resuscitative thoracotomy

introduction

survival rates of resuscitative thoracotomy:
- blunt chest trauma has a survival rate following cardiac arrest of only 1-2%
- blunt chest trauma with pericardial tamponade on US_FAST in a trauma centre has a survival rate of 70-80% if tamponade is promptly diagnosed and treated
- gun shot penetrative chest trauma has a survival rate of only 2-4%
- abdominal trauma has a survival rate of only 4-5%
- non-gun-shot penetrating chest trauma (eg. knife stabbings) have a survival rate of ~9-18% if there were signs of life witnessed prior to the procedure ¹⁾
  - signs of life may include:
    - GCS > 3
    - evidence of pupillary, corneal or gag reflexes
    - electrical activity on ECG (including pulseless electrical activity (PEA))
- in a follow up study of an urban US trauma centre's 37 survivors following emergency department thoracotomy over an 11 year period ²⁾:
  - 10% died after hospitalisation
  - 74% of hospital survivors had long-term social, cognitive, functional, or psychological impairment
  - 48% had impaired cognition and limited capacity to return to normal activity
  - 24% required assistance with activities of daily living
  - 13% were wheelchair dependent
the aims of resuscitative thoracotomy may include:
- release of cardiac tamponade (pericardial decompression)
- temporary haemorrhage control
- treatment of air embolism
- internal cardiac massage
- cross-clamping of descending thoracic aorta to control abdominal bleeding?

resuscitative thoracotomy poses major risks to the treating team in terms of blood borne infection risk with low survival rates for the patient and thus should only be done if there are no contraindications, and if there are accepted indications as outlined below
ie. if you are not at a major trauma service then this procedure probably should NOT be done!

if patient can be resuscitated to BP > 70mmHg and adequately stable, emergency thoracotomy in theatre may be considered instead of in the ED resus room

penetrative chest trauma with either:
- unresponsive hypotension with systolic BP < 70mmHg despite iv fluids and pleural decompression, and a FAST positive for pericardial tamponade
- a ventilated patient who is haemodynamically unstable on arrival to ED with suspected pericardial tamponade
blunt chest trauma and either:
- rapid exsanguination from a chest tube of at least 1500mL blood
- unresponsive hypotension with systolic BP < 70mmHg despite iv fluids and a FAST positive for pericardial tamponade
relative indications:
- penetrative trunk trauma with either:
  - chest wound with traumatic arrest without previously witnessed cardiac activity
  - other wound with traumatic arrest with previously witnessed cardiac activity
- blunt chest trauma with:
  - traumatic arrest with previously witnessed cardiac activity

use 100% FiO2
rapid sequence induction (RSI) for emergency intubation using iv ketamine 1-2mg/kg and iv rocuronium 1mg/kg
place in 10deg Trendelenberg to reduce risk of cerebral air embolism
iv fluid resuscitation aiming for systolic BP 70-90mmHg
avoid tidal volumes > 0.6mL/kg
avoid PEEP until pericardium is decompressed
avoid iv fluids and inotropes once pericardium is decompressed and wound controlled as there is risk of rebound hypertension and excessive filling, or increased haemorrhage
aspirate cardiac chambers once wound is opposed to reduce risk of air embolism

¹⁾ , ²⁾