1. 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

2. Question #1 Midlevel
Describe the steps of a resuscitative thoracotomy

3. Question #2 chief
Describe the indications of a resuscitative thoracottomy

4. Question #3 Intern
Why do we clamp the aorta?

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

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

7. 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

8. 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

9. 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

12. 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

13. 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

17. 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

18. 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