EMS World

FEB 2017

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EMSWORLD.com | FEBRUARY 2017 37 and heart while decreasing abdominal and lower-extremity hemorrhage. 6,7 Evidence for the Utility of Thoracotomies The first successful thoracotomy reported in medical literature was performed in 1902 on the kitchen table of a physician in Ala- bama. 8 It wasn't until 1966 that the first paper was published advocating for thora- cotomies to be performed in the emergency department. 9 Since this time emergency thoracotomies have become an accepted part of the traumatic arrest or periarrest algorithm in certain patients. In fact, there are many different published algorithms and recommendations for ED thoracotomy. The 2013 ATLS guidelines include the following indications and contraindications for resuscitative thoracotomy: Indications include evacuation of blood causing peri- cardial tamponade, direct control of exsan- guinating intrathoracic hemorrhage, open cardiac massage and cross-clamping of the descending aorta to slow blood loss below the diaphragm and improve blood f low to the brain and heart. Contraindications include no signs of life (SOL) on arrival, severe traumatic brain injury or a most likely extrathoracic cause of circulatory collapse. 6 The Eastern Association for the Surgery of Trauma published recommendations for ED thoracotomy in 2015. It strongly rec- ommends thoracotomy for patients who present pulseless but with SOL after pen- etrating thoracic injury. It conditionally recommends thoracotomy for patients who present pulseless with absent SOL after pen- etrating thoracic trauma, pulseless with and without SOL after penetrating extrathoracic trauma, and pulseless with SOL after blunt injury. It conditionally recommends against thoracotomy for pulseless patients without SOL after blunt injury. 10 The Western Trauma Association pub- lished an decision algorithm for ED tho- racotomy in 2012 that recommends it for trauma patients who meet the following criteria: » Profound refractory shock including SBP less than 60 or undergoing CPR with SOL; » Penetrating trauma patients with no SOL and CPR time less than 15 minutes; » Blunt trauma patients with no SOL and CPR time less than 10 minutes. 11 Additionally, a trauma and vascular sur- geon in the U.K. named Karim Brohi, who also worked with helicopter EMS in Lon- don, set up a website called Trauma.org to make trauma education resources publicly available worldwide. 12 He published a set of indications for ED thoracotomy in 2001 that recommended the following: Accepted indications include penetrating thoracic injury with unresponsive hypoten- sion (BP less than 70) or arrest with previ- ously witnessed cardiac activity; blunt tho- racic injury with unresponsive hypotension or rapid exsanguination from chest tube (greater than 1,500 mL). Relative indica- tions include penetrating thoracic injury and arrest without previously witnessed cardiac activity, and penetrating nontho- racic or blunt thoracic injury and arrest with previously witnessed cardiac activity. Contraindications include blunt thoracic injury with no witnessed cardiac activity, multiple blunt trauma and severe head injury. 7 The above indications are summarized in Table 1. Literature on emergency thoracoto- mies performed in trauma patients quotes an overall survival rate between 7% and 27%. 1,13–20 The wide variability of reported survival rates in these studies can par- tially be attributed to the varied locations of "emergency" thoracotomies (ED vs. OR) and the varied definitions of survival. Further, locations with physicians inte- grated into EMS systems (U.K. and Europe) TABLE 1: INDICATIONS AND CONTRAINDICATIONS FOR THORACOTOMY Indications Pericardial tamponade a Exsanguinating intrathoracic hemorrhage a Open cardiac massage a Aortic cross-clamping for exsanguination below the diaphragm a Pulseless with SOL after penetrating thoracic trauma b Traumatic injury and profound refractory shock/unresponsive hypotension c,d Pulseless with SOL after traumatic injury c Penetrating trauma and no SOL with CPR < 15 mins. c Blunt trauma and no SOL with CPR < 10 mins. c Penetrating traumatic arrest with previously witnessed cardiac activity d Blunt trauma with rapid exsanguination from chest tube d Relative Indications Pulseless with no SOL after penetrating thoracic trauma b Pulseless with penetrating extrathoracic trauma (with or without SOL) b Pulseless with SOL after blunt trauma b Penetrating thoracic trauma and no previously witnessed cardiac activity d Penetrating nonthoracic trauma and previously witnessed cardiac activity d Blunt thoracic trauma and previously witnessed cardiac activity d Relative Contraindications Pulseless without SOL after blunt trauma b Contraindications No SOL a Severe head injury/TBI a,d Extrathoracic cause of circulatory collapse a Blunt thoracic trauma and no previously witnessed cardiac activity d Multiple blunt trauma d a—ATLS, b—Eastern Association for the Surgery of Trauma, c—Western Trauma Association, d—Trauma.org

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