Resuscitative Thoracotomy


This is a recommended management algorithm from the Western Trauma Association (WTA) addressing the performance of resuscitative thoracotomy (RT). There are no published PRCTs and it is not likely that there will be; the recommendations herein are not based on Level I evidence but on the best available published prospective observational and retrospective studies, as well as expert opinion of WTA members. The algorithm (Fig. 1) and accompanying comments represent a rational approach that could be followed at trauma centers with the appropriate resources; it may not be applicable at all hospitals caring for the injured. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant deviation from the recommended guideline. The annotated algorithm is intended to serve as a quick bedside reference for clinicians.

In the past three decades there has been a significant clinical shift in the performance of RT, from a nearly obligatory procedure before declaring any trauma patient is deceased to a more selective application of RT. The value of RT in the resuscitation of the patient in profound shock but not yet dead is unquestionable. Its indiscriminate use, however, renders it a low-yield and high-cost procedure.1-4 Overall analysis of the available literature indicates that the success of RT approximates 35% for the patient arriving in shock with a penetrating cardiac wound and 15% for all patients with penetrating wounds.5 Conversely, patient outcome is relatively poor when RT is performed for blunt trauma, 2% survival for patients in shock and less than 1% survival for patients with no vital signs. Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be stratified based on injury and transport time to determine the utility of RT.6-11

Emerging data indicate that clinical results in the pediatric population mirror that of the adult experience. One might expect that children would have a more favorable outcome compared with adults; however, this has not been borne out in multiple studies.50-54 Thus, as in adults, outcome following RT in the pediatric population is largely determined by injury mechanism and physiologic status on presentation to the emergency department.