World Journal of Cardiovascular Surgery, 2012, 2, 1-4 Published Online March 2012 ( 1
Emergency Thoracotomy: Indications and Management
Challenges in a Developing World
Martins O. Thomas*, Ezekiel O. Ogunleye
Lagos University Teaching Hospital, College of Medicine,
University of Lagos, Lagos, Nigeria
Email: *
Received December 10, 2011; revised January 17, 2012; accepted February 15, 2012
Background: Emergency thoracotomies often challenge surgical logistics and they tend to produce inferior outcomes
when compared with elective surgery. Aims: We sought to identify the specific indications and therapeutic challenges
that go with patients who undergo thoracotomy within 24 hours of admission and the re-tho racotomies. Methodology:
Spanning a 7-year period, the bio-data of patients who met our criteria for emergency thoracotomies were collated. We
noted their indications for surgery, therapeutic challenges and outcome of care. Results: In all, 36 patients (28 males
and 8 females) met the inclusion criteria. Majority, (66.7%) fell into the 20 - 39 year age range. Diaphragmatic rupture
was the commonest indication, followed by massive intra-thoracic haemorrhage. Postoperative mortality occurred in
11.1% of patients. Postoperative ventilation was absolutely indicated in 6 patients. Discussion and Conclusion: Dia-
phragmatic rupture is the commonest indication for emergency thoracotomy. We noted the need for improvement in pre
hospital care for trauma patients as a way to improve the management outcome of emergency thoracotomies.
Keywords: Emergency Thoracotomy; Indications; Definition; Outcome
1. Introduction
The subject of emergency thoracotomy has been widely
studied worldwide [1-11]. However there has been no
dedicated reports on this topical issue from this part of
the world. Following Bilroth’s 1882 assertion that “the
surgeon who should attempt to suture a wound on the
heart would lose the respect of his surgical colleagues” [9]
(sic), there had been a lot of developments in this all im-
portant aspect of care.
The first pre-hospital thoracotomy was performed by
Hill in Montgomery, Alabama on a kitchen table in 1902
and since then, with good patient selection, postoperative
survival of patients has improved reasonably [9].
Emergency thoracotomy (ET) may serve as a life-
saving tool when performed for the right indications, in
selected patients and in the hands of trained surgeons [1].
Critically injured patients “in extremis” arrive at an in-
creasing rate in the trauma bay, as an effect of improved
pre-hospital trauma systems an d rapid transport [1].
By definition, some authors believe that emergency
department thoracotomy encompasses thoracotomies done
for patients who are in extremis [2]. Broadly taken, emer-
gency surgery is defined as sternotomy, thoracotomy,
laparotomy or major neck vascular repair performed on
the day of admission [3]. Operating on a patient might
not constitute emergency thoracotomy if the patient was
worked up for surgery as an outpatient. The lack of clar-
ity in medical literature, the need for rapid intervention in
patients deemed appropriate for the procedure, the life
and death nature of the decision and the low but finite
functional survival rates following emergency depart-
ment thoracotomy (EDT) for trauma have made the con-
duct of these procedures a subject of great controversy
among trauma experts [2]. The import of this is that the
definition of what constitute emergency thoracotomy is
still a subject for further studies till a more universally
accepted definition is arrived at. In view of the foregoing,
it might be expedient for practicing surgeons to individu-
alise the theory and practice of emergency thoracotomy
till that time.
The indications for ET vary widely. In many cases, ET
may be indicated for damage control when there is a
deadly triad of hypothermia, acidosis and coagulopathy
described as temperature of < 34˚C, pH of 7.2 or less and
clinically uncontrollable bleeding [4]. In such situations,
the strategy may include the following three steps:
1) Rapid control of haemorrhage and abbreviated sur-
gery in the emergency room or theatre;
2) Correction of hypothermia, acidosis and coagulo-
pathy; and re-evaluation of injuries in the intensive care;
*Corresponding a uthor.
opyright © 2012 SciRes. WJCS
3) Definitive surgery in the theatre.
Procedures for damage control include aortic cross-
clamping, hilar clamping, major vessel ligation, pulmo-
nary tractotomy, simultaneously stapled pneumonectomy
or lobectomy, cardiac stapling, balloon catheter tampo-
nade, temporary intraluminal shunt, towel packing, towel
clip closure, single en masse closure of the chest wall
among others.
ET might also be indicated in definitive treatmen t as in
conditions like pericardial tamponade, many cases of
intra-thoracic bleeding, systemic air embolism, some lung
contusions, lung lacerations and so on. Kaiser and his
colleagues [3] at Irvine Medical Centre, California came
up with early independent predictions of the need for
emergency surgery to include prolonged extrication (odds
ratio (OR) 2.3), no loss of consciousness (OR 2.8), intu-
bation (OR 1.7), central line placement (OR1.7) and
blood transfus ion (OR 2.1) in all P < 0.05.
Emergency room thoracotomy saves about one in five
patients with isolated penetrating cardiac injury [1]. Mul-
tiple studies have shown that patients with isolated pene-
trating chest trauma have better outcomes than patients
who suffer blunt chest trauma without signs of life at the
scene or in the emergency department [5]. This is further
corroborated by the work of Ahmad and his team in Ka-
rachi [6]. In their series, post-thoracotomy mortality was
13.3% in penetrating injuries and 18.2% in patients who
suffered blunt injuries. In the same series, the combined
survival of emergency thoracotomy in 475 patients was
95.58%. They therefore concluded that early recognition
of treatable injuries and an aggressive approach in man-
agement of patients who need emergency thoracotomy
can increase chances of survival of patients suffering
from severe chest trauma.
Resuscitative thoracotomy (RT) is a time tested prac-
tice that gives direct access to the heart during cardio-
pulmonary resuscitation. The procedure has been and is
still very relevant in modern day practice. RT is also
considered to be more successful in penetrating cardiac
trauma than in blunt injuries of the heart with cardiovas-
cular collapse [8].
Wise and his colleagues [10] have gone further to
simplify instrumentation for ET. Specifically, they stated
that a clamshell incision performed using a big scalpel,
large scissors, large clamp and a gigli saw will suffice for
In all the works mentioned above, a common phe-
nomenon is the various positions taken by different prac-
titioners on the various aspects of emergency thora-
cotomy from definition to treatment. Therefore, further
literature enrichment would highlight various aspects of
Our study was conducted to highlight the indications
and management challenges of ET in a developing coun-
try. It was also to further enrich the literature in the all
important search for a common ground in the whole sub-
ject of emergency thoracotomy.
2. Methodology
The study period spanned 7 years from 2000 January to
December 2006. A protocol was designed to accommo-
date details of all thoracotomies performed in the first 24
hours of admission into Lagos University Teaching Hos-
pital, in Nigeria.
We noted patients’ bio-data to include ages and sexes,
specific indications for surgery, timing, clinical features,
operations performed, specific details of postoperative
care including complications and interventions.
The cases that met the criteria for emergency thora-
cotomy were extracted from the lot. Inclusion criteria
were thoracotomy performed within 24hours of patient
admission and all cases of re-thoracotomies. The patients
were followed up on admission taking specific note of
postoperative care to include blood transfusion needs,
absolute indication for postoperative ventilation and the
need for re-thoracotomy. Our criteria for absolute indica-
tion for postoperative ventilation was persistently low
SpO2 (<80%) with intra-nasal ox ygen.
The data so collected were analysed normally looking
at population distribution, dispersion, correlation of post-
operative events (mortality) with elective or emergency
3. Results
There were 36 patients for emergency thoracotomies
within the study period. They comprised of 28 males and
8 females giving a male to female ratio of 3.5:1. Within
the 20 - 39 year age range, there were 24 patients consti-
tuting 66.7% of the population. Age 19 and below pro-
duced only 5 patients constituting 13.9% of the cases.
The mean age was 33.7 ± 12.1 years and the median
was 32.1years. The mean and median were fairly close in
value giving a tendency to being a normal distribution
but the distribution was fairly platykurtic with Pearson
Skewness of +0. 39 .
Massive Haemothorax was the indication in 11 (30.5%)
patients while diaphragmatic rupture occurred in 15
(41.7%) patents. Re-thoracotomy was the reason in 3
patients. Thoracotomy was done for 35 patients while
sternotomy was done for one patient who suffered pene-
trating cardiac trauma. Postoperative mortality occurred
in 4 (11.1%) of the patients. There were absolute indica-
tions for postoperative ventilatio n in 6 (16.7%) patients.
4. Discussion
In emergency situations, thoracotomy is done in most
Copyright © 2012 SciRes. WJCS
cases as a major therapeutic intervention. It is resorted to
for quick reversal of worsening situations like major
chest trauma, cardiac arrest and other similar conditions.
What constitute ET has been described in literature by
various authors [1-8]. There seems to be convergence of
opinion that ET as a procedure is performed within 24
hours of admission. This definition however is not ap-
propriate for re-thoracotomy which is also a type of ET
that may follow a well planned elective surgery done
days after admission. A patient whose elective surgery
workup was done as outpatient can be operated upon
within 24 hours of admission. There is also the issue of
ET in damage control [4]. In this situation, ET is done for
patients in clinical extremis with survival as the main
Resuscitative thoracotomy (RT) is another form of ET
which is indicated for open cardiac massage in cardio-
pulmonar y resuscit ation.
With this background information, the indications for
ET can be summed up to include all the indications for
the component parts of ET (vide supra).
The preponderances of indications for emergency tho-
racotomy (ET) seem to be different in various localities
[1,2,6,7] In our study with 36 patients, diaphragmatic
rupture was the commonest indication for ET while mas-
sive haemothorax was next (Table 1). These two indica-
tions constituted 72.2% of the cases. Even at that, the
main reason for doing thoracotomy for diaphragmatic
rupture was when additional intra-thoracic injury was
suspected or when diaphragmatic rupture was an inci-
dental finding during thoracotomy. Aside these, we main-
tained the practice of repairing the diaphragm thro ugh th e
abdomen in acute cases.
Ahmad and his colleagues [6] working in Karachi
noted that massive haemothorax was the commonest in-
dication in their series. Even at that, haemothorax only
occurred in 10.9% of the series and this is about a third
of the massive haemothorax rate in our study.
Another indication of interest is re-thoracotomy. This
was done in 8.3% of cases. One was done for postopera-
tive cardiac arrest while the remaining were done for
continuing haemorrhage after thoracotomy. It is impor-
tant to note that there was no case that rightly met the
Table 1. Indications for emergency thoracotomy.
Indications Males Females Total
Massive Haemothorax 8 3 11 (30.5%)
Penetrating cardiac injuries 1 - 1 (2.8%)
Diaphragmatic rupture 12 3 15 (41.7%)
Re-thoracotomy 2 1 3 (8.3%)
Others 5 1 6 (16.7%)
TOTAL 28 (77.8%) 8 (22.2%) 100 (100.0%)
Table 2. Age and sex distribution.
Age (Years) Males Females Total
< 10 1 2 3 (8.3%)
10 - 19 2 - 2 (5.6%)
20 - 29 9 2 11 (30.6%)
30 - 39 10 3 13 (36.1%)
40 - 49 4 1 5 (13.8%)
50 - 59 2 - 2 (5.6%)
Total 28 (77.8%) 8 (22.2%) 36 (100.0%)
criteria for damage control as described by Mashiko and
his team [4] This might be a reflection of poor pre-hos-
pital care in this environment. Patients who qualified for
this might have died at the scene or they could have been
brought in dead.
From our study, 77.8% of patients were males while
the remaining 22.2% were females (Table 2). The pre-
ponderance of males over the females eased a bit in the
groups below 20 years of age. A plausible explanation is
the general trend of males being more mobile and ad-
venturous that they get involved in trauma than their fe-
male counterparts. In all, age range 20 - 39 years consti-
tuted 66.7% of all cases. This again is the usually very
active age group that is relatively more exposed to
There were absolute indications for postoperative ven-
tilation in 16.7% of our patients. Post-thoracotomy mor-
tality occurred in 11.1% of our series. This is a bit lower
than 15.3% in the Karachi report [6]. This is despite the
poor pre-hospital care in our environment [12]. The im-
plication of this is that the patients with major chest
trauma and many others who could benefit from ET
would have died at the pre-hospital level.
We concluded that diaphragmatic rupture is the com-
monest indication for emergency thoracotomy because of
the frequent suspicion of add itional in tra-thoracic in juries.
This is followed closely by massive intra-thoracic haem-
We recommend further improvement in pre-hospital
care of trauma patients so that more patients can be saved
through emergenc y thoracotomy.
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