Emergency Department Thoracotomy

CPT 32160 · 12.77 wRVU · 90-day global

CPT32160

wRVU12.77

Global90-day

ApproachOpen

ComplexityComplex

Add-on / Variant CPTs

32110 wRVU: 24.65 — Thoracotomy with control of traumatic hemorrhage (if subsequent OR thoracotomy required for definitive repair)

Preoperative Diagnosis:

Traumatic cardiac arrest: [penetrating thoracic / abdominal trauma / blunt trauma] with loss of signs of life

Postoperative Diagnosis:

Same

Procedure Performed:

Emergency department / resuscitative thoracotomy, left anterolateral

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident / Team member]

Anesthesia:

None / [Ketamine for response to stimuli]; patient in traumatic arrest

Indications:

Patient presents with [penetrating thoracic / abdominal stab / gunshot wound / blunt thoracic trauma] and [witnessed arrest / loss of pulses in the trauma bay / loss of signs of life within [X] minutes of hospital arrival]. [CPR in progress x [X] minutes.] Emergency department thoracotomy performed per [EAST / ACS COT] guidelines for [penetrating trauma with loss of signs of life <15 arrest]< blunt minutes span witnessed>. Goal: [relief of pericardial tamponade / direct cardiac compression / aortic cross-clamping for distal hemorrhage control / air embolism management].

Findings:

[Pericardial tamponade: [blood evacuated / clot removed] / No tamponade]. Cardiac rhythm at opening: [asystole / ventricular fibrillation / PEA]. [Cardiac wound identified: [right ventricle / left ventricle / atrium] laceration.] [Aorta cross-clamped at descending thoracic level.] [RETURN OF SPONTANEOUS ACTIVITY after [X] minutes / No return of cardiac activity.]

Description of Procedure:

The patient was positioned supine in the trauma bay. Left anterolateral thoracotomy was performed with a [10-blade scalpel] through the [4th / 5th] intercostal space from the left sternal border to the posterior axillary line. Rib spreader placed. The left lung was retracted superiorly.
[PERICARDIOTOMY:] The pericardium was opened longitudinally anterior to the phrenic nerve. [Tamponade confirmed; blood and clot evacuated. Cardiac wound identified.]
[CARDIAC REPAIR:] The [right / left ventricular] laceration was controlled with [digital pressure / Foley catheter balloon tamponade]. [Horizontal mattress sutures of [0-Prolene] placed across the wound.]
[AORTIC CROSS-CLAMP:] The descending thoracic aorta was identified, mobilized, and cross-clamped with a [vascular / aortic cross-clamp] to redistribute blood flow to coronary and cerebral circulation and reduce distal hemorrhage.
[INTERNAL CARDIAC MASSAGE:] Bimanual internal cardiac massage performed. [Defibrillation x[X] with [X] joules; [ROSC achieved / no response].]
[Return of spontaneous cardiac activity noted at [X] minutes; patient taken to OR for definitive repair.]
[No return of cardiac activity after [X] minutes of resuscitative efforts. Cardiac activity absent. Patient pronounced at [time].]

Complications:

[Patient expired / ROSC achieved and transferred to OR]

Specimens:

None

Estimated Blood Loss:

[X] mL

Drains:

None

Disposition:

[Patient expired in trauma bay at [time] / Patient transferred to OR for definitive repair in [stable / critical] condition.]

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: Traumatic cardiac arrest: [penetrating / blunt] trauma with loss of signs of life
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Emergency department / resuscitative thoracotomy, left anterolateral
ATTENDING SURGEON: ***, MD/DO
ANESTHESIA: None; patient in traumatic arrest

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [penetrating thoracic / abdominal / blunt thoracic] trauma and [witnessed arrest / loss of signs of life within *** minutes of arrival]. CPR x *** minutes. EDT performed per [EAST/ACS COT] guidelines. Goals: [tamponade relief / cardiac massage / aortic cross-clamping].

FINDINGS: [Pericardial tamponade; clot evacuated.] [Cardiac wound: *** laceration.] Rhythm at opening: [asystole / VF / PEA]. [Aorta cross-clamped.] [ROSC achieved at *** min / No return of cardiac activity.]

DESCRIPTION OF PROCEDURE:
Left anterolateral thoracotomy through [4th / 5th] ICS, sternal border to posterior axillary line. Rib spreader placed; left lung retracted. [Pericardium opened anterior to phrenic nerve; tamponade confirmed; blood and clot evacuated.] [Cardiac wound controlled with digital pressure / Foley balloon; repaired with 0-Prolene mattress sutures.] [Descending thoracic aorta cross-clamped.] [Internal cardiac massage performed; defibrillation x ***.] [ROSC at *** minutes; to OR.] [No return of activity after *** minutes; patient pronounced at ***.]

ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: [Expired / ROSC and transferred to OR]
DRAINS: None
DISPOSITION: [Patient expired at *** / Patient transferred to OR in critical condition.]

Signed: .ME, .MYDEGREE
.TODAY

Variants

Cardiac stab wound (penetrating cardiac injury)

Highest survival of all EDT indications. Document wound location (right ventricle most common), tamponade, and repair technique. If ROSC, take immediately to OR for formal repair. Foley balloon temporizing for large wounds.

OR thoracotomy for hemorrhage control

CPT 32110. Planned operative thoracotomy for lung laceration, pulmonary hilar control, or descending aortic injury. Different from EDT; patient arrives in OR with some vital signs. Document approach (anterolateral vs. posterolateral) and injuries addressed.

Charting Tips

Document time of EDT initiation and total resuscitation time
State indication criteria met per EAST or ACS COT guidelines
Document cardiac rhythm and activity at time of pericardiotomy
{'Note each maneuver performed': 'tamponade evacuation, cardiac massage, cross-clamp, defibrillation'}
If ROSC achieved, document transfer to OR and time of ROSC
If patient expires, document time of pronouncement and efforts made

Billing Tips

Bill 32160 for resuscitative thoracotomy (cardiac massage, open, in the thorax, 12.77 wRVU) when performed for traumatic cardiac arrest. If pericardiotomy (relief of tamponade) is the primary procedure, it may be separately billable with 33010 (pericardiocentesis), but given the emergent open nature of EDT, 32160 captures the procedure.
Aortic cross-clamping (descending aorta) performed during EDT is included in the thoracotomy code. Do not separately bill aortic control. Document the procedure in the note as it is a critical intervention.
If the patient survives EDT and is taken to the OR for definitive repair of cardiac, pulmonary, or vascular injuries, those subsequent procedures are separately billable. EDT codes are for the resuscitative procedure; OR repair codes are distinct.
EDT performed in the trauma bay by a surgeon is billed as a surgical procedure (32160). Pronouncement of death does not negate the billing if the procedure was medically indicated and performed by a qualified physician. Documentation of indication and outcome is essential.
Survival rates: blunt trauma EDT ~1-2%, penetrating cardiac EDT ~15-30%. Document the indication, patient status at EDT initiation (witnessed loss of signs of life, CPR duration), and outcome clearly. These affect medicolegal documentation.

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