From the Guidelines
Resuscitative thoracotomy is indicated for patients with penetrating thoracic trauma who have signs of life at presentation or recent loss of vital signs, typically within 15 minutes for thoracic injuries and 10 minutes for extrathoracic injuries, as stated in the most recent and highest quality study 1. The procedure involves making a large incision in the left side of the chest, allowing direct access to the heart, major vessels, and lungs. The main goals are to:
- relieve cardiac tamponade
- control hemorrhage
- perform open cardiac massage
- cross-clamp the descending aorta to prioritize blood flow to the brain and heart
- repair cardiac injuries This procedure should only be performed by trained surgeons or emergency physicians in appropriate settings with immediate surgical backup. According to the study 1, the success rate of resuscitation emergency thoracotomy is 7–21%, and is generally higher for patients who lose their life signs for less than 45 min and those who are evacuated to Level III facilities alive but experience cardiac arrest later and were treated by closed chest cardiopulmonary resuscitation (CC-CPR) for less than 15 min. In addition to the indications and procedure, it is essential to consider the complications, including infection, damage to thoracic structures, and exposure of healthcare providers to bloodborne pathogens, as mentioned in the study 1. The study 1 provides some general guidelines for CPR and emergency cardiovascular care, but it does not specifically address the indications for resuscitative thoracotomy. Therefore, based on the most recent and highest quality study 1, resuscitative thoracotomy should be performed quickly to maximize chances of survival in patients with penetrating thoracic trauma who have signs of life at presentation or recent loss of vital signs.
From the Research
Indications for Resuscitative Thoracotomy
The indications for resuscitative thoracotomy, also known as emergency thoracotomy, are widely debated and have changed over the years. According to the available evidence, the following are some of the indications for this surgical procedure:
- Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform resuscitative thoracotomy 2
- Resuscitative thoracotomy can be performed for trauma patients with impending or full cardiovascular collapse, particularly those with thoracic trauma 3
- The procedure is potentially life-saving for patients with penetrating thoracic injuries in extremis and with signs of life 3
- Resuscitative thoracotomy can be considered for patients with cardiac arrest after penetrating trauma, especially if there is an experienced prehospital doctor present 4
Factors Associated with Survival
Several factors are associated with survival after resuscitative thoracotomy, including:
- Stab wound, single cardiac wound, cardiac tamponade, and loss of pulse in the presence of an experienced prehospital doctor 4
- Time from arrival on scene to prehospital resuscitative thoracotomy >5 min is associated with increased neurological complications, and time from the initial encounter to prehospital or emergency department resuscitative thoracotomy >10 min is associated with increased mortality 3
- ISS ≥ 25 and absent signs of life are also associated with increased mortality 3
Guidelines and Recommendations
Different guidelines and recommendations exist for resuscitative thoracotomy, including those from the Eastern Association for the Surgery of Trauma (EAST) and the Western Trauma Association (WTA) 5. The choice of guideline may affect the indication for resuscitative thoracotomy and subsequent outcomes.