure and also manage the patient after thoracotomy.

Emergency room thoracotomy is a life-saving procedure; however, its benefit should be weighed against its complications. One of the most frequent complications is operator injury, and the first and foremost precaution should be utilizing the correct personal protective equipment (PPE). Occupational exposures to human immunodeficiency virus or other blood-borne diseases are slightly higher than average, but strict usage of PPE dramatically reduces the risks of exposure.[15] During the primary incision, ribs can be transected, creating sharp edges that can puncture or lacerate the operator. A curvilinear incision following the contour of the ribs is essential to minimizing this risk. Additionally, if a scalpel is used to incise completely into the thorax, the pericardium and underlying structures can be further damaged. These iatrogenic injuries are most easily avoided by utilizing Mayo scissors to separate the intercostal muscles and soft tissues. During pericardiotomy, coronary arteries can be accidentally ligated or, more commonly, the phrenic nerve can be transacted. A functional understanding of anatomy and the techniques to be performed are essential to minimize the risk of accidental structural injury. Complete exposure of the aorta is essential to prevent incomplete cross-clamping of the aorta, clamping the esophagus with the aorta, or exclusively clamping the esophagus. Damage to the phrenic nerve Ischemia to distal organs due to cross-clamping of the aorta Recurrent bleeding from the chest wall or internal mammary artery

Emergency room thoracotomy is a last resort effort for life-saving treatment in a specific patient population. The resuscitation of patients who qualify for emergency room thoracotomy will, at a minimum, involve an emergency provider, nurses, and potential assistants, technicians, or any other available staff. It is not a procedure that can be performed in isolation, and a unified, focused team will improve outcomes. Often there will also be a trauma surgeon, as well as their support staff, also present for the procedure. Otherwise, the surgical team will be involved directly after the procedure for definitive treatment in the operating room. Definite indications for patients who qualify for this last-resort attempt will help improve outcomes by reducing efforts in hopeless cases with other unsurvivable injuries. Additionally, a review of the steps involved in the procedure and expected next-steps can enhance the efficiency of interprofessional communication. [Level 4]