1 In patients who present pulseless to the emergency department with signs of life after penetrating thoracic injury, EAST strongly recommends resuscitative ED thoracotomy.

• This is the only recommendation considered strong in this guideline, based on patient preference for improved chance of survival and a moderate quality of evidence (21.3 percent survival among 853 patients, of which 90 percent were neurologically intact).

2 In patients who present pulseless to the emergency department without signs of life after penetrating thoracic injury, EAST conditionally recommends resuscitative ED thoracotomy.

• This is based on patient preference and moderate overall quality of evidence (8.3 percent survival based on 920 patients in 32 studies). Among the 641 patients in whom neurologic outcome was reported, 3.9 percent survived neurologically intact.
• Length of CPR time as a factor to consider was discussed within this clinical question. The authors concede that data are lacking to give exact durations for traumatic CPR arrest. However, the authors stated, “We are unable to offer any alteration to the commonly held dictum: ED thoracotomy is likely futile after 15 minutes of arrest time after penetrating injury.”

3 In patients who present pulseless to the emergency department with signs of life after penetrating extra-thoracic injury, EAST conditionally recommends resuscitative ED thoracotomy.

• There was a small patient population that provided data for this clinical scenario. Among the 160 patients in 11 studies, there was a 15.6 percent survival rate. Neurologic outcomes were cited in only 85 patients; 16.5 percent survived intact.

4 In patients who present pulseless to the emergency department without signs of life after penetrating extra-thoracic injury, EAST conditionally recommends resuscitative ED thoracotomy.

• Survival was 2.9 percent among this small data set of 139 patients from eight studies. Neurologic outcome was reported for 60 patients, and only three of those survived neurologically intact.

5 In patients who present pulseless to the emergency department with signs of life after blunt injury, EAST conditionally recommends resuscitative ED thoracotomy.

• Survival was 4.6 percent among 454 patients in 22 studies. Neurologic outcome was reported in 298 of these patients, and only 2.4 percent survived ED thoracotomy neurologically intact.

6 In patients who present pulseless to the emergency department without signs of life after blunt injury, EAST conditionally recommends against resuscitative ED thoracotomy.

• This was the only conditional recommendation against the procedure.
• Survival was 0.7 percent based on data from 995 patients in 24 studies. Neurologic outcome in 825 patients showed only 0.1 percent surviving neurologically intact (one patient out of 825).

Limitations and Discussion

• Data are mostly from Level I trauma centers, and the authors concede that these guidelines may not be applicable to smaller, community, or rural centers with fewer operative resources.
• While the term “neurologically intact” was used repeatedly throughout the guideline, this term was not clearly defined.
• “Signs of life” were defined by the authors as pupil response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, or cardiac electrical activity. These may be controversial and not universally applied to all studies. Some providers may also not consider cardiac electrical activity alone (or pulseless electrical activity) as a true sign of life.
• The authors of the guideline note that all of the studies that inform the recommendations have serious limitations.
• The risk to providers while performing ED thoracotomy was discussed, including concerns of bloodborne pathogens and risk of provider injury. These should be taken into consideration with this highly invasive procedure.

Conclusions

Guidelines aren’t meant to replace clinical judgment but rather to augment the decision-making process. As with much of medicine, there’s always a need for more and better data, and this set of recommendations is no exception. The decision to perform an ED thoracotomy depends heavily on the institutional setting and the downstream resources available to the emergency physician.