By: Kelvy Levit, PGY3
Reviewed by: David Slattery, MD
The ED thoracotomy (EDT) was originally intended as an access point for open cardiac massage to treat cardiac arrest prior to the 1960’s. Interestingly, this was the only method of providing CPR until closed chest compressions were described by Dr. Kowenhoven in 1960 (1).
The ED thoracotomy, also known as a resuscitative thoracotomy (RT), is a controversial but potentially lifesaving procedure in certain patients. It involves exposure of the heart, lungs, and major vessels with the hope that the source of injury can be identified and managed. It is a temporizing measure and usually considered a last resort until definitive treatment in the operating room. Survival rates after an EDT have been shown to be as high as 35% in hypotensive patients with isolated cardiac injuries and 20% in isolated cardiac injuries presenting without signs of life. Survival rates are around 1 to 2% in blunt trauma patients (2).
It’s important to know your limitations as an emergency physician performing this procedure. The most likely and most critical interventions that the EM physician can perform are:
It’s important to note that there are no randomized control trials that exist to support the recommendations to perform an EDT. The indications are not absolute and still remain debatable. The populations that are most likely to benefit are those that can be definitively and rapidly managed. For example: cardiac tamponade, penetrating cardiac injury, or pulmonary hilar bleeding.
There have been multiple studies that have been conducted to identify which patients will benefit from an EDT. Current practice guidelines have been published by several organizations, including: the Eastern Association for the Surgery of Trauma (EAST), the Western Trauma Association (WTA) and American College of Surgeons.
All three societies mention signs of life (SOL) as part of their guidelines and it’s important to know what these are defined as. Signs of life include: any cardiac activity including pulseless electrical activity, brainstem reflexes (pupil reactivity, gag reflex, corneal reflexes, or spontaneous respirations), purposeful movement, palpable pulses, or a measurable blood pressure.
The American College of Surgeons performed a rigorous literature search in 2001. They had no class 1 evidence in the studies they reviewed. They found 29 studies with class 2 evidence and 63 studies with class 3 evidence. Their recommendations are to “rarely perform” an EDT in patients in cardiac arrest due to blunt trauma. They also state that an EDT is best applied to penetrating cardiac injuries who arrive at trauma centers after a “short scene and transport time” with signs of life. Lastly, they state that an EDT should be “judiciously” performed in exsanguinating abdominal vascular injuries and to be used as an adjunct to definitive repair (3).
The EAST group performed a systematic review of 72 studies with a total of 10,238 patients in which ED thoracotomy was performed. The objective was to evaluate whether EDT actually improves the outcome for the patient, when compared with resuscitation without thoracotomy, in a combination of possible circumstances in which the patient might present to the ED. Their final recommendations were established by an expert committee estimating the chance of survival if each group received standard resuscitation without EDT. They also factored in neurologic status as part of their recommendations.
For penetrating thoracic trauma who present with signs of life, survival after an EDT was 21.3% with 90% of these patients being neurologically intact. They estimated that survival without an EDT was 2.8%. The committee strongly recommends an EDT for these patients.
If there are no signs of life, survival after an EDT was 8.3%. Estimated survival without an EDT was 0.2% with 0.18% being neurologically intact. The committee conditionally favors an EDT for these patients.
For patients with extra-thoracic penetrating trauma who present with signs of life survival with an EDT was 15.6%. Estimated survival without an EDT was 1.7%. For patients presenting without signs of life, survival with an EDT was 2.9%. Estimated survival without an EDT was 0.1%. The committee conditionally recommends an EDT for these patients.
For patients with blunt thoracic trauma who present with signs of life, survival after an EDT was 4.6% with 2.4% being neurologically intact. The estimated survival without an EDT was 0.5%. For patients who present without signs of life, survival was 0.7%. The estimated survival without an EDT was 0.001%. The committee conditionally does not recommend an EDT for these patients.
In contrast to the EAST guidelines which are based on the presence or absence of SOL, the recommended by the WTA stratifies patients based on injury and transport time. In 2012 they performed a review of the literature and also had a committee give their expert opinions. They evaluated prospective data over 6 years from 18 different hospitals and had a total of 56 survivors after an EDT. They found that 35% of patients with penetrating trauma in profound shock with signs of life survived. They found that 2% of patients after blunt trauma survived an EDT if they were in profound shock with signs of life and 1% if they present with no signs of life.
The WTA recommends an EDT (4) if:
The patient sustained penetrating thoracic trauma, presents with no SOL and CPR has been less than 15 minutes.
The patient sustained blunt thoracic trauma, presents with no SOL and CPR has been less than 10 minutes.
The patient sustained penetrating neck or extremity trauma with no SOL and CPR has been less than 5 minutes.
Contraindications to consider are patients with non-survivable traumatic brain injuries or no signs of life on scene. Relative contraindications to consider prolonged CPR time (greater than15 minutes for penetrating trauma and 10 minutes for blunt trauma with no SOL in either). Lastly, if there is no trauma surgery support within approximately 45 minutes, including time required to transport the patient to a facility with surgical support, a EDT should not be performed (3)(4)(5).
There have been some studies that address the question: Can ultrasound help guide the decision to perform an EDT?
In 2016, Inaba et al., performed a prospective observational study at LAC/USC. They wanted to examine the ability of the FAST examination to predict survivors vs non-survivors after an EDT. They performed a FAST on 187 patients preceding an EDT after traumatic arrest over 4 years. The primary outcome was survival until discharge or organ donation. A total of 9 patients survived. 6 survived to discharge (3.2%) and 3 (1.6%) were organ donors. Survival of patients without cardiac motion was zero. In other words, there were 126 patients with no cardiac activity or pericardial fluid and not a single patient survived or went to organ donation. They found that cardiac motion on ultrasound has a negative predictive value of 100%. They concluded that absence of cardiac motion or pericardial fluid on a FAST exam in patients with traumatic cardiac arrest can be helpful in identifying those in whom resuscitative thoracotomy might be appropriate (5). In the WTA’s study they found 7 of their 56 survivors had asystole with pericardial fluid or tamponade (4).
Ultrasound provides an objective and useful measure that the team can see and buy in on. If considering the EDT and cardiac motion is visualized or asystole is seen with an effusion, an EDT can still be considered as these have been shown to show survivability.
Return of Spontaneous Circulation (ROSC)
The endpoint ideally is ROSC, when a few things may happen. The patient may wake up and so will require appropriate sedation. The internal mammary arteries may start bleeding and should be controlled with hemostats or tied off. The chest should be lightly packed with sterile lap pads soaked with warm saline. The patient should expediently be taken to the OR while continuing resuscitation.
Ultimately, the decision to perform should be based on the risks and benefits to patient, the provider, staff, and available support. Once the decision to perform an EDT is made, the ED provider should slow down. As Scott Weingart commonly says, “slow is smooth and smooth is fast”. Patients who remain in asystole despite an EDT, decompression of tamponade, and control hemorrhage should be pronounced dead. However, decision stop resuscitation efforts can be difficult and are multifactorial. Remember the overall low survival rate following an EDT and if the patient doesn’t survive, known that you gave them their best chance of survival.
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