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.

Methodology

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.

Recommendations

Each guideline recommendation is presented below with highlighted corroborating data and discussion pertinent to emergency physicians.

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.

Dr. Ingalsbe is chief resident at the Denver Health Residency in Emergency Medicine in Colorado. Dr. Wolf is associate professor of emergency medicine at the University of Virginia School of Medicine in Charlottesville.

Reference

1. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;9(1):159-173.