Clam shell thoracotomy – Indications and outcomes

Case: A multiple gun shot wound victim was found at the roadside barely conscious. He was intubated, ventilated and given bilateral thoracostomies by our HEMS crew. He went into cardiac arrest and so the team decided to perform an open thoracotomy¹. His pericardium was full of clot and when opened revealed a linear tear in his right ventricle. During bimanual cardiac compressions his heart felt empty. The extent of his injuries, including the one described above, were judged to be an ELE (Extinction Level Event).

Challenge: What are the indications and reported outcomes for prehospital thoracotomy?

Learning Points: Here’s an excerpt from the Traumatic Cardiac Arrest HOP:

4.6.3. Penetrating Trauma

4.6.3.1 Thoracic or upper abdominal penetrating injury resulting in cardiac arrest should initially be managed as in 4.1.1 and 4.2.1 (see below). If there are signs of life withint a 10 min window prior to team arrival and there is no response to intubation / bilateral thoracostomy, a clamshell thoracotomy should be made with the specific purpose of relieving cardiac tamponade, controlling a cardiac wound(s) and providing internal cardiac massage. A detailed description of this technique is beyond the scope of this HOP but is clearly explained elsewhere¹ .

4.1.1 All cardiac arrest patients should be intubated without anaesthetic drugs.

4.2.1 Unless the possibility of tension pneumothorax can be reliably excluded, bilateral open thoracostomies should be made². Needle thoracocentesis may be performed initially for reasons of access or expediency but these should not be considered to provide definitive pleural drainage.

Anterior bilateral thoracotomy (Clam Shell): Provides excellent exposure of the heart and mediastinum. The idea is that a non-cardiothoracic surgeon should be able to access the pericardium with 2-3 mins. 

Indication: Penetrating chest or epigastric trauma associated with cardiac arrest.

Contraindications: Cardiac arrest for greater than 10mins (or if there is still a cardiac output?!). Evidence from one case series suggested a poor neurological outcome for those patients who were in cardiac arrest for anymore than 10 mins³.

It is important to have realistic expectations. This procedure best tackles a single pathology – cardiac tamponade with a controllable wound in the heart. If the underlying injury is any more complex, a good outcome is unlikely. A 25 year review of ED thoracotomies conducted in 2000 highlighted survival rates based on mechanism of injury. In descending order: 19.4% for isolated cardiac wounds, 16.8% for stab wounds, 4.3% for gunshot wounds and 1% for blunt trauma⁴.

Summary: Clam shell thoracotomy is a useful tool in the desperate attempt to resuscitate penetrating trauma victims who are in extremis. If applied selectively, this procedure can be lifesaving.

References:

1. Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A. Emergency thoracotomy: “how to do it” Emergency Medicine Journal 2005;22:22-24.

2. Massarutti D, Trillò G, Berlot G, Tomasini A, Bacer B, D’Orlando L, Viviani M, Rinaldi A, Babuin A, Burato L, Carchietti E. Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. Eur J Emerg Med. 2006 Oct;13(5):276- 80.

3. Davies GE, Lockey DJ. Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results. J. Trauma. 2011 May;70(5):E75-8.

4. Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000 Mar;190(3):288-98.

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