October 2015 REBELCast: The All Thoracotomy Episode

08 Oct
October 8, 2015

ED ThoracotomyWelcome to the October 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Trauma, specifically ED Thoracotomy. Now we all know that ED thoracotomy is a last ditch salvage effort, performed under specific clinical circumstances, during a traumatic arrest. The purpose of the ED thoracotomy is to evacuate pericardial tamponade, control hemorrhage, improve coronary/cerebral blood flow, and if needed internal cardiac massage. The purpose of this podcast is to discuss specific indications where this already low yield procedure may have some benefit.

  • Topic #1: FAST US Examination as a Predictor of Outcomes After Resuscitative Thoracotomy
  • Topic #2: Blunt Trauma Thoracotomy

October 2015 REBELCast Podcast

Click here for Direct Download of Podcast

Topic #1: FAST US Examination as a Predictor of Outcomes After Resuscitative Thoracotomy

  • Question #1: Can a FAST exam predict which patients with traumatic cardiac arrest will benefit from a thoracotomy?
  • Article #1: Inaba K et al. FAST Ultrasound Examination as a Predictor of outcomes After Resuscitative Thoracotomy: A Resuscitative Thoracotomy. Ann Surg 2015; 262 (3): 512 – 8. (26258320)
  • Background #1: In patients who suffer a traumatic cardiac arrest, a final salvage maneuver that is performed in the Emergency Department (ED) is a resuscitative thoracotomy (RT). There are two lines of thought about RT that are on opposite sides of the spectrum. The first line of thought is that if RT is not performed the patient is going to die anyways, so why not try it as a last ditch effort. The second line of thought is that due to the low yield in survival with RT, why expend resources and create a potential risk of harm to providers. The Focused Assessment Using Sonography for Trauma (FAST) has a high sensitivity and specificity for identifying hemopericardium and cardiac activity in a matter of seconds. Since there is really no good way to discriminate between which patients with traumatic cardiac arrest would benefit from RT, maybe adding a bedside FAST could help make this distinction.
  • What They Did #1:
    • Prospective, Observational Trial in 1 Trauma center in California
    • Patients undergoing RT in the ED
      • All penetrating trauma patients with absent vital signs
      • All blunt trauma patients with loss of vital signs en route or in the resuscitation bay
    • FAST performed just before or concurrently with RT
  • Bottom Line #1: ALL survivors and organ donors had visible cardiac motion on FAST. If no cardiac motion or pericardial effusion was seen on FAST, then survival was zero.

Topic #2: Blunt Trauma Thoracotomy

  • Question #2: Does doing an RT on a patients suffering blunt trauma with loss of vital signs, help improve survival rates with good neurologic outcomes?
  • Article #2: Slessor D and Hunter S. To Be Blunt: Are We Wasting Our Time? Emergency Department Thoracotomy Follwing Blunt Trauma: A Systematic Review and Meta-Analysis. Ann Emerg Med 2015; 65(3): 287 – 307. (25443990)
  • Background #2: RT after blunt trauma is a very controversial procedure with opinions on both sides of the spectrum. Just to show you how confusing it is you have to look no further than guidelines from different societies. The Western Trauma Association recommends RT after blunt trauma if there are any signs of life or no signs of life with less than 10 minutes of CPR. The Advanced Trauma Life Support (ATLS) course states any patient who is pulseless upon arrival after blunt trauma does not benefit from RT.
  • What They Did #2:
    • Systematic Review and Meta-Analysis of RT after blunt trauma
    • Primary Objective: Do adult patients in cardiac arrest or periarrest after blunt trauma, treated with RT survive and have a good neurologic outcome
  • Bottom Line #2: Although survival rates with good neurologic outcome are low in patients with blunt trauma having undergone RT, there may be some yield to the procedure in patients with vital signs on admission, or ≤15 minutes of CPR. What is clear however, is that in patients with no vital signs at any time or non-survivable head trauma, RT should not be performed.

For More Details of the above Studies Checkout the October 2015 REBELCast Show Notes

For more on what others thought on these topics checkout:

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

Bibliography

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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
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