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KEY POINTS

KEY POINTS

  • Resuscitative thoracotomy (RT) refers to an emergent thoracotomy, most commonly performed in the emergency department for patients arriving in extremis; RT may also be performed in the operating room or intensive care unit within hours after injury for physiologic deterioration.

  • The primary objectives of RT are to release pericardial tamponade, control cardiac or intrathoracic hemorrhage, evacuate bronchovenous air embolism, perform open cardiac massage, and temporarily occlude the descending thoracic aorta.

  • The critical determinants of survival following RT include the injury mechanism, anatomic location of injury, and the patient’s physiologic condition at the time of thoracotomy.

  • The highest survival rate following RT is in patients with penetrating cardiac wounds, especially when associated with pericardial tamponade.

  • Based on the literature to date, RT should be performed for (1) penetrating nontorso trauma with cardiopulmonary resuscitation (CPR) of less than 5 minutes, (2) blunt trauma with CPR of less than 10 minutes, and (3) penetrating torso trauma with CPR of less than 15 minutes.

  • RT is unlikely to yield productive survival when patients (1) sustain blunt trauma and require more than 10 minutes of prehospital CPR, (2) have penetrating wounds and undergo more than 15 minutes of prehospital CPR, (3) have isolated extremity trauma with more than 5 minutes of prehospital CPR, or (4) manifest asystole without pericardial tamponade.

  • Outcome following RT in the adolescent population is largely determined by injury mechanism and physiologic status on presentation to the emergency department; for patients under 15 years of age, there are only isolated cases of survival following penetrating trauma and no apparent survival benefit following blunt trauma.

INTRODUCTION

The number of patients arriving at hospitals in extremis, rather than dying in the prehospital setting, has increased due to the maturation of regionalized trauma systems (see Chapter 4). Salvage of individuals with imminent cardiac arrest or those already undergoing cardiopulmonary resuscitation (CPR) often requires immediate thoracotomy as an integral component of their initial resuscitation in the emergency department (ED). The optimal application of a resuscitative thoracotomy (RT) requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences. Although resuscitative endovascular balloon occlusion of the aorta (REBOA) has been advocated as a resuscitation maneuver that should replace RT, there is a paucity of objective data to clarify the precise role of REBOA versus RT. In fact, aortic occlusion can be achieved quicker with RT than REBOA in patients arriving with CPR in progress.1 Furthermore, RT is indicated for life-threatening thoracic injuries. However, we believe REBOA is ideal for unstable pelvic fractures with advanced hemorrhagic shock (see Chapter 39), and we have placed a REBOA in patients who have recovered perfusion following RT when it is evident that a pelvic fracture is the source of acute blood loss. This chapter reviews the features of RT and highlights the specific clinical indications, all of which are essential for the appropriate use of ...

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