The resuscitative emergency thoracotomy in trauma – rarely used and rarely successful. However, for appropriately selected patients in extremis, such timely intervention may be literally life-saving.
The downside: resource utilization associated with saving the neurologically unsalvageable and the risks to providers associated with the procedure.
This is an evidence synthesis performed by a group of authors affiliated with the Eastern Association for the Surgery of Trauma, addressing the topic of patient selection for Emergency Department thoracotomy. Screening 2,152 studies to review, ultimately, 72, these authors review a total of 10,238 patient encounters in which patients underwent ED thoracotomy. This results in six recommendations for patients presenting pulseless to the Emergency Department after trauma:
- In patients with signs of life after penetrating thoracic injury: strongly recommend EDT.
- In patients without signs of life after penetrating thoracic injury: conditionally recommend EDT.
- In patients with signs of life after penetrating extra-thoracic injury: conditionally recommend EDT.
- In patients without signs of life after penetrating extra-thoracic injury: conditionally recommend EDT.
- In patients with signs of life after blunt injury: conditionally recommend EDT.
- In patients without signs of life after blunt injury: conditionally recommend against EDT.
However, before you start rummaging around in your toolbox for the rib spreaders, it should be recognized the conditional recommendations – except in penetrating thoracic injury – result in absolute intact survival increases only in the range of 20-40 patients per 1000. Therefore, unless you’re working in a setting of maximal effectiveness and experience, it is unlikely you’ll see even this small absolute benefit. And, even in the setting with the strong recommendations and excess intact survival benefits of 100 patients per 1000 – your individual hospital system, based on institutional support and experience level of the providers involved, will need to develop specific policies for these situations. Even though many ED physicians are capable of performing these heroic procedures based on their training, the remaining ED staff and systems in place may not be adequate to support the intervention.
“An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma”
http://www.ncbi.nlm.nih.gov/pubmed/26091330