TERMINATION
OF RESUSCITATION ON THE BASIS OF PREHOSPITAL CRITERIA
Emergency resuscitative thoracotomy (ERT)
has a poor salvage rate with a high risk of iatrogenic blood borne pathogen
exposure and/or injury to health care providers.
Indications:
The American College of Surgeons (ACS)
position in resuscitative thoracotomy, taught in Advanced Trauma Life Support
(ATLS), is simple. For blunt trauma, ERT is not indicated. For penetrating
trauma, ERT is appropriate when signs of life are present.
Signs of Life:
1.
Reactive pupils
2.
Spontaneous movement
3.
Organized ECG activity (VF, VT, PEA, etc)
4.
Cardiac activity on ultrasound
The Western Trauma Association (WTA)
has promulgated a simpler and perhaps more pragmatic algorithm that is more
liberal with ERT. If CPR has been performed fewer than 10 minutes for blunt
trauma, ERT is appropriate. The same applies with up to 15 minutes of CPR for
penetrating trauma.
http://westerntrauma.org/documents/PublishedAlgorithms/WTACriticalDecisionsResuscitativeThoracotomy.pdf
EAST updated its ERT recommendations in 2015 as follows:
1.
In patients who present pulseless to the Emergency
Department with signs of life after penetrating thoracic injury,
we strongly recommend resuscitative Emergency Department thoracotomy.
2.
In patients who present pulseless to the Emergency
Department without signs of life after penetrating thoracic injury,
we conditionally recommend resuscitative Emergency Department
thoracotomy.
3.
In patients who present pulseless to the Emergency
Department with signs of life after penetrating extra-thoracic injury,
we conditionally recommend resuscitative Emergency Department
thoracotomy.
4.
In patients who present pulseless to the Emergency
Department without signs of life after penetrating extra-thoracic
injury, we conditionally recommend resuscitative Emergency
Department thoracotomy.
5.
In patients who present pulseless to the Emergency
Department with signs of life after blunt injury, we conditionally
recommend resuscitative Emergency Department thoracotomy.
6.
In patients who present pulseless to the Emergency
Department without signs of life after blunt injury, we conditionally
recommend against resuscitative Emergency Department thoracotomy
The performance of ERT is at the
discretion of the Trauma Chief Resident, Fellow and Attending. If all the
above-mentioned physical findings establishing absence of signs of life are
verified, the patient may be pronounced DOA and no further resuscitation is
required. The Trauma Service faculty and residents should ensure completion of
the Trauma H&P in its entirety, completing under diagnosis “Patient pronounced
DOA” and noting any injuries diagnosed by gross physical examination (e.g.,
femur fracture, penetrating head injury, etc.).
References: American College of
Surgeons’ Committee on Trauma: Advanced Trauma Life Support, ed.9, Chicago,
2013, The American College of Surgeons.
Trauma Alert RED should be activated for ALL trauma codes.
Trauma Alert RED should be activated for ALL trauma codes.
EMERGENCY RESUSCITATIVE
THORACOTOMY (ERT)-TECHNIQUE
The procedure is performed in
conjunction with other resuscitative efforts and should not be employed in
isolation. Under certain conditions, resuscitative efforts might best be
accomplished in the Operating Room. An Emergency resuscitative thoracotomy
should only be performed by general surgery PGY-3, or higher, level residents
or attendings. If there is a delay in arrival of the surgery team, it is
appropriate for the ERT to be initiated by the emergency department attending.
Procedure:
1.
Rapid bilateral antero-lateral Betadine or Chlorhexidine
prep while thoracotomy tray opened. Thoracotomy trays are located in Trauma Bay
Omni cells.
2.
Left antero-lateral thoracotomy incision located beneath
nipple in males and in inferior breast fold in females. Incision extends from
left sternal border to anterior border of latissimus dorsi and chest entered
along the superior aspect of fourth or fifth rib. Care must be taken to avoid
injury to heart and lung. A right antero- lateral thoracotomy may ALSO be
preferred for primary right chest wounds.
3.
Insert rib spreader with handle located toward table
laterally.
4.
Examine pericardium, if tense hemopericardium present
(pericardium distended with maroon discoloration) then proceed to step 7.
5.
If systemic air embolism is suspected or massive hemorrhage
from lung parenchyma or hilum is present, then place Satinsky clamp across
hilum medially.
6.
Retract left lung with left hand. Locate aorta by running
right hand medically along posterior chest wall. Aorta located along lateral
aspect of vertebral bodies and will be postero-lateral to esophagus. Dissect
around aorta inferior to pulmonary hilum and apply aortic cross-clamp.
7.
Enter pericardium by longitudinally incising pericardium
anterior and parallel to phrenic nerve. This is best accomplished by grasping
pericardium with forceps and cutting with Metzenbaum scissors. Pericardial
incision is carried inferiorly to diaphragmatic reflection and superiorly to level
of superior pulmonary hilum. Care must be taken to avoid injury to left atrial
appendage and phrenic nerve. This is best accomplished by lifting tip of
scissors laterally as incision is made.
8.
Manually lift heart from pericardial sac. If hemopericardium
present, then examine for cardiac perforation. Teflon pledgetted 3-0 prolene
suture on a taper needle is present in thoracotomy suture pack for repair of
cardiovascular wounds. If hemopericardium is not present, then begin open
cardiac compression. Aortic cross-clamping, if not previously performed, is
indicated if no hemodynamic response is noted.
9.
Additional exposure may be accomplished by extending
thoracotomy incision across sternum into contralateral chest cavity.
Powell DW,
Moore EE et al. Is emergency department resuscitative thoracotomy futile care
for the critically injured patient requiring prehospital cardiopulmonary
resuscitation? J Am Coll Surg. 2004 Aug; 199(2):211-5.
Emergency Resuscitative Thoracotomy Tray
1 Finochetto
1 Pediatric
Finochetto Medium
1 Tuffier
Rib spreader
1 Medium
weitlander retractor
2 army/navy
retractor
1 str
liston bone cutter
1 lebsche
sternal chisel
1 mallet
1 med
Richardson
1 sm
Richardson
2 9
½ “ Debakey forceps
2 7
1/2 “ Debakey forceps
4 hemostats
2 8”
Kelly
2 Vanderbilt
2 7”
Tonsil
6 8”
Tubing clamp
1 st
Mayo
1 Curved
Mayo
2 9”
Metz
2 8”
Crilewood Needle holder
1 lg
towel clip
1 sm
satinsky
1 Med
Satinsky
1 lg
satinsky
1 sm
rummel
1 peds
yankauer suction
1 wire
cutter