Abstract & Commentary
Source: Powell DW, et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg 2004;199:211-215.
The role of resuscitative emergency department thoracotomy (EDT) remains controversial; most studies of this procedure have been retrospective with few survivors. To reduce futile care and minimize health care provider risk in resuscitative EDT for patients with prehospital arrest after trauma, the National Association of Emergency Medical Services Physicians Standards and Clinical Practice Committee and the American College of Surgeons Committee on Trauma released guidelines that address the topic. The guidelines state that EDT "does not appear to have a role in prehospital traumatic cardiopulmonary arrest as a result of blunt trauma " and that traumatic cardiopulmonary arrest "secondary to penetrating trauma, while still having a dismal prognosis, may be more amenable [to EDT] in the case of isolated penetrating trauma to the thorax."1
This study questioned whether selected patients who fail to respond to prehospital cardiopulmonary resuscitation (CPR) are potentially salvageable, and should be transported to the nearest trauma center for evaluation and prompt EDT. The study authors prospectively collected a database of all patients receiving EDT during a 26-year study period. The data included mechanism of injury, prehospital and ED vital signs, need for and duration of prehospital CPR, presence or absence of prehospital endotracheal intubation, cardiac rate and rhythm at the time of EDT, survival to hospital discharge, and neurologic outcome deficits (i.e., none, mild, or severe). During the study period, 959 patients underwent EDT with 62 (6.5%) survivors. The injury mechanism for survivors was stab wound in 39 (63%), gunshot wound in 12 (19%), and blunt trauma in 11 (18%). Thirty-three of these patients had no detectable vital signs on arrival tothe ED. Twenty-six (42%) of the survivors required prehospital CPR, and were the focus of data analysis.
Among the 26 patients surviving EDT after prehospital CPR, the mean age was 30 + 3 years and the mean base deficit was 21.5 (range 14 to 25). The mechanism of injury was stab wound in 18 (69.2%), gunshot wound in four (15.4%), and blunt trauma in four (15.4%). Twenty-one of the 26 patients left the hospital with no or mild neurologic deficits (15 none, six mild). Thirteen of the 15 (87%) patients discharged with no neurologic impairment were victims of stab wounds. Of the five patients with severe neurologic deficits, four were associated with a blunt mechanism of injury. Thus, all patients with a blunt mechanism of injury who survived prehospital CPR and EDT had severe neurologic impairment.
Five survivors had asystole documented at the time of EDT. Four of these patients survived with no or mild neurologic deficits, and all had pericardial tamponade due to stab wounds to the ventricle. The initial base deficit in the ED did not appear to predict neurologic outcome. All survivors had successful endotracheal intubation in the prehospital setting and fewer than 15 minutes of prehospital CPR.
The authors submit the following guidelines based on their study. Patients with blunt mechanism of injury should be declared dead on arrival if they have received more than 5 minutes of prehospital CPR and have no signs of life (e.g., pupillary response, motor activity, or respiratory effort). A patient with penetrating mechaof injury should be declared dead on arrival if he has received more than 15 minutes of prehospital CPR with no signs of life in the ED, or if he has asystole on arrival and does not have a penetrating wound that could result in pericardial tamponade.
Commentary by Jacob Ufberg, MD
A great deal of effort has been devoted to the discussion of when a trauma patient should be declared dead on arrival, and when heroic efforts, such as EDT, are warranted and may yield neurologically functional survival. Unfortunately, we are unlikely to see a large, randomized trial of the use of EDT in the near future. The number of patients who receive EDT in a given center is small, and the number of survivors is far smaller (as evidenced by only 62 survivors in one major trauma center during a 26-year period). Thus, we are forced to rely upon studies such as this one to help us decide when EDT is indicated.
This report echoes previous reports in that the highest EDT survival rates are seen among patients with ventricular injury and pericardial tamponade due to stab wounds. A small number of patients survived other penetrating mechanisms after requiring prehospital CPR. Thus, their recommendations regarding EDT for penetrating trauma seem reasonable.
Unfortunately, the authors do not provide the mechanism of injury for the 897 non-survivors of EDT so that we can draw conclusions on the overall survival rates according to the mechanism of injury. Even without this information, we can see the incredibly small numbers of EDT survivors among patients with blunt mechanism of injury requiring prehospital CPR. We also can see that all of these survivors had dismal neurologic outcomes. The authors base their recommendation of fewer than 5 minutes of prehospital CPR in blunt trauma on sporadic reports of patients with good outcomes who lost vital signs just before arrival. Even with these case reports, it would seem reasonable to withhold EDT in all patients with blunt mechanism of injury and no signs of life on arrival to the ED.
Dr. Ufberg, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA, is on the Editorial Board of Emergency Medicine Alert.
1. Hopson LR, et al. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. Joint Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg 2003;196:106-112.