The ACEP Clinical Policies Committee regularly reviews guidelines published by other organizations and professional societies. Periodically, new guidelines are identified on topics with particular relevance to the clinical practice of emergency medicine. This article highlights recommendations on the indications for emergency department thoracotomy from the Eastern Association for the Surgery of Trauma (EAST) published in the Journal of Trauma and Acute Care Surgery in 2015.
“Stab wound to the chest, CPR in progress, three minutes out!”
You stop what you’re doing on a busy shift and head to the trauma bay. The room quickly becomes abuzz with nurses, techs, and respiratory therapists preparing for an injured trauma patient. Trauma blood arrives. You prepare your airway tools, line up your procedure trays, and assign roles to the members of your team. Suddenly, the paramedic crew rushes into the room with compressions under way; they lost pulses approximately eight minutes prior. The trauma team is scrubbing out of a case and won’t be down for five minutes. What do you do?
Few procedures in emergency medicine evoke more heated controversy than that of the resuscitative thoracotomy. Often a last-resort Hail Mary procedure, opening a chest in the emergency department is never taken lightly. Variations in practice across the country prompted EAST to pore over existing data and make specific recommendations for when it’s most appropriate (or not) to consider performing an emergency thoracotomy.
The authors, composed mostly of trauma surgeons and one emergency physician, used the Grading of Recommendations Assessment,
Development, and Evaluation (GRADE) methodology for a systematic review and developed six population, intervention, comparator, and outcomes (PICO) questions. A systematic search using PubMed and Embase databases was performed using the following combination of medical subject headings terms and related key words: thoracotomy, emergency medical services, emergency treatment, emergencies, emergency room, emergency department, emergency service, and emergency ward. Only studies published in English were included. Exclusion criteria were meta-analyses, reviews without original data, case reports, letters, and studies that involved either prehospital or operating room thoracotomy.
The questions developed cover specific traumatic scenarios, including penetrating thoracic trauma, penetrating extra-thoracic trauma, and blunt trauma with or without signs of life.
A comparator was necessary for the PICO format. (Studies with an active comparator compare the treatment with another treatment commonly used for the same indication, rather than with no treatment, to help limit bias.) Interestingly, as no such comparator could be identified for patients who had not undergone ED thoracotomy, the guideline developers estimated baseline survival using a poll of panel members who were provided trauma scenarios treated without ED thoracotomy (eg, intravenous access, blood product resuscitation, thoracostomy tube placement, and transfer to the operating room). High and low outliers were excluded, and the remaining predicted outcomes were averaged to give a comparator survival percent.
Often a last-resort Hail Mary procedure, opening a chest in the emergency department is never taken lightly. Variations in practice across the country prompted EAST to pore over existing data and make specific recommendations for when it’s most appropriate (or not) to consider performing an emergency thoracotomy.
Each guideline recommendation is presented below with highlighted corroborating data and discussion pertinent to emergency physicians.