ED Thoracotomy –Discussion by Dr. Rebecca Gardner at Regions Hospital Critical Case Conference
One suggested approach to blunt traumatic arrest (Dr. Scott Weingart):
Secure airway
Bilateral thoracostomies (finger or needle)
US — if no pericardial tamponade, should just call the code
If they have pericardial tamponade or if vitals are lost in the ER (or CPR < 5 min), consider thoracotomy
If signs of massive head trauma, do not do thoracotomy
Penetrating traumatic arrest:
Better chance of success with thoracotomy than in blunt trauma
Best outcome if stab wound, GSW 2nd best
— loss of vitals signs en route or in ER — do thoracotomy unless CPR > 15 min
If loss of vitals on scene (CPR > 15 min), do not do thoracotomy unless signs of life in ER
Consider exposure to provider as well as chance of meaningful neurologic recovery when making the decision to do the thoracotomy. Avoid the vast consumption of resources for someone who is not going to recover.
Other indications:
Persistent severe post-injury hypotension (SBP<60-70 mmHg) due to:
— Cardiac tamponade
— Hemorrhage — intra-thoracic, intra-abdominal, extremity, cervical
— Air embolism — consider when trauma patient crashes just after intubation — positive pressure introduces air into damaged vasculature
Purpose of ED Thoracotomy:
— Evacuate tamponade
— Control intra-thoracic or cardiac hemorrhage
— Open cardiac massage — 10x the cardiac output than external compressions
— Evacuate massive air embolism
— Occlude descending aorta (can’t be for more than 30 minutes because if longer, release of occlusion releases cytokines which cause patient to crash and die)
Success of ED Thoracotomy:
- Penetrating cardiac trauma — 35%
- All penetrating trauma 15%
Blunt trauma
- 2% success if lose vitals in ED
- 1% success if lose vital signs en route to ED, 0% if lose vitals at scene
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