When a patient presents in extremis, it is important to differentiate between blunt and penetrating mechanisms of injury. The salvage rate using emergency department (ED) thoracotomy after blunt traumatic cardiac arrest is much less than in penetrating traumatic cardiac arrest. In general, patients who present without vital signs in the field or in transport should be pronounced dead on arrival to the ED. We recommend performing a cardiac ultrasound in patients undergoing blunt traumatic cardiac arrest to guide further, more aggressive resuscitative measures. The threshold for performing an ED thoracotomy in penetrating thoracic injury should be low, especially if the patient lost vital signs en route to the hospital or in the ED. Consider using resuscitative endovascular balloon occlusion of the aorta (REBOA) when abdominal hemorrhage is suspected—but only if resources and skill sets allow quick placement. Both the Western Trauma Association and the Eastern Association for the Surgery of Trauma have extensive guidelines on when to utilize the ED thoracotomy, and we recommend reviewing these respective recommendations when creating an institution-level protocol for ED thoracotomy or REBOA use.
KeywordsAdvanced cardiac life support (ACLS) Advanced trauma life support (ATLS) Blunt trauma Cardiopulmonary resuscitation (CPR) ED thoracotomy Penetrating trauma Resuscitation Resuscitative endovascular balloon occlusion of the aorta (REBOA) Shock Traumatic cardiac arrest Thoracic trauma
- American College of Surgeons. Advanced trauma life support. 9th ed. Chicago: American College of Surgeons; 2012. 336 p.Google Scholar
- American Heart Association. Advanced cardiac life support. Dallas: American Heart Association; 2015. 183 p.Google Scholar
- Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, 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;79(1):159–73.CrossRefGoogle Scholar
- Western Trauma Association [Internet]. Resuscitative Thoracotomy. 2012 [cited 2017 Aug 13]. Available from: http://westerntrauma.org/algorithms/WTAAlgorithms_files/gif_8.htm