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Eur J Cardiothorac Surg 2004;26:386
© 2004 Elsevier Science NL
First Department of Thoracic Surgery, General Hospital for Chest Diseases "Sotiria" 34A Konstantinoupoleos str., 15562 Holargos, Athens, Greece
* Tel.: +30-210-651-0388; fax: +30-210-654-7695
e-mail: kallatha{at}otenet.gr
Emergency thoracotomy (ET) as a life-saving measure either in a prehospital or hospital setting remains a controversial procedure. Its role in traumatic cardiac arrest is defined as resuscitative allowing the evacuation of pericardial tamponade, direct control of intrathoracic hemorrhage, open cardiac massage and cross-clamping of the descending aorta.
In this issue of the European Journal of Cardiothoracic Surgery the authors Athanasiou et al. have reviewed their experience with ET in a prehospital or hospital setting (53 patients in 9 years) with a high survival rate of 18.8% and suggest that ET might be a significant procedure in a well-selected group.
Although cardiopulmonary arrest after trauma is associated with a poor prognosis, there are also other reports on the use of resuscitative thoracotomy in the emergency department that seem to hold some promise for injured patients with cardiopulmonary arrest [1–6]. Generally, the ET literature consists of retrospective series suffering from methodological limitations. Analysis of this literature turns to be really complicated. Survival rates vary from 2 to 31% [7] but have not always been correlated with the mechanism and location of injury, the field and transport times, the duration of arrest and the physiologic status of the patient. Often survival data do not present neurologic outcomes in survivors.
The ATLS guidelines regarding ET make recommendations solely on the basis of mechanism of trauma and do not take into account the duration of the arrest [1,7]. All studies [1,3,4] reporting higher survival with significantly larger proportions of patients in severe shock had a more recent onset of cardiopulmonary resuscitation than those studies with a lower survival rate. However, whereas the duration of the arrest affects greatly the decision to perform an ET, the exact time of the trauma and the length of the ‘down time’ are in most of the cases uncertain.
The recently published guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest by the American College of Surgeons [7] state that resuscitation may be withheld in any blunt trauma, apneic and pulseless patient without organized ECG activity, while in cases of apneic and pulseless victims of penetrating trauma, when other vital signs such as papillary reflexes are present, resuscitation should be performed.
The decision to withhold or terminate resuscitation attempts in the field is very difficult. To deprive a patient of a potentially life-saving measure such as an ET might be considered also unethical by some physicians. Despite advances in modern medicine most recent reports indicate that trauma patients requiring a cardiopulmonary resuscitation have a dismal prognosis (survival rate ranges from 0 to 5%) [7]. At last, only a small subset of these patients may be salvaged with timely interventions. In my opinion, the potential salvage must be weighed against the high costs and risks of resuscitation attempts. Another question that might raise is whether patients with severe traumatic injuries should be transported without delay or might benefit from an on-scene stabilization. Coats et al. suggest that if the trauma center is more than 10 min, a prehospital ET is a necessity. In his series, ET was performed by a non-surgeon but the small number of survivors (n=4) precludes any firm conclusion about perioperative complications and about the influence of the specialty of the operator on survival. According to the ATLS guidelines the expert is the only responsible physician for performing ET being not included among the four life-saving prehospital interventions such as peritoneal lavage, pericardiocentesis, chest drainage and cricothyroidotomy.
I personally feel that thoracotomy is not a procedure that shall be included in the prehospital care setting and performed by a non-surgeon, although it could be argued that even lower survival rates might justify its use. Most series [2–7] agree that for victims of blunt trauma and extrathoracic injuries submitted to ET the prognosis is very poor, whereas cases of cardiac arrest after penetrating chest injury with cardiac tamponade represent the only well-recognized indication for resuscitative ET either in a prehospital or hospital setting with a high survival rate.
This study along with other reports has raised an important issue—more prospective well-designed studies focusing on guidelines, indications and protocols should be conducted so that a selective approach will prevent from unnecessary thoracotomies on unsalvageable patients and direct the resources of a National Health Care System to those patients who would most likely benefit.
Finally, I would like to stress that the ET should never be performed for the "benefit of the doubt" in the same manner as cardiopulmonary resuscitation is used in medical cases.
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