Defining the limits of resuscitative emergency department thoracotomy: A contemporary western trauma association perspective

Ernest E. Moore, M. Margaret Knudson, Clay C. Burlew, Kenji Inaba, Rochelle A. Dicker, Walter L. Biffl, Ajai K. Malhotra, Martin Schreiber, Timothy D. Browder, Raul Coimbra, Ernest A. Gonzalez, J. Wayne Meredith, David H. Livingstn, Krista L. Kaups

    Research output: Contribution to journalArticle

    84 Citations (Scopus)

    Abstract

    Background: Since the promulgation of emergency department (ED) thoracotomy >40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival. Methods: Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively. RESULTS:: During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge. Conclusion: Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

    Original languageEnglish (US)
    Pages (from-to)334-339
    Number of pages6
    JournalJournal of Trauma - Injury, Infection and Critical Care
    Volume70
    Issue number2
    DOIs
    StatePublished - Feb 2011

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    Thoracotomy
    Hospital Emergency Service
    Cardiopulmonary Resuscitation
    Wounds and Injuries
    Torso
    Cardiac Tamponade
    Heart Arrest
    Survivors
    Penetrating Wounds
    Stab Wounds
    Gunshot Wounds
    Thoracic Injuries
    Nonpenetrating Wounds
    Health Care Reform
    Survival
    Abdomen
    Nervous System
    Multicenter Studies
    Patient Care
    Neck

    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

    Cite this

    Defining the limits of resuscitative emergency department thoracotomy : A contemporary western trauma association perspective. / Moore, Ernest E.; Knudson, M. Margaret; Burlew, Clay C.; Inaba, Kenji; Dicker, Rochelle A.; Biffl, Walter L.; Malhotra, Ajai K.; Schreiber, Martin; Browder, Timothy D.; Coimbra, Raul; Gonzalez, Ernest A.; Meredith, J. Wayne; Livingstn, David H.; Kaups, Krista L.

    In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 70, No. 2, 02.2011, p. 334-339.

    Research output: Contribution to journalArticle

    Moore, EE, Knudson, MM, Burlew, CC, Inaba, K, Dicker, RA, Biffl, WL, Malhotra, AK, Schreiber, M, Browder, TD, Coimbra, R, Gonzalez, EA, Meredith, JW, Livingstn, DH & Kaups, KL 2011, 'Defining the limits of resuscitative emergency department thoracotomy: A contemporary western trauma association perspective', Journal of Trauma - Injury, Infection and Critical Care, vol. 70, no. 2, pp. 334-339. https://doi.org/10.1097/TA.0b013e3182077c35
    Moore, Ernest E. ; Knudson, M. Margaret ; Burlew, Clay C. ; Inaba, Kenji ; Dicker, Rochelle A. ; Biffl, Walter L. ; Malhotra, Ajai K. ; Schreiber, Martin ; Browder, Timothy D. ; Coimbra, Raul ; Gonzalez, Ernest A. ; Meredith, J. Wayne ; Livingstn, David H. ; Kaups, Krista L. / Defining the limits of resuscitative emergency department thoracotomy : A contemporary western trauma association perspective. In: Journal of Trauma - Injury, Infection and Critical Care. 2011 ; Vol. 70, No. 2. pp. 334-339.
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    author = "Moore, {Ernest E.} and Knudson, {M. Margaret} and Burlew, {Clay C.} and Kenji Inaba and Dicker, {Rochelle A.} and Biffl, {Walter L.} and Malhotra, {Ajai K.} and Martin Schreiber and Browder, {Timothy D.} and Raul Coimbra and Gonzalez, {Ernest A.} and Meredith, {J. Wayne} and Livingstn, {David H.} and Kaups, {Krista L.}",
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    T1 - Defining the limits of resuscitative emergency department thoracotomy

    T2 - A contemporary western trauma association perspective

    AU - Moore, Ernest E.

    AU - Knudson, M. Margaret

    AU - Burlew, Clay C.

    AU - Inaba, Kenji

    AU - Dicker, Rochelle A.

    AU - Biffl, Walter L.

    AU - Malhotra, Ajai K.

    AU - Schreiber, Martin

    AU - Browder, Timothy D.

    AU - Coimbra, Raul

    AU - Gonzalez, Ernest A.

    AU - Meredith, J. Wayne

    AU - Livingstn, David H.

    AU - Kaups, Krista L.

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    N2 - Background: Since the promulgation of emergency department (ED) thoracotomy >40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival. Methods: Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively. RESULTS:: During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge. Conclusion: Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

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