From the Guidelines
Resuscitative thoracotomy is indicated in trauma patients with penetrating thoracic trauma and signs of life on arrival or within 15 minutes prior to arrival, as well as in cases of penetrating non-thoracic trauma or blunt trauma with recent loss of signs of life. The primary goal of this procedure is to improve survival rates and reduce morbidity and mortality in these critically injured patients. According to the most recent and highest quality study, the indications for resuscitative emergency thoracotomy include short-term cardiac arrest or impending cardiac arrest caused by penetrating and blunt trauma, with a success rate of 7-21% 1. The procedure should be performed by experienced providers in appropriate settings, typically trauma centers, and allows for direct cardiac massage, control of intrathoracic hemorrhage, cross-clamping of the descending aorta, relief of cardiac tamponade, and open cardiac massage. Some key points to consider when deciding to perform a resuscitative thoracotomy include:
- The mechanism of injury, with penetrating thoracic trauma having better outcomes compared to blunt trauma
- The time elapsed since the loss of signs of life, with delays beyond 15 minutes dramatically reducing survival chances
- The presence of signs of life, including pupillary response, spontaneous breathing, palpable pulse, measurable blood pressure, extremity movement, or cardiac electrical activity
- The availability of experienced providers and appropriate settings, such as trauma centers, to perform the procedure. It is also important to note that resuscitative emergency thoracotomy should be performed on the basis of effective blood transfusions, fluid infusions, and other anti-shock treatments 1. Overall, the decision to perform a resuscitative thoracotomy should be made on a case-by-case basis, taking into account the individual patient's circumstances and the available resources.
From the Research
Trauma Indications for Resuscitative Thoracotomy
The indications for resuscitative thoracotomy (RT) in trauma patients are as follows:
- Blunt trauma patients with less than 10 minutes of prehospital cardiopulmonary resuscitation (CPR) 2
- Penetrating torso trauma patients with less than 15 minutes of CPR 2
- Patients with penetrating trauma to the neck or extremity with less than 5 minutes of prehospital CPR 2
- Patients in profound refractory shock 2
- Penetrating trauma with witnessed cardiopulmonary arrest and presence of vital signs at the trauma center 3
- Cardiac tamponade due to penetrating chest injury, even if not clinically obvious on admission 4
Patient Selection and Outcome
Patient selection is crucial in determining the outcome of RT. The success of RT approximates 35% for patients arriving in shock with a penetrating cardiac wound and 15% for all patients with penetrating wounds 2. However, patient outcome is relatively poor when RT is performed for blunt trauma, with a 2% survival rate for patients in shock and less than 1% survival rate for patients with no vital signs 2. The overall survival rate for EDRT is around 7.8% 3.
Technical Considerations and Training
Technical considerations of RT, as well as proper training, personnel, and location, are essential for a successful outcome 5. The procedure should be reserved for acute resuscitation of selected dying trauma patients, and the risks of futility, costs, and benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure 3.