Resuscitative thoracotomy

Even though the technique of resuscitative thoracotomy belongs predominantly in the domain of emergency medicine, the College of Intensive Care Medicine has recently included it as a 70%-weighted part of Question 10 from the first paper of 2016. This is perhaps in response to the idea that opening the chest is a resuscitative step in scenarios outside of trauma. For instance, reopening the sternum is the final common pathway of the post-cardiac-surgery arrest algorithm, and opening the pericardium is one of the last-ditch measures to improve cardiac output in otherwise refractory cardiogenic shock. Prior to the advent of effective external cardiac compression training, internal cardiac massage was used to resuscitate patients who had collapsed from medicla causes. That said, this chapter focuses mainly on the applications of resuscitative thoracotomy to acute chest trauma.

This heroic act is certainly a favourite among adrenaline-loving emergency jocks, because it is represents the hottest sexiest form of maximally aggressive resuscitation. You open the chest and save the patient's life, goddamnit. Whatever the outcome at the end, as you wipe the blood from your face the junior nurses swoon, bowled over by the pulsating waves of your raw masculinity.

As far as published literature goes, there is plenty to look at. LITFL have a wonderfully gory article about this practice, engaging the important question of whether or not it represents the initial stages of an autopsy.

Definition of resuscitative thoracotomy

"Resuscitative thoracotomy" or "emergency department thoracotomy" refers to a left-sided clamshell thoracotomy performed for the specific purpose of gaining rapid access to the heart and major thoracic vessels.

Characteristic features which define the procedure include:

• Rapid access is rthe priority; aseptic technique is expected to be sub-optimal
• Usually performed by non-surgical staff
• Usually involves pericardiotomy, or aortic clamp, or both.

Rationale and indications for resuscitative thoracotomy

Rationale for resuscitative thoracotomy (Burlew et al, 2012)

• Access to the left chest cavity offers an opportunity to correct life-threatening thoracic injuries
• Internal cardiac massage can be performed, which may be more effective
• Aortic clamping may be performed, which may control blood loss.This also redistributes the remaining circulating volume to perfuse the myocardium and brain
• Direct epicardial defibrillation can be performed (30J) if the patient degenerates into a shockable cardiac arrest rhythm.
• A trauma patient who is a candidate for this procedure is usually a premorbidly healthy person who has a very high chance of death from trauma , which justifies this level of aggression. Keller et al (2013) performed a review of 21 resuscitative thoracotomy survivors, of whom 81% were were freely mobile and functional, in spite of crippling social issues ( unemployment 75%, daily alcohol 50%, and drug use 38%).

Indications for resuscitative thoracotomy  (Rabinowici et al, 2014)

• The patient is in cardiac arrest
• The cause is  penetrating chest trauma. Evidence is strongest for penetrating cardiac trauma, where the survival rate is apparently 40% ( JACS, 2001). People also do this for blunt trauma, but the survival there is about 2%.
• Arrest is after arrival to hospital, or shortly before. The "down-time" should be less than 10 minutes for blunt trauma and less than 15 minutes for penetrating trauma.
• There is suspicion that reversible pathology is present in the chest, which includes cardiac tamponade or injury to the greater vessels. The college answer to Question 10 from the first paper of 2016 mentions that the immediate loss of 1500ml of blood from the chest drain is an "accepted indication" to crack the chest.
• There is sufficient surgical expertise available to carry on with a more formal damage control surgery after the patient is stabilised (otherwise, there is no point opening the chest)

Contraindications for resuscitative thoracotomy

• No signs of life witnessed in the pre-hospital setting
• Prolonged pre-hospital CPR
• Asystole on presentation, and no cardiac tamponade
• Massive extrathoracic injuries which may be unsurvivable

Arguments against resuscitative thoracotomy

• "indiscriminate use... renders it a low-yield and high-cost procedure" - Burlew et al, 2012
• There is no satisfactory definition for exactly how dead you need to be in order to warrant this approach, and most studies uses lay terms such as "no signs of life" or "moribund".
• Indications are vague and not supported by high levels of evidence
• Use of this procedure gives rise to "turf wars" over whose job it is to perform it: ED, surgery, ICU?
• There are no high quality follow up studies, and it is unknown whether there really is a major long term neurological cost to this procedure. In the study mentioned above ( Keller et al, 2013) only 37 of 448 resucitative thoracotomy recipients had survived, and only 21 of these were interviewed.