Thoracotomy in Blunt Trauma: What's the Harm?

To Be Blunt: Are We Wasting Our Time? Emergency Department Thoracotomy Following Blunt Trauma: A Systematic Review and Meta-analysis

Slessor D, Hunter S
Ann Emerg Med. 2014 Oct 23. [Epub ahead of print]

Introduction

The emergency department (ED) thoracotomy for traumatic arrest is one of the smost dramatic procedures in emergency medicine. It is the procedure that every emergency medicine trainee looks forward to performing during the trauma rotation and is often used as an unofficial barometer of the quality of the rotation.

Though often referred to as a "heroic" procedure, it is mandatory learning in every emergency medicine residency. However, the procedure is not indicated in every traumatic arrest. Traditional teaching has been that the thoracotomy has a reasonable chance of success in cases of penetrating chest trauma, but the success rate in blunt trauma is abysmal and therefore not indicated.

In teaching hospitals, however, there's often a sentiment toward performing procedures when there is even a remote chance of success. After all, what's the harm? The following publication has already evoked that sentiment among some of our own residents, even though the article has not even made it to print yet!

What's the harm in just trying the thoracotomy in every traumatic arrest, including those associated with blunt trauma?

Study Summary

The authors performed a structured review of 27 articles focused on ED or out-of-hospital thoracotomy for blunt trauma. All of the articles were case reviews and included 1369 patients. In total, 1.5% of the patients survived with a good neurologic outcome, all of whom had vital signs at the scene or in the ED and a maximum duration of cardiopulmonary resuscitation (CPR) of less than 15 minutes.

The authors conclude, "There may be a role for ED thoracotomy after blunt trauma—in a limited group of patients. Good outcomes have been achieved for patients who had vital signs on admission and for patients who received an ED thoracotomy within 15 minutes of cardiac arrest." They propose a guideline for patients with blunt trauma in whom providers should "consider" performing an ED thoracotomy when cardiac arrest/CPR has not been prolonged, in the absence of "obvious head injury that is incompatible with good outcome," and when "there is appropriately experienced and skilled staff available."

Viewpoint

I work at an inner-city teaching hospital, and I enjoy the opportunity to teach procedures to residents and students whenever possible. Often patients present to the ED moribund, and questions arise as to whether a procedure with a minimal chance of success is worth doing.

On the one hand, if there's even a small chance of success, then the benefit of performing the procedure might justify the cost. Even if the procedure fails, perhaps the residents and students will learn from the procedure such that a future success will occur. Aside from some time and effort, what's the harm in doing the procedure? Such is the typical mindset in many teaching hospitals. However, whenever this quandary arises, I always remember an incident from my own residency training that puts "what's the harm in giving it a try?" in perspective.

During my final year of training, a patient arrived by ambulance as a trauma alert. The patient had been shot multiple times in the chest during a drug deal that went bad. The patient had already lost vital signs prior to the ambulance arrival, but he was transported emergently to our ED anyway.

Upon arrival, our entire ED staff, including the lead trauma surgeon, was waiting. We quickly took him into the trauma room and went through our usual A-B-Cs. By this point, the patient had been pulseless for more than 10-15 minutes and given the multiple entry wounds to the chest had almost no chance of survival.

Nevertheless, the trauma surgeon offered to walk me through a thoracotomy. After all, we were at a teaching hospital and she knew that this was likely to be my final chance to perform a thoracotomy as a supervised resident. She said to me, "Let's give it a try. What's the harm?"

The rest of the team hurriedly secured the airway, initiated IV fluids, and sent labs. The intern splashed Betadine across the patient's chest and I followed with a quick cut through a large tattoo. I spread the ribs, clamped the aorta, and reached for the heart. The surgeon pointed out the phrenic nerve and where to cut. I quickly reached in with the knife to cut the pericardium and... I stabbed her finger. It was firm and deep, right through her double gloves. As she yelled "Ouch!" the team suddenly stopped and the room became dead-silent. I looked at the surgeon's finger, then the patient's tattoos and track marks, then to the surgeon's distraught face and to the rest of the members on the team, and I recalled the words "What's the harm?"

Thoracotomies are not casual procedures. Even in the setting where we all knew that the patient had practically no chance of survival, the setting was tense and hurried; it's a perfect setup for mistakes to occur. Needlestick injuries or injuries from broken ribs are potential risks to consider.

One should also consider that during the care of the trauma patient, the rest of the ED often grinds to a standstill. The ED staff, blood bank, lab, and radiology personnel focus their efforts on the trauma patient rather than the medical patients who might be suffering from cardiac ischemia, strokes, mesenteric ischemia, or other conditions that are equally time-sensitive. The medical costs of such low-yield procedures should be considered as well, something that we in the United States have traditionally been hesitant to consider. So what's the harm in just giving the procedure a try? There are many harms to consider, however. Very many, in fact.

An ED thoracotomy is an important procedure that emergency physicians should be willing and able to do in the right circumstances. But like any other medical procedure, we must also always weigh the potential harms of the procedure against the potential benefits. I would suggest that ED thoracotomy for blunt trauma is more likely associated with harm than benefit in the vast majority of circumstances. The search for a 1.5% success rate must always be weighed against that potential harm.

Don't wait to learn this the hard way.

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