ED Thoracotomy–to do or not to do: that is the question.

ED thoracotomies were introduced into medicine circa 1900, with endless debate and controversy to follow.

It’s a procedure that no doubt can save a patient’s life, as without this “last ditch” effort, mortality would be 100% in a trauma patient left in cardiac arrest.  Survival outcomes have been quoted anywhere from nil to 60%.

Let’s review the current indications for ED thoracotomies:

It is a procedure for patients in extremis, but who may still have a chance of survival, namely:

–       Patients who have sustained witnessed penetrating trauma with less than 15 minutes of prehospital CPR.

–       Patients who have sustained blunt trauma with less than 5 minutes of prehospital CPR.

–       Patients with persistent severe hypotension (systolic BP less than/equal to 60mmHg) due to cardiac tamponade, air embolism or hemorrhage—intrabdominal/intrathoracic.

And when would you not perform this procedure? Contraindications:

–       Patients with penetrating trauma who have had greater than 15 minutes of CPR and without signs of life described as pupillary response, respiratory effort or motor activity.

–       Patients with blunt trauma in whom greater than 5 minutes of CPR has been futile, and patient is without signs of life or asystole is the presenting rhythm.

Why is this procedure so controversial? Well, it’s expensive, it poses a great risk to the healthcare provider and the outcomes can be extremely poor if use indiscriminately.

What are the outcomes? Well, the efficacy of the ED thoracotomy depends on a few factors: the type of injury—stab wounds are associated with higher success rates than gunshot wounds, length of prehospital care, location of injury, presence or absence of vital signs at time of procedure.

For penetrating trauma, the survival rate after ED throcotomy has been reported as 18-33%. It is much lower for blunt trauma at 1-2%. Actually for this reason, many argue that this procedure should be altogether abandoned in patients with blunt trauma. This is, however, one of the many controversies surrounding ED thoracotomies. The countering argument is that it is indeed useful, but in the select group of patients who are severely hypotensive in the ER due to exanguination from blunt traumatic injury.

The presence of vital signs is directly related to outcomes. In one study, survival rates of ED thorocotomies performed after cardiac arrest at the scene were 0%, after cardiac arrest in the ambulance were 4% and after cardiac arrest in the ED were 19%. Patients who did not arrest had the greatest survival rate at 27%.

Now, let’s discuss the risks of this procedure.  There is one very interesting study that highlights the societal costs of this procedure. It is a study from Toronto published in 2011; investigators evaluated the personal and monetary cost of this inherently dangerous (and many times—futile) procedure.  They looked retrospectively at 14,690 trauma patients over a 17 year period, in which they found 123 patients on whom thoracotomies were performed.  They used the criteria aforementioned for appropriateness of the procedure (inappropriate being defined as performing an ED thoracotomy in a penetrating trauma when >15 minutes had elapsed, patient without vital signs on arrival and blunt trauma when >5 minutes had passed, patient without vital signs on arrival).  They determined that 63 patients (51%) of ED thoracotomies performed were not indicated.  In this group, mortality was 100%.  There were 3 cases of needlestick injuries to health care providers.  335 units of blood products were used. 4 patients survived to the operating room and required a total of 6 operating room visits.  3 of these patients had an ICU stay of 1 day and 1 died on day 5.  In short, the study concluded that from a societal point of view, the inappropriate use of this procedure carries with it, great risk for healthcare providers as well as substantial costs and waste of resources with no survival benefit for patients.

Bottom line: an ED thoracotomy is not a benign procedure; discretion should be used when performed and it should be reserved only for the salvageable patient based on objective indications.

**Note: I didn’t include a “how to” for ED thoracotomies in this blog post, as I find it best to visualize with a video.  I will refer you to a decent one I found from the University of Maryland. It doesn’t show how to cross-clamp the aorta, but it’s otherwise pretty good.

References:

Cothren, C., Moore, E. Emergency Department Thoracotomy for the Critically Injured Patient: Objectives, Indications, and Outcomes. World Journal of Emergency Surgery. 1:4, March 2006.

Brohi, K. Emergency Department Thoracotomy. www.trauma.org. Accessed March 20, 2013.

Tyburski JG, Astra L, Wilson RF. Factors affecting prognosis with penetrating wounds of the heart. J Trauma. 2000; 48: 587-590

Passos EM, et al. Societal Costs of Inappropriate Emergency Department Thoracotomy. Journal of American College of Surgeons. 214(1):18-26, 2012.

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