Life-saving emergency clamshell thoracotomy with damage-control laparotomy

Abstract

Clamshell thoracotomy for thoracic injuries is an uncommon emergency department procedure. The survival rates following emergency thoracotomy are very low at 9%–12% for penetrating trauma and 1%–2% for blunt trauma. We report an unusual case of survival after emergency department clamshell thoracotomy for penetrating thoracic trauma with cardiac tamponade in a 23-year-old man with multiple stab wounds on the chest and abdomen. The patient was awake and alert on arrival in the emergency department. Bilateral chest decompression by needle thoracostomy released air and blood. During subsequent chest drain insertion, the patient suddenly deteriorated and arrested. Clamshell thoracotomy was performed, and sinus rhythm restored before transfer to theatre. Following repair of the thoracic injuries, a midline laparotomy was performed as bleeding was suspected from the abdomen and a splenic injury repaired. The patient survived and has made a full recovery. This case demonstrates how clamshell thoracotomy can be a life-saving procedure.

Background

Trauma is a leading cause of death, with blunt and penetrating thoracic injuries responsible for almost 25% of trauma deaths in the UK.¹ Major causes of thoracic injury are relatively limited in the UK, with blunt trauma accounting for most injuries. The annual death rate from stabbing and gunshot wounds is less than 250 in England and Wales.² Road traffic accidents are a major cause of fatal thoracic injuries, with one study showing 75% of motorcycle accident fatalities had sustained thoracic trauma compared with only 20% in surviving riders.³

Emergency thoracotomy is described by various terms including emergency department thoracotomy, emergent thoracotomy and resuscitative thoracotomy. Outcomes following emergency thoracotomy for thoracic trauma are generally poor, with survival rates around 9%–12% for penetrating trauma and only 1%–2% after blunt trauma.⁴ Mortality remains high, but survival with good neurological outcomes from traumatic cardiac arrest is well documented.⁵

Respiratory and haemodynamic functions are often compromised as a result of chest trauma. Death resulting from thoracic injury is usually a consequence of impaired gas transfer from loss of mechanical function or insufficient oxygen delivery due to inadequate cardiac output. Penetrating injuries can cause tension pneumothorax and cardiac tamponade, which lead to reduced venous return to the heart and end-diastolic volume. The resulting decrease in cardiac output can result in shock and may precipitate cardiac dysrhythmias.

Cardiac tamponade can present differently depending on the nature of the underlying injury. Rapid development of tamponade often occurs following coronary artery laceration or myocardial rupture. Minor lacerations will lead to a more gradual increase in intrapericardial pressure and less sudden onset of tamponade. As in this case, it is usually due to the arrest of bleeding by cardiac tamponade that enables patients with penetrating cardiac injuries to survive until admitted to hospital.⁴

Case presentation

A 23-year-old man presented to the emergency department of a regional trauma centre with multiple stab wounds. On arrival, he was awake and alert with a Glasgow Coma Scale of 15, heart rate of 74 bpm, blood pressure 100/60 mm Hg, respiratory rate of 18 breaths/min and maintaining an oxygen saturation of 96% breathing spontaneously on room air. On examination, there were three stab wounds to the anterior chest, two on the left and one on the right side of the chest, with a further three stab wounds along the margin of the diaphragm anteriorly. The total time interval from injury to hospital presentation was 60 min.

The patient deteriorated abruptly in the department becoming tachypnoeic and hypotensive with blood pressure 70/45 mm Hg. Due to the acute deterioration on arrival, there was no time to perform common trauma imaging investigations, such as Focused Assessment with Sonography for Trauma (FAST) scan. Bilateral chest decompression by needle thoracostomy with 14G intravenous cannulas was performed, which released air and blood. It was, therefore, decided to insert bilateral chest drains. During chest drain insertion, the patient developed ventricular fibrillation and the blood pressure was unrecordable. Cardiopulmonary resuscitation (CPR) was commenced, and the decision was made to perform clamshell thoracotomy given the stab wounds close to the pericardium. The clamshell incision was performed (figure 1), and the pericardium found to be tense and full of clotted blood. The pericardium was opened, clotted blood evacuated and internal cardiac massage started. A shock was delivered with internal defibrillator paddles and the patient reverted to sinus rhythm with the blood pressure recordable to 80 mmHg systolic.

Figure 1.

Arrow showing clamshell thoracotomy incision in the fifth intercostal space.

The patient was transferred to an emergency theatre where we found a penetrating wound on the right ventricular outflow tract, which was secured with 3/0 pledgeted prolene sutures. Continued bleeding was observed coming from the upper thoracic cavity and the patient remained haemodynamically unstable despite ongoing blood transfusion and resuscitation. Extension of the clamshell incision to the posterior axillary line is typically performed to increase exposure; however, in this case, bleeding from the superior mediastinum was suspected. As cardiothoracic expertise was available, it was, therefore, decided to perform a median sternotomy to enable a thorough examination of the superior mediastinal structures, which are not easily accessed through the clamshell incision. Bleeding was identified from the inside of the left upper chest wall, which was secured and haemostasis achieved.

We noticed bulging of the diaphragm into the thoracic cavity and the patient remained haemodynamically unstable along with a tense abdomen. Although diagnostic peritoneal lavage (DPL) is a recognised diagnostic modality for trauma patients; in our unit, it is not practised routinely. In view of the haemodynamic instability, bulging of the diaphragm, tense abdomen and abdominal stab wounds, intra-abdominal bleeding was suspected. Therefore, the decision was made to proceed with midline laparotomy instead of DPL. Laparotomy findings confirmed a laceration to the lower pole of the spleen. Haemostasis was achieved with fibrin sealant. The patient received in total 17 units packed red cells, four units fresh frozen plasma, two units cryoprecipitate and two units of platelets.

Post-operatively, the patient was intubated and ventilated for 5 days and had a surgical tracheostomy inserted. Initially, the patient was agitated, aggressive and not oriented. CT brain was performed and showed a hypoxic brain injury.

Differential diagnosis

The major causes of cardiac arrest following penetrating thoracic trauma are:

• Tension pneumothorax.

• Cardiac tamponade.

• Hypovolaemia secondary to haemorrhage.

Outcome and follow-up

The agitation and confusion began to resolve over the next few weeks while the patient remained stable and recovered slowly. The patient was discharged after 3 months in hospital and review at 6 months showed almost complete recovery with only minor residual dexterity problems (figure 2).

Figure 2.

Healthy healing scar tissue.

Discussion

The evidence for emergency thoracotomy for traumatic cardiac arrest is mainly based on retrospective data. The procedure continues to be shrouded in controversy due to the lack of randomised controlled trial evidence and the often poor outcomes.⁴ The primary objectives of emergency thoracotomy in thoracic trauma are to allow the release of cardiac tamponade to improve cardiac output, control of intrathoracic haemorrhage and to enable open cardiac massage.

Patients who had thoracotomy performed in the emergency department have been shown to have worse survival than those who underwent operating room thoracotomy.⁶ In the literature, it is also noted that in most cases blunt trauma to the thorax resulted in very poor survival after emergency department thoracotomy in comparison to penetrating thoracic wounds.⁷ It has been demonstrated in the emergency department that if patients with blunt thoracic trauma have received more than 5 min of pre-hospital CPR or more than 15 min in penetrating thoracic trauma patients, emergency thoracotomy is likely to be futile.⁸ These findings are included in the criteria for emergency thoracotomy in the Western Trauma Association guidelines.⁹ Emergency thoracotomy performed during CPR has been shown to improve outcomes in penetrating trauma especially if signs of life are present initially.¹⁰

In the emergency situation, clamshell thoracotomy provides the best exposure and enables fastest control of thoracic injuries compared with other incisions, such as left anterolateral thoracotomy.¹¹ The clamshell incision allows access to both thoracic cavities, the lower mediastinum and heart. Median sternotomy gives complete access to the mediastinum and thoracic structures. When greater exposure is required and cardiothoracic expertise is available, this is the preferred approach and enables access to the superior mediastinum.¹² However, for the non-specialist, the clamshell incision can be extended to the posterior axillary line on each side if required.

As this case highlights, in thoracic trauma patients, it is important to consider the abdomen as a source of bleeding especially when the patient remains haemodynamically unstable. Penetrating trauma to the lower thorax may cause intra-abdominal pathologies, such as lacerations to the spleen or liver. Injuries to the spleen frequently present non-specifically without reliable clinical signs.¹³ Point-of-care tests, such as FAST, can be used to rapidly identify free intra-abdominal fluid in trauma patients.

There is a lack of consensus in the literature regarding the indications for emergency thoracotomy in thoracic trauma. Generally accepted indications include cardiac arrest due to penetrating thoracic trauma with previously witnessed cardiac activity, and sustained hypotension caused by either traumatic intrathoracic haemorrhage, cardiac tamponade or systemic air embolism.⁴ The Eastern Association for the Surgery of Trauma guidelines strongly recommend emergency thoracotomy for cardiac arrest following penetrating thoracic trauma with signs of life.¹⁴

There are circumstances in which emergency thoracotomy is typically contraindicated, including blunt thoracic trauma with no signs of life, no witnessed cardiac activity or signs of life following more than 5 min CPR, and lastly, co-existing multiple severe trauma.⁴

Learning points.

• Traumatic cardiac tamponade is a life-threatening condition requiring immediate surgical intervention.

• Delay in the release of tamponade can result in an unfavourable neurological outcome or death.

• The keys to successful resuscitation of the traumatised heart are a high index of clinical suspicion, early recognition and rapid intervention.

• A study showed that the clamshell incision takes no longer than left anterolateral thoracotomy when performed by inexperienced surgeons and it is easy to learn.

• It is important to not to forget the abdomen as a source of bleeding in patients with trauma to the thorax.