Western Trauma Association Critical Decisions in Trauma: Resuscitative thoracotomy

Burlew, Clay Cothren MD; Moore, Ernest E. MD; Moore, Frederick A. MD; Coimbra, Raul MD; McIntyre, Robert C. Jr. MD; Davis, James W. MD; Sperry, Jason MD; Biffl, Walter L. MD

Journal of Trauma and Acute Care Surgery: December 2012 - Volume 73 - Issue 6 - p 1359–1363
doi: 10.1097/TA.0b013e318270d2df
WTA 2012 Algorithms
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BACKGROUND: In the past three decades, there has been a significant clinical shift in the performance of resuscitative thoracotomy (RT), from a nearly obligatory procedure before declaring any trauma patient deceased to a more selective application of RT. We have sought to formulate an evidence-based guideline for the current indications for RT after injury in the patient.

METHODS: The Western Trauma Association Critical Decisions Committee queried the literature for studies defining the appropriate role of RT in the trauma patient. When good data were not available, the Committee relied on expert opinion.

RESULTS: There are no published PRCT and it is not likely that there will be; recommendations are based on published prospective observational and retrospective studies, as well as expert opinion of Western Trauma Association members. Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be stratified based on injury and transport time. Indications for RT include the following: blunt trauma patients with less than 10 minutes of prehospital CPR, penetrating torso trauma patients with less than 15 minutes of CPR, patients with penetrating trauma to the neck or extremity with less than 5 minutes of prehospital CPR, and patients in profound refractory shock. After RT, the patient’s intrinsic cardiac activity is evaluated; patients in asystole without cardiac tamponade are declared dead. Patients with a cardiac wound, tamponade, and associated asystole are aggressively treated. Patients with an intrinsic rhythm following RT should be treated according to underlying primary pathology. Following several minutes of such treatment as well as generalized resuscitation, salvageability is reassessed; we define this as the patient’s ability to generate a systolic blood pressure of greater than 70 mm Hg with an aortic cross-clamp if necessary.

CONCLUSION: The success of RT approximates 35% for the patient arriving in shock with a penetrating cardiac wound and 15% for all patients with penetrating wounds. Conversely, patient outcome is relatively poor when RT is performed for blunt trauma, 2% survival for patients in shock and less than 1% survival for patients with no vital signs. Patients undergoing CPR on arrival to the hospital should be stratified based on injury and transport time to determine the utility of RT. This algorithm represents a rational approach that could be followed at trauma centers with the appropriate resources; it may not be applicable at all hospitals caring for the injured. There will be patient, personnel, institutional, and situational factors that may warrant deviation from the recommended guideline. The annotated algorithm is intended to serve as a quick bedside reference for clinicians.

Submitted: February 15, 2012, Revised: July 6, 2012, Accepted: August, 15, 2012.

From the Department of Surgery (C.C.B., E.E.M., W.L.B.), Denver Health Medical Center, Department of Surgery (R.C.M.), University of Colorado, Denver, Colorado; Department of Surgery (F.A.M.), University of Florida, Gainesville, Florida; Department of Surgery (R.C.), University of California, San Diego, La Jolla; Department of Surgery (J.W.D.), University of California, Fresno, California; and Department of Surgery (J.S.), University of Pittsburgh, Pittsburgh, Pennsylvania.

This study was presented at the 42nd annual meeting of the Western Trauma Association, February 26–March 2, 2012, in Vail, Colorado.

Address for reprints: Clay Cothren Burlew, MD, Department of Surgery, Denver Health Medical Center, 777 Bannock St, MC 0206, Denver, CO; email: clay.cothren@dhha.org.

© 2012 Lippincott Williams & Wilkins, Inc.