What's New in Emergencies Trauma and Shock? Resuscitative Thoracotomy in Emergency Room - Selective not Obligatory.

We have read and reviewed with interest the article entitled “A National Study of Emergency Thoracotomy for Trauma,” highlighting the importance of this life-saving procedure. Thoracic trauma occurrence gas a global variation, but on the whole accounts for 25%–50% of deaths. For penetrating thoracic trauma, <30% require an operation compared to <10% in the blunt chest trauma group. Management is often relatively straightforward, with the vast majority of cases requiring just thoracocentesis.[1]

It is important, from the outset to understand the terminology. With regard to the patients who have sustained a trauma involving their chest, with suspicion of cardiac/great vessel involvement, there are three main groups; those who are clinically/physiologically noncompromised to wait for further investigations (such as Extended-FAST (Focused assessment with Sonography for Trauma)), those who are physiologically compromised and will need surgery (resuscitative thoracotomy) in the emergency department and those who are well enough to be transferred in the emergency theater (emergent thoracotomy). There are two distinct types of thoracotomy which may be undertaken, depending on patient physiology and available resources: Resuscitative thoracotomy and emergent thoracotomy. For this commentary, we will focus on resuscitative thoracotomy.

Although, one point of contention and possible contradiction to the authors, is that this procedure is not a salvage procedure, but a life-saving procedure. Resuscitative thoracotomy is a component of damage control resuscitation and is usually performed in the resuscitation room. This is undertaken in the patient who has circulatory arrest or is on the precipice of arrest. The “classical” teaching is to undertake a left anterolateral thoracotomy, followed by opening the pericardium to relieve a cardiac tamponade (if present) or to apply pressure to the descending thoracic aorta (for subdiaphragmatic bleeding). It can take as little as 50 ml of blood in the pericardial sac to impair cardiac function and cause arrest. Applying pressure to the descending thoracic aorta or the application of a clamp will increase cardiac and cerebral blood flow. In reality, a left anterolateral thoracotomy seldom allows satisfactory access to the intrathoracic cavity, and a clamshell thoracotomy is undertaken. Overall though, in the past decades, there is clearly a clinical shift in the performance of resuscitative thoracotomy from a nearly obligatory procedure to a procedure kept for selected patients only.[2]

There are many studies on resuscitative thoracotomy. The clear majority are case reports or small observational studies. However, there are a few systematic reviews of the literature and several retrospective cohort studies. Their often-conflicting results reflect the variability on the outcome and controversies on resuscitative thoracotomy. Over the past few decades, there has clearly been a clinical shift in the performance of resuscitative thoracotomy from a nearly obligatory procedure to selected patients based on the outcome from the large series of patients. The use in penetrating injuries is more common and results better compared to blunt injuries.[3] These results are echoed also in low-volume centers.[4]

There is no universal guidance with regard to the indications of resuscitative thoracotomy. Current evidence suggests that outcome is best for penetrating trauma with pending (or witnessed) cardiac arrest. Most favorable outcomes also reported for those with an isolated stab cardiac injury. Critical point in the studies we found was whether they included demographic data, mechanism of injury, injury severity, signs of life, vital signs as well as neurological outcome.[35]

The location of the thoracotomy is a point of discussion. Should it take place on the scene, in the emergency room or in the operating theater? The optimal results are, as expected for thoracotomies performed in hospital with an experienced team, most likely because those patients have had a witnessed arrest or have self-selected themselves to arrive in the hospital. Poor outcomes are seen in the resuscitative thoracotomies where there is less experienced team, high severity of injury. The on-scene thoracotomy has proven to be of no benefit in the military setting[678] and in the civilian setting, only a select group when undertaken by a specialist team.[9] Otherwise, it has not been proven to show any benefit and an approach of “scoop and play” is recommended.[10]

It is necessary to appreciate the primary goal of resuscitative thoracotomy: relief of cardiac tamponade and cross clamping the descending thoracic aorta. Definitive surgery should follow if and when the patient's physiology allows. While the evidence shows poor outcomes in blunt trauma, if there are witnessed signs of life, and arrest has occurred within 10 min of arrival into the resuscitation room, then resuscitative thoracotomy should be performed. Resuscitative thoracotomy for penetrating injury, with the patient having signs of life on arrival to resuscitation room, has higher survival rate. Undoubtedly, the presence of an experienced team and adequate resources also increases the chances of survival. Alternatives are practically limited. The neurologic outcome of the survivors is impressive; however, the cost and the risks for the providers are significant.