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When to Crack the Pediatric Chest – New Guidelines

October 24, 2023

Written by Clay Smith

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Emergency department thoracotomy (EDT) is recommended in pulseless pediatric patients with signs of life (SOL)* who have penetrating thoracic/abdominopelvic trauma; if pulseless with SOL* and blunt trauma, a conditional recommendation is made.

When to crack the pediatric chest
EAST EDT guidelines for adults recommend EDT in more scenarios. Also, WEST found (in adults) blunt trauma patients with CPR > 10 minutes, penetrating trauma with CPR > 15 minutes, or asystole without tamponade (on ultrasound) were cases in which ED thoracotomy was futile.

This systematic review included 11 articles (319 pediatric patients). The author/experts made the following recommendations based on this very low quality evidence with high risk of bias.

  • EDT is recommended when a child presents pulseless with SOL and has penetrating thoracic or abdominopelvic trauma; EDT is conditionally recommended in blunt trauma with SOL.
  • EDT is conditionally NOT recommended if a child is pulseless without SOL after penetrating thoracic or abdominopelvic trauma.
  • EDT is strongly not recommended if a child is pulseless with no SOL after blunt thoracic or abdominopelvic trauma.

How will this change my practice?
The key is SOL*. Pulseless penetrating trauma with SOL is a pretty clear indication for EDT in children, though the evidence base is weak. However, pulseless blunt trauma with SOL in children is less clear. In such cases, if ultrasound or bilateral thoracostomies indicate a thoracic source of injury, authors favored EDT. But the same child with concomitant severe head injury may not benefit from EDT. The surgeon or emergency physician in the room with all the information is in the best position to make the call.

Here is a summary of pediatric vs adult EDT guidelines:

ED thoracotomy in pediatric patients vs adult patients
From cited article

*Signs of life = cardiac electrical activity, respiratory effort, pupillary response, palpable pulses, measurable blood pressure, or extremity movement.

Emergency department thoracotomy in children: A Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma systematic review and practice management guideline. J Trauma Acute Care Surg. 2023 Sep 1;95(3):432-441. doi: 10.1097/TA.0000000000003879. Epub 2023 Mar 11.

What are your thoughts?