Hey guys! Here’s the latest overview of ED thoracotomies from LITFL.com posted on March 11, 2016.  I’ve only seen 3 of these during my medical career, two of them were last week. One was my patient and the other was Jenny’s. While both didn’t survive their hospital course, my patient did regain a pulse and make it through several hours of surgery. If you haven’t encountered this scenario yet, I’m sure you aren’t alone. Still, it’s important to know not only how to perform it, but when.

Interesting articles to review:

• #1 To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis.

  Slessor D¹, Hunter S².

  Author information

  Abstract

  STUDY OBJECTIVE:

  The role of emergency department (ED) thoracotomy after blunt trauma is controversial. The objective of this review is to determine whether patients treated with an ED thoracotomy after blunt trauma survive and whether survivors have a good neurologic outcome.

  METHODS:

  A structured search was performed with MEDLINE, EMBASE, CINAHL, and PubMed. Inclusion criteria were ED thoracotomy or out-of-hospital thoracotomy, cardiac arrest or periarrest, and blunt trauma. Outcomes assessed were mortality and neurologic result. The articles were appraised with the system designed by the Institute of Health Economics of Canada. A fixed-effects model was used to meta-analyze the data. Heterogeneity was assessed with the I(2) statistic.

  RESULTS:

  Twenty-seven articles were included in the review. All were case series. Of 1,369 patients who underwent an ED thoracotomy, 21 (1.5%) survived with a good neurologic outcome. All 21 patients had vital signs present on scene or in the ED and a maximum duration of cardiopulmonary resuscitation of 11 to 15 minutes. Thirteen studies were included in the meta-analysis. If there were either vital signs or signs of life present in the ED, the probability of a poor outcome was 99.2% (95% confidence interval 96.4% to 99.7%).

  CONCLUSION:

  There may be a role for ED thoracotomy after blunt trauma, but only in a limited group of patients. Good outcomes have been achieved for patients who had vital signs on admission and for patients who received an ED thoracotomy within 15 minutes of cardiac arrest. The proposed guideline should be used to determine which patients should be considered for an ED thoracotomy, according to level 4 evidence.

  #2 Inaba K et al. FAST Ultrasound Examination as a Predictor of outcomes After Resuscitative Thoracotomy: A Resuscitative Thoracotomy. Ann Surg 2015; 262 (3): 512 – 8. (Inaba et al. 2015)*

  • Background #1: In patients who suffer a traumatic cardiac arrest, a final salvage maneuver that is performed in the Emergency Department (ED) is a resuscitative thoracotomy (RT). There are two lines of thought about RT that are on opposite sides of the spectrum. The first line of thought is that if RT is not performed the patient is going to die anyways, so why not try it as a last ditch effort. The second line of thought is that due to the low yield in survival with RT, why expend resources and create a potential risk of harm to providers. The Focused Assessment Using Sonography for Trauma (FAST) has a high sensitivity and specificity for identifying hemopericardium and cardiac activity in a matter of seconds. Since there is really no good way to discriminate between which patients with traumatic cardiac arrest would benefit from RT, maybe adding a bedside FAST could help make this distinction.
  • This was a prospective, observational trial in 1 Trauma center in California
    • Patients undergoing RT in the ED
      • All penetrating trauma patients with absent vital signs
      • All blunt trauma patients with loss of vital signs en route or in the resuscitation bay
    • FAST performed just before or concurrently with RT
  • Bottom Line #1: ALL survivors and organ donors had visible cardiac motion on FAST. If no cardiac motion or pericardial effusion was seen on FAST, then survival was zero.

These are useful especially when you’re looking at who to perform this on. End goal is for the patient to survive the hospital course or in the case of possible organ donation.

Due to the large regional and facility variation in practice of who/when to perform this procedure, it will be very important for you to know what your facility’s policy is or your trauma team’s stance is as well.

Quick ED thoracotomy video. ..no instructional audio, so go over the steps prior to watching this. Otherwise, you may be lost. ..

Below is LITFL’s most recent post from 03/11/16: