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s Emergency Department Resuscitativehoracotomy Futile Care for the Critically Injuredatient Requiring Prehospitalardiopulmonary Resuscitation?

anny W Powell, BS, Ernest E Moore, MD, FACS, C Clay Cothren, MD, David J Ciesla, MD,on M Burch, MD, FACS, John B Moore, MD, FACS, Jeffrey L Johnson, MD

BACKGROUND: Documented prehospital asystole justifies termination of resuscitation, but recently it has beenproposed to extend this policy to patients in the field with pulseless electrical activity. Conse-quently, we questioned whether resuscitative thoracotomy is warranted in the critically injuredpatient who fails to respond to prehospital CPR.

STUDY DESIGN: A prospective database of all emergency department resuscitative thoracotomies (EDT) per-formed at our Level I trauma center has been maintained since January 1977.These registry datawere augmented by a review of prehospital paramedic records for all survivors of EDT to verifylength of CPR.

RESULTS: During the 26-year study period, 959 patients underwent EDT. Of the 62 patients whosurvived to leave the hospital, 26 (42%) required prehospital CPR. The injury mechanism inthese 26 patients was stab wounds in 18 (69%), gunshot wounds in 4 (15%), and blunt traumain 4 (15%). The duration of prehospital CPR ranged from 3 to 15 minutes and in 7 patientsCPR exceeded 10 minutes. Five survivors had asystole documented at the time of EDT; four ofthese patients had good functional outcomes at discharge. Each of these patients had pericardialtamponade from ventricular stab wounds. Patients with blunt trauma had uniformly dismalneurologic outcomes.

CONCLUSIONS: EDT after prehospital CPR can be used to salvage select critically injured patients. Based onthese data, we propose that resuscitative thoracotomy is futile care in patients with blunt traumarequiring prehospital CPR longer than 5 minutes, and in patients with penetrating trauma withmore than 15 minutes of prehospital CPR. EDT is warranted in those patients with penetratingtrauma with less than 15 minutes of prehospital CPR, and should be performed despite docu-mented asystole on arrival if pericardial tamponade is the proximate event. ( J Am Coll Surg2004;199:211–215. © 2004 by the American College of Surgeons)

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he role of emergency department resuscitative thora-otomy (EDT) is controversial and remains debated inn effort to reduce futile care and minimize risks toealth-care providers.1 Documented prehospital asystolefter trauma justifies termination of resuscitation,2,3 butecently it has been proposed to extend this guideline of

o competing interests declared.

upported in part by the Jourdan Block Trauma Research Foundation andational Institutes of Health P50GM4922 and U54GM62119.

eceived February 25, 2004; Revised April 2, 2004; Accepted April 6, 2004.rom the Department of Surgery, Denver Health Medical Center, and theniversity of Colorado Health Sciences Center, Denver, CO.orrespondence address: Ernest E Moore, MD, Department of Surgery,enver Health Medical Center, 777 Bannock St, MC 0206, Denver, CO

0204-4507.

2112004 by the American College of Surgeons

ublished by Elsevier Inc.

ermination to those patients with pulseless electricalctivity, rather than performing CPR.4-6 A recent state-ent of the National Association of EMS Physicians

tandards and Clinical Practice Committee and themerican College of Surgeons Committee on Traumaoncluded that EDT “does not appear to have a role inrehospital traumatic cardiopulmonary arrest as a resultf blunt trauma . . . [Traumatic cardiopulmonary ar-est] secondary to penetrating trauma, while still havingdismal prognosis, may be more amenable. . . . in the

ase of isolated penetrating trauma to the thorax.”3

These recommendations are based largely on retro-pective reviews with relatively few survivors,1 so weuestioned if EDT is warranted in the critically injured

ISSN 1072-7515/04/$30.00doi:10.1016/j.jamcollsurg.2004.04.004

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212 Powell et al Is Emergency Department Thoracotomy Futile Care? J Am Coll Surg

atient who fails to respond to prehospital CPR basedn a large database in a single institution. We hypothe-ize that select patients requiring prehospital CPR areotentially salvageable and should be transported to arauma center for evaluation and prompt EDT.

ETHODShe Rocky Mountain Regional Trauma Center at Den-er Health Medical Center is a state-certified and Amer-can College of Surgeons verified Level I trauma centerith pediatric commitment. Denver Health Medicalenter serves as the base hospital for the Denver emer-ency medical services system, which is a two-tieredrehospital system using fire department responders cer-ified in basic life support and ground-based paramedic-taffed ambulances with advanced life support capabil-ty. The Denver emergency medical services criterion foraramedics to initiate postinjury CPR is lack of a palpa-le carotid pulse in an unresponsive patient who iseemed potentially salvageable. On arrival at the emer-ency department, initial management of the injuredatient is a team effort of trauma surgeons and emer-ency medicine physicians. Postinjury EDT is per-ormed by the trauma surgery team.

A prospective database of EDT performed at Denverealth Medical Center since January 1977 has beenaintained by the senior author (EEM).7,8 Specific in-

ormation collected includes mechanism of injury, pre-ospital and emergency department vital signs, need fornd length of prehospital CPR, and outcomes includingeurologic deficits. Base deficit from the initial emer-ency department arterial blood gas has been recordedrospectively since 1995. Data from this registry wereugmented with specific review of the prehospital para-edic reports for all survivors of EDT. The Coloradoultiple Institutional Review Board approved this

tudy.

ESULTSuring the 26-year study period, 959 patients under-ent resuscitative thoracotomy in the emergency de-artment. The population in question comprises the 62atients who survived to leave the hospital. Injury mech-nism was stab wound in 39 (63%), gunshot wound in2 (19%), and blunt trauma in 11 (18%); 33 patientsad no detectable vital signs on arrival in the emergencyepartment. Twenty-six (42%) of these survivors re-uired prehospital CPR and are the focus of the current

nalysis (Table 1). The patient’s age, injury mechanism,ength of prehospital CPR, cardiac rate/rhythm at theime of thoracotomy, and outcomes including neuro-ogic status are individually categorized in Table 2. The

ean age of the 26 patients surviving EDT after prehos-ital CPR is 30.2 � 3.3 years, and the mechanism is stabound in 18 (69%), gunshot wound in 4 (15%), andlunt trauma in 4 (15%). The mean base deficit of the3 survivors since 1995 is 21.5 (range 14 to 35). Allatients underwent successful endotracheal intubationn the field.

Of the 26 patients requiring prehospital CPR whourvived EDT, 21 (81%) patients were neurologicallyunctional. Five patients suffered severe neurologic in-ult and associated disability; the mechanism of injury inhese patients included four patients sustaining bluntrauma and one patient with a stab wound to the heart.ix patients sustained mild neurologic deficits, whichncluded short-term memory problems, emotional lia-ility, and ataxia. Mechanism of injury in these six pa-ients includes four with stab wounds to the heart, oneunshot wound to the neck, and one gunshot wound tohe chest. Interestingly, five survivors had asystole doc-mented at the time of EDT; four of these patients, allith pericardial tamponade because of stab wounds to

he ventricle (three right, one left), had good functionalutcomes. In contrast, only four patients with bluntrauma survived prehospital CPR and all remained neu-ologic invalids. The emergency department initial baseeficit did not appear to predict neurologic outcomes.

ISCUSSIONesurgent efforts to define futile care during prehospitalvaluation have focused appropriately on cardiachythm.2,3 There is no debate that asystole justifies dec-aration of death at the scene, and there is emergingvidence that profound bradycardia (heart rate � 40/in) represents an unsalvageable situation.2 Recently

able 1. Postinjury Emergency Department Resuscitativehoracotomy Survival by Mechanism of Injury

echanism

Overallsurvival(n � 62)

Survival withprehospital

CPR (n � 26)

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tab wound 39 63 18 70unshot wound 12 19 4 15lunt trauma 11 18 4 15

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213Vol. 199, No. 2, August 2004 Powell et al Is Emergency Department Thoracotomy Futile Care?

his discussion has been extended to patients with pulse-ess electrical activity.4-6 Regrettably, most emergency

edical services systems do not provide cardiac mon-toring for critically injured patients and when a pa-ient arrives in the emergency department undergoingPR, a critical question is whether to perform EDT.he purpose of this study was to define the popula-

ion of patients that benefits from transport to arauma center to undergo EDT despite the need forrehospital CPR.Survival because of the physiologic benefits of exter-

al cardiac massage is questionable in critically injuredatients. Luna and colleagues9 have demonstrated con-incingly in primate studies simulating postinjury hypo-olemia or pericardial tamponade that external chestompression has minimal effects in promoting bloodlow. CPR produces relatively high jugular venous pres-ure, compromising cerebral perfusion pressure. Sur-ival is limited by tissue tolerance to low oxygen tension,

able 2. Critically Injured Patients Who Survived Emergency

echanismAge(y)

CPR(min) Rate (b

lunt: Head/chest 40 12SW: Chest/abd 25 14

W: Chest/abd 16 13lunt: Chest/ext 32 10W: Heart (tamp) 29 3W: Heart (tamp) 23 3SW: Chest 34 15lunt: Head/chest 35 6lunt: Head/ext 29 5W: Heart (tamp) 29 10W: Neck 46 5W: Heart (tamp) 27 8W: Chest 35 5SW: Chest 23 5

W: Heart (tamp) 17 5W: Heart (tamp) 34 11W: Chest 27 5W: Heart (tamp) 23 5W: Ext 69 5W: Neck 36 5W: Chest 31 4W: Heart (tamp) 19 5W: Heart (tamp) 36 8W: Heart (tamp) 22 3W: Heart (tamp) 17 3SW: Neck 31 3

bd, abdomen; Ext, extremity; GSW, gunshot wound; SW, stab wound; Tam

nd this is presumably the survival advantage of fieldntubation shown by Durham and colleagues10 in theirnalysis of EDT. In fact, all survivors of prehospital CPRn this series were intubated in the field. This may alsoxplain failure of excessive time for in-field stabilizationf the critically injured patient.11,12 In our study, theiming and length of CPR was critical; all survivors hadess than 15 minutes of CPR during prehospitalransport.

Pericardial tamponade from a ventricular stab wounds conspicuously favorable in these case scenarios becauseardiac arrest is a relatively precipitous event comparedith ongoing torso or external blood loss.13 Conse-uently, when pericardial decompression is accom-lished through EDT, there is often sufficient bloodolume to permit effective internal cardiac massage,ence restoring functional tissue oxygen delivery. Ourtudy supports previous findings that patients with stabounds to the heart consistently have the highest sur-

artment Resuscitative Thoracotomy after Prehospital CPR

/min)/rhythm Base deficit Neurologic deficit

ib — Severe— None— None

ib — Severeib — Nonestole — Noneib — Mild

— Severe— Severe

ib — None— None— None— None

ib 20 Nonestole 26 Nonestole 18 Mildib 21 Noneib 17 Mild

22 None21 None17 None

stole 24 Mild22 None

stole 35 Mildstole 14 Severeib 23 Mild

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ival rate of all patients undergoing EDT.1 The corollaryo this is that prompt EDT is the only chance to salvagehe injured patient failing to respond to prehospitalPR.In recent reports,4-6 it is proposed that injured patients

ith prehospital pulseless electrical activity should beeclared dead at the scene based on a series of suchatients delivered to trauma centers. But most of theatients have not undergone EDT. Recent emphasis onhe potential risk to the health care providers duringesuscitative thoracotomy may be a possible reason forhis reluctance.14 The findings in our specific analysis ofDT after prehospital CPR are consistent with most of theontemporary literature addressing this topic.1,7,10,14-18 Inur analysis, 26 patients survived prehospital CPR andDT to be discharged from the hospital. Excluding

hose patients with blunt injury, and uniformly dismalutcomes, 71% of the patients were neurologically in-act, although 27% were minimally impaired; only 1atient with a penetrating wound who survived prehos-ital CPR and EDT required longterm care assistance.Despite the spiraling costs of US health care, no phy-

ician is comfortable endorsing practice guidelines thateny anyone an opportunity for productive survival,articularly a previously healthy young patient. Conse-uently, until there is further data, such as the ongoingestern Trauma Association multicenter prospective

tudy, we suggest a conservative policy. There is unques-ionable evidence that prehospital CPR and EDT areore effective for penetrating wounds. There continue

o be sporadic reports of survival for blunt trauma in theituation when the patient “loses vital signs just beforerrival.”1 We submit rationale guidelines (Table 3) toeclare the blunt injured patient “dead on arrival” arerehospital CPR for more than 5 minutes with no signsf life (pupillary response, respiratory effort, or motorctivity) in the emergency department or documentedsystole through cardiac monitoring. The guidelines toerminate resuscitation after a penetrating wound are

able 3. Contraindications for Emergency Department Re-uscitative Thoracotomy after Prehospital CPRlunt trauma CPR � 5 min and no signs of life

(pupillary response, respiratoryeffort, or motor activity)Asystole

enetrating trauma CPR � 15 min and no signs of lifeAsystole without the possibilityof cardiac tamponade

rehospital CPR for more than 15 minutes with no signsf life in the emergency department or asystole withoutpenetrating wound that could result in pericardial tam-onade. These recommendations are compatible withhe recent National Association of EMS Physicians Stan-ards and Clinical Practice Committee and Americanollege of Surgeons Committee on Trauma guidelines

o withhold or terminate resuscitation in the field.3 Fur-her, we believe every emergency medical services systemhould routinely initiate cardiac monitoring in the pre-ospital care of all injured patients to better define futileare—in the field and on arrival to the trauma center.

uthor Contributionstudy concept and design: EE Moorecquisition of data: Powell, EE Moorenalysis and interpretation of data: EE Moore, Cothren,Ciesla, Burch, JB Moore, Johnsonrafting of manuscript: Powell, EE Moore, Cothrenritical revision: EE Moore, Cothren, Ciesla, Burch, JBMoore, Johnson

tatistical expertise: Cieslabtaining funding: EE Moore, Johnson

upervision: EE Moore

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1. Biffl WL, Moore EE, Johnson JL. Emergency department tho-racotomy. In: Moore EE, Feliciano DV, Mattox KL, eds.Trauma. 5th ed. New York: McGraw-Hill; 2004:239–254.

2. Battistella FD, Nugent W, Owings JT, Anderson JT. Fieldtriage of pulseless trauma patients. Arch Surg 1999;56:96–100.

3. NAEMSP Standards and Clinical Practice. Committee and theACS Committee on Trauma. Guidelines for withholding or ter-mination of resuscitation in prehospital traumatic cardiopulmo-nary arrest. J Am Coll Surg 2003;196:106–112.

4. Martin SK, Shatney CH, Sherck JP, et al. Blunt trauma patientswith prehospital pulseless electrical activity (PEA): poor endingassured. J Trauma 2002;53:876–881.

5. Rosemurgy AS, Norris PA, Olsen SM, et al. Prehospitaltraumatic arrest: the cost of futility. J Trauma 1993;35:468–473.

6. Stockinger ZT, McSwain NE. Additional evidence in supportof withholding or terminating cardiopulmonary resuscitationfor trauma patients in the field. J Am Coll Surg 2004;198:227–231.

7. Moore EE, Moore JB, Galloway AC, Eiseman B. Post injurythoracotomy in the emergency department: a critical evaluation.Surgery 1979;86:590–598.

8. Branney SW, Moore EE, Feldhaus KM, Wolfe RE. Critical anal-ysis of two decades of experience with postinjury emergencydepartment thoracotomy in a regional trauma center. J Trauma1998;45:87–95.

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215Vol. 199, No. 2, August 2004 Powell et al Is Emergency Department Thoracotomy Futile Care?

9. Luna GK, Pavlin EG, Kirkman T, et al. Hemodynamic effects ofexternal cardiac massage in traumatic shock. J Trauma 1989;29:1430–1433.

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