Indications for Early Thoracotomy in the

Management of Chest Trauma

George Kish, M.D., Louis Kozloff, M.D., William L. Joseph, M.D.,

and Paul C. Adkins, M.D.

ABSTRACT Trauma to the thorax represents a significant portion of injuries seen in an inner-city
emergency room. Although most of these patients
may be successfully managed without thoracotomy, a
certain percentage require operative intervention
either immediately or within several hours.
The records of more than 380 patients with major
chest trauma seen in recent years have been reviewed.
Three hundred twenty-one of these patients (84%)
required only good supportive measures such as correction of hypovolemia, temporary ventilatory support, tube thoracostomy, and careful observation.
Forty-four additional patients (12%) required immediate operation following preliminary resuscitative treatment. Indications included hemorrhage,
cardiac tamponade, injury to a great vessel, and rupture of the diaphragm. There were 10 deaths in this
group. In 15 other individuals (4%) delayed operation was undertaken following careful reappraisal of
initial injuries by continued examination, monitoring of vital signs, and appropriate roentgenographic
and laboratory studies. Indications for delayed operation included continued or recurrent bleeding,
widening of the mediastinum, hemoptysis, and recurrent hemothorax. There was only 1 death in this
group.
Thus, although it may be clear which patients require immediate operation, only careful and continuous monitoring can identify those who initially
appear to be in stable condition but eventually will
require exploration.

In any large inner-city hospital, trauma to the

chest has become an increasingly common reason for admission through the emergency room
From the Department of Surgery, George Washington University Medical Center, Washington, DC.
Presented at the Twenty-second Annual Meeting of the
Southern Thoracic Surgical Association, Nov 643,1975, New
Orleans, LA.
Address reprint requests to Dr. Joseph, George Washington
University Medical Center, H. B. Burns Memorial Building,
2150 Pennsylvania Ave, NW, Washington, DC 20037.

23

[6, 101. For the vast majority of these patients,

insertion of chest tubes, careful monitoring of
vital signs, replacing blood and fluid, and obtaining serial chest roentgenograms constitute
adequate therapy. A small percentage of these
individuals arrive in extremis, however, and a
decision to operate must be made immediately,
with thoracotomy at times being performed in
the emergency room as a life-saving measure. In
addition, a few patients appear stable when initially evaluated but demonstrate a reason for
exploratory thoracotomy following further
diagnostic studies or after being observed for a
period of hours or days. In some this is simply
an operation to remove a foreign body or to perform decortication for persistent hemothorax
or empyema, but in others the operation becomes life saving. This report concerns our experience with the operative management of patients following thoracic trauma.

Clinical Material
From January, 1968, through December, 1974,
380 patients with chest trauma were seen in the
emergency rooms at either the District of Columbia General Hospital (George Washington
Service) or at The George Washington University Hospital. Both institutions are located
within the District of Columbia, and emergency
room admissions consist primarily of patients
from the urban area. (For the purpose of
analysis, patients initially treated at other institutions and subsequently transferred are
excluded.) All patients were initially evaluated
in the emergency room by the surgical intern,
and preliminary laboratory studies, roentgenograms, and resuscitative efforts were carried out
in the trauma section under the direction of the
junior resident covering that service.
Three hundred twenty-one of the patients
(84%) either were stable on admission or
quickly became so following insertion of chest
tubes, volume replacement, and ventilatory

24 The Annals of Thoracic Surgery Vol 22

No 1 July 1976

support when indicated. Most of these patients

were then admitted to the intensive care unit
and carefully observed. Each was cared for by a
team of thoracic surgeons, pulmonary intensive
care specialists, surgical house officers, and
nurses particularly oriented to acute cardiovascular and respiratory problems. The electrocardiogram was continuously monitored in each
patient, and arterial and centralvenous pressures
were determined when indicated. Hourly vital
signs, intake, and output from chest tubes and
urethral catheters along with serial hematocrit
measurements, chest roentgenograms, and arterial blood gas determinations were also part of
the regimen. Respiratory support, when necessary, was maintained by a volume respirator.
When all clinical indicators had stabilized, the
patients were transferred to the surgical floor for
continued convalescence.
The remaining 59 patients (16%) required
either immediate or delayed operative intervention in the course of therapy (Table 1).In this

Immediate

Gunshot wound
Stab wound

15 ( 2 )

Blunt trauma
Total

Table 2, lndications for lmmediate Operation in

Patients Sustaining Thoracic Trauma
Indication

Gunshot
Wounds

Stab
Blunt
Wounds Trauma

Hemorrhage &

12 (2)

14 (2)

shock

Cardiac
tamponade
Injury to great
vessels
Rupture of
diaphragm

7 (5)

5 (1)

The majority of early operations were performed for hemorrhage, observed

directly by measuring chest tube drainage or
indirectly by noting hypotension and a continuing transfusion requirement. Of the 33 patients
requiring immediate operation for hemorrhage,
4 sustained a cardiopulmonary arrest in the
emergency room and thoracotomy was performed there. Sixteen of the patients were in
shock when admitted and required multiple,
rapid blood transfusions to maintain a normal
blood pressure. Thirteen of them became normotensive quickly and remained that way following administration of small amounts of fluid
and blood. However, drainage from their chest
tubes was at such a rapid rate that multiple
transfusions were required to equal volume
loss.
An intercostal or internal mammary vessel
was the site of bleeding in 11of the 33 patients,
as shown in Table 3. As might be expected, this
site was most common in stab wounds, while
patients sustaining gunshot wounds were more
likely to have multiple areas of bleeding, often
including abdominal organs. The 2 patients who
died from their gunshot wounds had bleeding
HEMORRHAGE.

No. of Patients

Operation

lmmediate Thoracotomy
The indications for immediate thoracotomy are
shown in Table 2.

Numbers in parentheses represent deaths.

Table 1. Operative Treatment of Patients

with Thoracic Trauma

Mode of Injury

indication for thoracotomy later developed, they

were taken to the operating room for exploration; this occurred from six hours to thirty days
after admission.

Delayed
Operation

19 (3)
10 (5)

8
2
5 (1)

44 (10)

15 (1)

Numbers in parentheses represent deaths.

series of patients the mode of injury could be

separated into three groups: gunshot wounds,
stab wounds, and blunt trauma. Those patients
who required immediate thoracotomy (44,or
12%) were initially evaluated in the emergency
room and either underwent immediate
thoracotomy there or were taken to the operating room within four hours of admission, allowing time for initial resuscitation or diagnostic
procedures. The remaining 15 patients (4%)
were first taken to the intensive care unit and
observed with repeat examinations, laboratory
studies, and serial roentgenograms. When an

25 Kish et al: Early Thoracotomy for Chest Trauma

Table 3. Source of Bleeding in Patients Undergoing

lmmediate Operation for Hemorrhage and Shock
~

Bleeding
Site

Gunshot Stab
Wounds Wounds

Intercostal or
internal
mammary vessels
Lacerated lung
Medias tinum
Thoracoabdominal
region

1
4

1
6 (2)

10

0
1 (1)
3 (1)

Blunt
Trauma

0
1
3 (3)
3 (2)

Numbers in parentheses represent deaths.

from the lung as well as the liver and spleen. One

died in the operating room of continued hemorrhage; the other died seven days postoperatively
of respiratory and hepatic failure.
Patients sustaining blunt trauma and secondary hemorrhage were more likely to have extensive, multiple-system injury and bleeding
sources. One patient was a 70-year-old woman
pedestrian who was struck by an automobile.
O n arrival in the emergency room she was noted
to have a flail chest. Shock rapidly developed
and her heart arrested, and emergency left
thoracotomy was performed. Although she was
resuscitated initially, electromechanical dissociation developed and she could not sustain
cardiac function. At postmortem examination
the cause of death was found to be mediastinal
hemorrhage secondary to paravertebral vein
avulsion. Of the other 4 deaths from hemorrhage
following blunt trauma, 2 were secondary to automobile accidents and 2 were the result of falls
on a construction project. Two of these patients
died in the operating room of diffuse bleeding
from the mediastinum as well as multiple intraabdominal sites, while the remaining 2 died
in the intensive care unit, both from complications of sepsis and multiple-organ failure.
Four patients bled significantly from gunshot
lacerations of the lung. These were either oversewn or a wedge resection was performed, and
all survived.
CARDIAC TAMPONADE. As seen in Table 2, 7
patients required immediate operation because
of cardiac tamponade. As soon as the diagnosis
was suspected in any patient, pericardicentesis

was performed in the emergency room. If the

condition stabilized, the patient was admitted
to the intensive care unit where cardiac function
was carefully monitored. In these 7 patients,
however, tamponade reformed and cardiac
function deteriorated, making operation mandatory.
Penetrating stab wounds of the heart were
found in 2 of these patients and proved fatal in 1
of them; the other was controlled, and a hole in
the right ventricle was closed. In the other 5
patients the myocardium was lacerated but
there was no active bleeding from the chambers
of the heart, and these patients were treated by
creation of a pericardial window.
OTHER
INDICATIONS. Two
patients developed widened mediastinum after being involved in automobile accidents. Both of them
also had decreasing intensity of the left radial
pulse. Aortography was immediately performed. The first patient was found to have an
injury of his left subclavian artery and had exploration through a trap-door incision made by
transecting the clavicle and rotating the chest
wall laterally. With this exposure it was possible
to control the proximal and distal ends of the
vessel, and sufficient length was achieved to
allow an end-to-end anastomosis of the artery
with restoration of flow. In the second patient
the left carotid and left subclavian arteries were
found to be avulsed, as shown in the Figure.
This injury was repaired successfully using a
reversed Y-graft from the aortic arch.
The remaining 2 patients who required immediate thoracotomy were found to have sustained traumatic rupture of the left hemidiaphragm, which was repaired through a left
thoracotomy incision. In addition, both patients
required splenectomy.

Delayed Thoracotomy
Fifteen patients, or 4% of the total number with
chest trauma, were subsequently operated on
after being admitted to the intensive care unit
for observation. Indications for delayed
thoracotomy are shown in Table 4.
HEMORRHAGE. The 6 patients who had continued bleeding were operated on from six to
thirty-six hours after admission. None of these

26 The Annals of Thoracic Surgery Vol 22 No 1 July 1976

Aortic arch arteriogram showing az1ulsI'oti of the left

subrlnviafi atid left carotid arteries.

patients was in shock, but because the rate of

bleeding either was greater than 150 ml per hour
for more than ten hours or amounted to 1,500 ml
in a shorter period, or because more than 3 units
of blood was required to maintain normal vital
signs in a ten-hour period, they were taken to
the operating room for exploration.
The 2 patients sustaining stab wounds had
lacerations of the internal mammary artery. Of
the 2 patients suffering gunshot wounds, 1was
found to have a transected intercostal artery
with persistent bleeding, while the other reTable 4. Indications for Delayed Operation
in Patients with Thoracic Trauma

Indication
Continued
hemorrhage
Hemoptysis
Widened
mediastinum
Persistent
hemothorax

Gunshot
Wounds

Stab
Wounds

Blunt
Trauma

3
0

0
0

0
3 (1)

Numbers in parentheses represent deaths.

quired suturing of the entrance wound in the

right lower lobe. This latter patient had been
operated upon earlier for bleeding, and at that
time an intercostal vessel had been ligated. Inspection of the lung had failed to show active
bleeding, and the chest was therefore closed.
Twenty-four hours after return to the intensive
care unit, however, he began to bleed and was
reexplored.
Two patients suffering blunt trauma required
delayed exploration for bleeding. One had multiple rib fractures and bleeding of the lung
parenchyma. The second was a 25-year-old
woman wrestler with a past history of pulmonary tuberculosis. During a match, she was
struck in the right chest and was admitted with a
fractured third rib and a right hemopneumothorax. She continued to bleed, and at
exploration fourteen hours after admission she
was found to have a torn apical adhesion from
her old inflammatory disease. This was suture
ligated, and she was discharged nine days later.
OTHER
INDICATIONS.
Three patients developed the late manifestation of a widened
mediastinum following blunt trauma. All 3 had
previously had a normal mediastinal diameter
on chest roentgenogram and had been admitted
to the intensive care unit for observation. As
soon as the mediastinal widening was recognized, aortography was performed. The 1fatality in this group was that of a 49-year-old man
who was involved in an automobile accident
and had sustained multiple fractures. After
evaluation he was admitted to the intensive care
unit and placed in traction. Several hours after
admission he began to complain of increasing
back pain, and a repeat chest roentgenogram
showed widened mediastinum. Aortography
disclosed a tear of the descending aorta, and he
was taken to the operating room where he exsanguinated despite an attempt to institute
bypass.
The other 2 patients had normal aortograms.
However, on repeat chest roentgenograms the
mediastinal diameter appeared to expand
slowly while hematocrit levels continued to fall,
and exploration was considered necessary.
Large hematomas of the mediastinum were
found in both patients; because no major arterial
bleeding site could be identified, the

27 Kish et al: Early Thoracotomy for Chest Trauma

hematomas were not dissected. Both patients

reached stable condition without further decompensation.
Three patients required delayed thoracotomy
because of hemoptysis and were found to have a
foreign body reaction secondary to bullets entering near the hilum of the lung. The times of these
operations ranged from seven to thirty days following injury. Three additional patients who
had suffered gunshot wounds developed persistent hemothorax and were taken to the operating
room for elective decortication.

Comment
Although most large series of thoracic injuries
have been from military experience, which
formed the basis for early guidelines for treatment, increasingly large numbers of thoracic injuries are being seen in civilian hospital
emergency rooms [8,9]. According to all reports,
the vast majority of these patients may be
adequately managed by careful observation, but
a small percentage will require thoracotomy,
either initially or at some further point in their
hospital course.
The total mortality in our series was 2.9%
among all those admitted and 19% (11 of 59
patients) for those requiring operation. The
highest mortality, 40% (6 of 15 patients), was
seen among those sustaining blunt trauma and
requiring operation. Ten of these 15 patients
also had associated injuries that contributed
substantially to their demise. In 1968 Bassett and
colleagues [l] reviewed patients sustaining
blunt trauma to the thorax in Detroit and concluded that as the number of extrathoracic injuries increased, so did the mortality rate. They
also found a correlation between mortality and
the number and location of rib fractures, which
would seem to be a reliable indicator of the force
of trauma.
In our series the frequency of associated injuries was not as high in patients sustaining
gunshot wounds to the chest as in those experiencing blunt trauma. Of the 23 patients who
suffered gunshot wounds and required operation, however, both deaths occurred in patients
with liver and spleen penetration in addition to
lung lacerations. Boja and Ransdell [3] reviewed 145 patients with gunshot wounds to the

chest and found that thoracoabdominal wounds

were the most common cause of death. They
advocated separate incisions to permit thorough
evaluation of each body cavity and to prevent
possible thoracic contamination from perforated
abdominal viscera. Most of the patients in the
current series were explored through a combined thoracoabdominal incision if the liver and
right chest were involved. Separate incisions
were made in patients sustaining left chest and
abdominal injuries or rupture of the diaphragm
and in those requiring emergency left thoracotomy in the emergency unit.
In 1963 Hatcher and Bahnson [71 advocated
aspiration of the pericardium in patients with
tamponade or suspected cardiac injury and recommended that open thoracotomy be reserved
for those patients in whom tamponade reformed. On the other hand, McNamara and
co-workers [9], in their review of combat injuries, considered the presence of tamponade an
indication for exploration and reported only 1
death among 13 patients. In the present series 7
patients were operated on for cardiac tamponade. All had undergone at least one attempt
at pericardicentesis and had either reaccumulated blood or were experiencing deteriorating
cardiac function, making operation mandatory.
Thus we would advocate at least one attempt at
pericardial tap before operating upon patients
with recurrent tamponade.
Early aortography has proved to be a valuable
tool in the diagnosis of vascular trauma within
the mediastinum. In the current series 2 patients
displayed a decreased radial pulse. Brawley and
colleagues 141 described 20 patients with upper
extremity vascular injury and outlined a specific
plan for management. They stressed the value of
angiography in making an accurate diagnosis of
injury and planning the operation to get
adequate control of all injured vessels. Often
this included thoracotomy to tamponade the
vessel initially and then a direct approach
through either a median sternotomy with right
supraclavicular extension or a left anterior
thoracotomy. Strum and co-workers [121 shared
the same aggressive approach to diagnosis but
preferred a supraclavicular incision. Hematomas of the mediastinum were found in 2
of their patients; they were not expanding and

28 The Annals of Thoracic Surgery Vol 22 No 1 July 1976

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