When Is ED Thoracotomy Futile

December 23, 2017

On the Shoulders of Giants

Spoon Feed
Patients who had blunt trauma with CPR > 10 minutes, penetrating trauma with CPR > 15 minutes, or asystole without tamponade should not undergo resuscitative thoracotomy in the ED as it would be futile.

Why does this matter?
A resuscitative thoracotomy is the most drastic, invasive procedure in the ED.  It is often done very hastily, by necessity, and may lead to injury for the operators or assistants, i.e. needlestick. In certain scenarios, survival is rare and neurologic disability may occur in survivors, so it only makes sense to critically analyze the risk vs. benefit of this procedure.

Crack the chest…or not
This was a look at a large trauma registry.  Data were collected prospectively.  They found that in the 6 years of data collection, 56 people survived to hospital discharge.  Of these, 10/56 (18%) had severe neurologic disability, requiring total care.  The authors concluded that blunt trauma patients with CPR > 10 minutes, penetrating trauma patients with CPR > 15 minutes, or asystole without tamponade were all cases in which ED thoracotomy was futile and should not be performed.

Source
Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective.  J Trauma. 2011 Feb;70(2):334-9. doi: 10.1097/TA.0b013e3182077c35.

Another Spoonful

• EAST has done an excellent clinical practice guideline which reviews the evidence.
• Ultrasound at the bedside may be one of the best ways to tell when to cut or not.  No pericardial fluid and no cardiac activity = no survivors.