03 / Trauma & Acute Care Surgery · open
Resuscitative thoracotomy
The last operation in the book: opening the chest of a patient in extremis to relieve tamponade, control the hilum, or clamp the aorta.
Indication: Penetrating chest trauma with recent loss of signs of life; the indications are narrow because the returns are.
On the tray for this operation
Test yourself on the tray
Scalpel
Sharp division of tissue, most visibly the skin incision.
Mayo scissors
Cutting heavy tissue (curved) and suture (straight).
Metzenbaum scissors
Fine dissection of delicate tissue and planes.
DeBakey forceps
Atraumatic handling of vessels, bowel, and delicate tissue.
Needle driver
Holding the curved needle while suturing.
Kelly clamp
General-purpose clamping of vessels and tissue pedicles.
Stage
1 / 4
Left anterolateral thoracotomy
Incision along the fifth intercostal space from sternum toward the axilla, entering the pleura fast.
Watch for: Injury to intercostal vessels and the internal mammary artery · Operator injury in a fast, sharp field
Why are we operating?
The resuscitative thoracotomy is the last reversible moment of a traumatic arrest: the chest is opened in the emergency department to relieve tamponade, control a cardiac or pulmonary wound, and clamp the descending aorta so the remaining blood serves the heart and brain. Its survivors cluster tightly around one scenario, witnessed penetrating arrest with minimal downtime, and outside that scenario it mostly adds risk to the team.
Pulls toward surgery
Gives the team pause
Shared foundations
What the surgeon is thinking
Left anterolateral thoracotomy
Why this incision, of all the ways into a chest?
The left anterolateral thoracotomy is the fastest reliable door: fourth or fifth space, sternum to axilla, no special equipment, and it presents exactly the structures the operation needs, the pericardium, the left lung, the descending aorta. It can extend across the sternum (clamshell) when the right chest holds the answer.
Opening the pericardium
Why open the pericardium longitudinally and anteriorly?
The phrenic nerve runs down the pericardium's lateral face: a longitudinal incision anterior to it releases the tamponade without cutting the diaphragm's nerve. Tamponade release is the manoeuvre with the best survival attached, clot delivered, the heart given room, and any cardiac wound now visible for a finger and a suture.
Cardiac wound and hilar control
What can actually be fixed through this incision in an ED?
The short list: a cardiac wound occluded with a finger, staple or suture; a hilar injury controlled with a clamp or twist; massive lung bleeding tamponaded. The ED thoracotomy is a bridge measured in minutes, its job is to restore enough circulation to reach an operating theatre that can finish the sentence.
Clamping the descending aorta
What does clamping the descending aorta buy, and what does it cost?
It redistributes a starving circulation to the coronaries and brain and slows abdominal bleeding below the clamp: bought minutes. The cost is ischaemia to everything distal and a left ventricle suddenly facing full afterload: the clamp has a clock, and its time is written down.
Decision points
Blunt trauma arrest, downtime unknown, asystole on the monitor. Open the chest?
Do not open
Blunt arrest with prolonged or unknown downtime has near-zero thoracotomy survival: the procedure spends team risk on no realistic benefit.
Open
Reserved for the witnessed blunt arrest with signs of life moments ago in systems whose doctrine permits: even then, expectations are honest.
The entry criteria are the operation: penetrating mechanism, witnessed arrest, minimal downtime. A team that knows its stopping rules performs the heroic version better too, because the decision was made by doctrine, not adrenaline.
The heart refills after tamponade release and an output returns. What now?
Straight to theatre with the chest as-is
The ED thoracotomy is a bridge: definitive repair, washout and closure belong in an operating theatre with light, instruments and blood.
Complete the repair in the ED
Only what prevents re-arrest in transit: a finger, a temporising suture, a clamp. Elaboration in the ED spends the minutes the bridge just bought.
Return of output changes the venue, not the urgency: the patient is transported with the surgeon's hand still in the field if necessary. The operation's success is measured at the theatre door, not at the moment the monitor blipped.
Leaving the OR
The handoff
- Procedure
- ED left anterolateral thoracotomy: tamponade released, right ventricular wound sutured in theatre
- Downtime
- Witnessed arrest, output restored at ~6 minutes
- Operative course
- Formal washout and closure in theatre; chest drains bilaterally
- Physiology
- Massive transfusion protocol used; lactate 6.8 falling; on noradrenaline
- Watch for
- Re-accumulation (drains), coagulopathy, ischaemic sequelae of the arrest and clamp time, sternal/rib wound care
A fictional educational patient, handed over the way real ones are.
The postoperative course
- ICU, first 24hThe arrest's bill arrives: coagulopathy corrected to a recipe, lactate clearance watched, and neurology assessed honestly once sedation allows.
- POD 1-3The repaired heart under echo surveillance; drains and the thoracotomy wound managed; ventilation weaned as the lungs and chest wall permit.
- POD 3-7Infection surveillance for a wound made without sterility's luxuries; the ICU's usual campaigns (feeding, mobilising, delirium) run alongside.
- RecoverySurvivors of this operation earn long rehabilitation and honest follow-up of neurological and cardiac function: the story is measured in months, and it started with a doctrine correctly applied.
Watch it done
Resuscitative thoracotomy
A trauma centre's teaching session on the ED thoracotomy: when, how, and what the team does in the first minute.
Source: UCSD Trauma and Burn · Watch on YouTube