Defining the Limits of Resuscitative Emergency Department Thoracotomy: A Contemporary Western Trauma Association Perspective J Trauma. 2011;70:334 –339

17 Aug

Moore EE et al Defining the Limits of Resuscitative Emergency Department Thoracotomy: A Contemporary Western Trauma Association Perspective. The Journal of Trauma: Injury, Infection, and Critical Care 2011 Feb.;70(2):334–339. PMID 21307731

We don’t get much penetrating trauma in Ireland (though it’s not by any means unheard of) and I’ve heard of only one ED thoracotomy in the place I work most of the time.

It’s a much bigger deal in the US understandably.

METHODS

  • The Western Trauma Association collected prospective data from 18 trauma centres on people who got an ED throacotomy for trauma.
  • they don’t tell us if they missed any patients
  • they don’t tell us a denominator
  • they just tell us that 56 survived to discharge

RESULTS

  • without knowing a denominator it’s hard to say much about whether routine use can be considered a good thing or not
  • of note 6 who survived didn’t have any injury identifiable in the thorax after throacotomy (2 of these were bleeding out from scalp wounds!).

These guys don’t seem to have had any injury in the chest amenable to interventon from a throactomy, so you could say that they survived in spite of ED thoracotomy rather than because of it

  • 20% had moderate to severe hypoxic brain injuries – which is to be expected
  • 5 survived after blunt trauma (though only one neurologically intact who had an atrial rupture)
  • CPR longer than 5 mins was a bad thing

They suggest that you should not do ED throactomy if:

  • Prehospital CPR >10 min after blunt trauma without response
  • Prehospital CPR >15 min after penetrating injury without response
  • Asystole is the presenting rhythm, and there is no pericardial tamponade

 INTERPRETATION

a key fault in the study is that we don’t know what informed the decision to do the ED thoracotomy in the first place. The guys on the ground making the decisions may have tried to apply the very criteria that these guys suggest.

This paper can’t tell us much about whether ED thoracotomy is a good idea or not but there are still some interesting things in it.

I was always told not to do it unless

  • it was penetrating trauma
  • pulses were lost on the way through the door or in front of you

Of note the height of my training in this is YouTube and some textbooks. I think i’ll be deferring to the surgical reg…

Since writing this I see the paper has been reviewed in the abstracts with similar points made

And Cliff Reid has a great post on pre-hospital procedures and competencies that I whole heartedly agree with. I’m the type that lies in bed at night running through my head what to do (or what I should have done) with any given patient.

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