What is the survival rate after Return of Spontaneous Circulation (ROSC) following an open Emergency Department (ED) thoracostomy?

Survival Rate After ROSC Following Open ED Thoracotomy

The survival rate after Return of Spontaneous Circulation (ROSC) following an open Emergency Department (ED) thoracotomy is extremely poor, with approximately 0% survival for blunt trauma patients without signs of life and up to 30-35% survival for penetrating trauma patients who had signs of life before arrest.

Survival Rates by Trauma Type

Penetrating Trauma

• Overall survival rate: 22% (58 of 269) 1
• Survival rates by specific mechanism:
  • Stab wounds: 34% (48 of 141) 1
  • Gunshot wounds: 8% (10 of 131) 1
• Patients with penetrating trauma in profound shock (BP <60 mmHg) who achieve ROSC: 64% survival 1
• Patients with penetrating trauma in mild shock (BP 60-90 mmHg) who achieve ROSC: 56% survival 1
• Pediatric patients with penetrating trauma: 10.2% survival 2

Blunt Trauma

• Overall survival rate: 2% (3 of 193) 1
• Pediatric patients with blunt trauma: 1.6% survival 2
• No reported survivors under 14 years of age following blunt trauma 2

Prognostic Factors Affecting Survival After ROSC

Positive Prognostic Factors

1. Presence of signs of life (SOL):

   • Strongest association with ROSC (OR 11.297,95% CI 1.496-85.309) 3
   • Patients with SOL had significantly higher ROSC rates (86.5% vs 28.0%) 3

2. Short CPR duration:

   • ROSC group had shorter CPR times (6 [2-10] min vs 11 [8-12] min) 3
   • CPR >15 minutes is predictive of death or poor outcome 4

3. Lower injury severity:

   • ROSC group had lower Injury Severity Scores (26 [25-39] vs 37 [30-75]) 3

4. Mechanism of injury:

   • Penetrating trauma has significantly better outcomes than blunt trauma 1, 2

Negative Prognostic Factors

1. Absence of signs of life in the field:

   • No patients with absent signs of life on initial prehospital assessment survived 1
   • ROSC was less likely among patients with no prehospital SOL (OR 0.30,95% CI 0.13-0.69) 5

2. Prehospital intubation in penetrating trauma:

   • Lower odds of ROSC with any prehospital intubation attempt (OR 0.39,95% CI 0.19-0.82) 5

3. Blunt mechanism:

   • Uniformly poor outcomes, especially without signs of life 1, 2

Post-ROSC Survival Trends

The survival to discharge rate for patients who achieve ROSC after cardiac arrest in the intensive care setting has shown a modest improvement over time, from approximately 30.3% to 31.4% between 2006 and 2018 6. However, this data is not specific to traumatic arrests requiring thoracotomy.

Key Considerations in ED Thoracotomy

1. Timing is critical:

   • Survival correlates with physiologic status at time of intervention 1
   • Shorter time to intervention improves outcomes

2. Patient selection:

   • ED thoracotomy should be considered for:
     • Penetrating trauma patients with signs of life or recent loss of signs of life
     • Patients in profound shock (BP <60 mmHg) with subsequent arrest
   • ED thoracotomy is generally not indicated for:
     • Blunt trauma patients with no signs of life
     • Patients with prolonged CPR (>15 minutes)

3. Post-ROSC care:

   • Hemodynamic goals (MAP, SBP) should be considered as part of post-resuscitation care 4
   • Targeted temperature management may be considered for eligible patients

Conclusion

The survival rate after achieving ROSC following ED thoracotomy varies significantly based on mechanism of injury, presence of signs of life, and time to intervention. While overall survival remains poor, proper patient selection can identify those with the best chance of meaningful recovery.