27 y/o man Delta TTA at 2225 Pedestrian struck by SUV In cardiac arrest on arrival King airway exchanged to ETT IO epinephrine, ED thoracotomy, 2 U PRBC, IC epinephrine with ROSC Aorta crossclamped Taken immediately to OR

Question #1 Midlevel Describe the steps of a resuscitative thoracotomy

Question #2 chief Describe the indications of a resuscitative thoracottomy

Question #3 Intern Why do we clamp the aorta?

In OR, multiple rounds of IC epinephrine, cardiac massage Laparotomy performed Ventricular fibrillation arrest Pupils fixed and dilated Resuscitative efforts terminated at 2256

Question #4 Last- Chief resident State reasons for NOT doing a thoracotomy

Indications for ED thoracotomy Salvageable postinjury cardiac arrest Witnessed penetrating trauma with <15 min prehospital CPR Witnessed blunt trauma with < 5 min prehospital CPR Severe postinjury hypotension due to Cardiac tamponade Hemorrhage, air embolism

Contraindications Penetrating trauma Blunt trauma CPR >15 min and no signs of life (pupillary response, respiratory effort, motor activity) Blunt trauma CPR >5 min and no signs of life, asystole

Steps Anterolateral incision through 4th intercostal space, sternal border to midaxillary line Heavy scissors to cut intercostal mm Insert rib spreader, handle down Open pericardium anterior to phrenic n Mobilize lung Control pulmonary hilum Crossclamp aorta Open cardiac massage/defibrillation

AIM: identify injury patterns consistent with survival after ED thoracotomy To define limits of resuscitative thoracotomy to enable development of rational guidelines to withold or terminate efforts Prospective multicenter study, 18 institutions representing Western Trauma Association, 6 year period

Results 56 patients surviving hospital discharge 30% survivors = stab to ventricle 16% GSW lung 9% after blunt trauma 34% underwent prehospital CPR 7 patients survived with asystole at ED arrival 18% had moderate-severe anoxic brain injury

Conclusions WTA multicenter experience suggests unlikely EDT survival when Blunt trauma with > 10 minutes prehospital CPR Penetrating trauma with > 15 minutes prehospital CPR Asystole without tamponade Mechanism alone is not a discriminator of futility

Take home points Resource-intensive procedure High risk for personnel Precise indications remain to be defined Consider duration of prehospital CPR Consideration for blunt trauma victims supported in literature