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Defining the Limits of Resuscitative Emergency Department Thoracotomy: A Contemporary Western Trauma Association Perspective

Moore, Ernest E. MD; Knudson, M. Margaret MD; Burlew, Clay C. MD; Inaba, Kenji MD; Dicker, Rochelle A. MD; Biffl, Walter L. MD; Malhotra, Ajai K. MD; Schreiber, Martin A. MD; Browder, Timothy D. MD; Coimbra, Raul MD; Gonzalez, Ernest A. MD; Meredith, J. Wayne MD; Livingston, David H. MD; Kaups, Krista L. MDthe WTA Study Group

The Journal of Trauma: Injury, Infection, and Critical Care: February 2011 - Volume 70 - Issue 2 - p 334-339
doi: 10.1097/TA.0b013e3182077c35
Original Article

Background: Since the promulgation of emergency department (ED) thoracotomy >40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival.

Methods: Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively.

Results: During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15–64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge.

Conclusion: Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

From the Department of Surgery (E.E.M., C.C.B., W.L.B.), Denver Health, Denver, Colorado; Division of Trauma and Acute Care Surgery (E.E.M., C.C.B., W.L.B.), University of Colorado Denver, Denver, Colorado; Division of Trauma and Acute Care Surgery (M.M.K., R.A.D.), San Francisco General Hospital, San Francisco, California; Division of Trauma and Acute Care Surgery (M.M.K., R.A.D.), University of California San Francisco, San Francisco, California; Division of Trauma and Acute Care Surgery (K.I.), University of Southern California, Los Angeles, California; Division of Trauma and Acute Care Surgery (A.K.M.), Medical College of Virginia, Richmond, Virginia; Division of Trauma and Acute Care Surgery (M.A.S.), Oregon Health and Sciences University, Portland, Oregon; Division of Trauma and Acute Care Surgery (T.D.B.), University of Nevada, Las Vegas, Nevada; Division of Trauma and Acute Care Surgery (R.C.), University of California San Diego, La Jolla, California; Division of Trauma and Acute Care Surgery (E.A.G.), University of Texas at Austin, Austin, Texas; Division of Trauma and Acute Care Surgery (J.W.M.), Wake Forest University, Winston-Salem, North Carolina; Division of Trauma and Acute Care Surgery (D.H.L.), University of Medicine and Dentistry of New Jersey, Newark, New Jersey; and Division of Trauma and Acute Care Surgery (K.L.K.), University Medical Center, Fresno, California.

Submitted for publication March 18, 2009.

Accepted for publication November 18, 2010.

Presented at the 40th Annual Meeting of the Western Trauma Association, February 28–March 7, 2010, Telluride, Colorado.

Address for reprints: Ernest E. Moore, MD, Department of Surgery, Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204; email: ernest.moore@dhha.org.

© 2011 Lippincott Williams & Wilkins, Inc.