27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy, 2

U PRBC, IC epinephrine with ROSC Aorta crossclamped Taken immediately to OR

Question #1 Midlevel

Describe the steps of a resuscitative thoracotomy

Question #2 chief

Describe the indications of a resuscitative thoracottomy

Question #3 Intern

Why do we clamp the aorta?

In OR, multiple rounds of IC epinephrine, cardiac massage

Laparotomy performed Ventricular fibrillation arrest Pupils fixed and dilated Resuscitative efforts terminated at

2256

Question #4 Last- Chief resident

State reasons for NOT doing a thoracotomy

Indications for ED thoracotomy

Salvageable postinjury cardiac arrest Witnessed penetrating trauma with <15 min

prehospital CPR Witnessed blunt trauma with < 5 min

prehospital CPR

Severe postinjury hypotension due to Cardiac tamponade Hemorrhage, air embolism

Contraindications

Penetrating trauma CPR >15 min and no signs of life

(pupillary response, respiratory effort, motor activity)

Blunt trauma CPR >5 min and no signs of life,

asystole

Steps

Anterolateral incision through 4th intercostal space, sternal border to midaxillary line

Heavy scissors to cut intercostal mm Insert rib spreader, handle down Open pericardium anterior to phrenic n

Mobilize lung Control pulmonary hilum Crossclamp aorta Open cardiac massage/defibrillation

• AIM: identify injury patterns consistent with survival after ED thoracotomy

•To define limits of resuscitative thoracotomy to enable development of rational guidelines to withold or terminate efforts

•Prospective multicenter study, 18 institutions representing Western Trauma Association, 6 year period

Results

56 patients surviving hospital discharge 30% survivors = stab to ventricle 16% GSW lung 9% after blunt trauma 34% underwent prehospital CPR 7 patients survived with asystole at ED

arrival 18% had moderate-severe anoxic brain

injury

Conclusions

WTA multicenter experience suggests unlikely EDT survival when Blunt trauma with > 10 minutes

prehospital CPR Penetrating trauma with > 15 minutes

prehospital CPR Asystole without tamponade

Mechanism alone is not a discriminator of futility

Take home points

Resource-intensive procedure High risk for personnel Precise indications remain to be

defined Consider duration of prehospital

CPR Consideration for blunt trauma

victims supported in literature