“To Do or Not to Do an Emergency Department (ED) Resuscitative Thoracotomy”: Alternatives to ED Thoracotomy at Non-Trauma Centers
The Actual Case (not hypothetical):
You are working in a 64-bed non-trauma center. In the middle of a busy shift, you are frantically called to the ambulance entrance. From the back of an SUV, an adult male, diaphoretic, actively bleeding, is thrust into your arms.
The drivers stated that another vehicle had struck the patient while walking, pinning him by the pelvis against a brick wall. Police who followed state that he had been stabbed in the anus prior to the blunt trauma. He was able to state that he has sickle cell anemia, but no other medical problems.
A stretcher was obtained, and a primary survey performed while the patient was rolled to a room. His airway was intact, breath sounds were clear and equal bilaterally, he had weak peripheral pulses, cool extremities, and was actively bleeding (non-pulsatile) from the rectum and from a wound in the anterior abdominal wall. The pelvis was stable to palpation. His initial GCS was 13 and declining (Eyes: 3, Verbal: 4, Motor: 6).
You give direction to nursing, including completing exposure, connecting him to a monitor, obtaining a manual blood pressure and IV access, initiating a saline bolus, and sending labs. Nursing reports that the blood pressure was 158/100, which, on repeat by a seasoned nurse was actually 68/30. Heart rate was 130-150 beats/minute. Un-crossmatched blood was started following 1L saline. Chest x-ray and pelvic x-ray were unremarkable for obvious injury. Secondary survey revealed copious, active bleeding at the anus. A pelvic binder was applied for tamponade, and gauze packed into the rectal wound. The anterior abdominal wall wound was believed to be secondary to blunt trauma, while the anal wound appeared penetrating. A FAST ultrasound revealed no free fluid in the pelvis. Following three units of blood, one unit of platelets, one unit of fresh frozen plasma, and the original crystalloid, the patient’s blood pressure, heart rate, and mental status normalized. Bleeding slowed at the anal wound. He was transported via physician-accompanied critical care transport to a Level 1 Trauma Center, as would be ultimately required for any case like this presenting to a hospital without trauma capability. He received an exploratory laparotomy and partial colectomy. Following fifteen days inpatient with a moderately complicated course, he was discharged home.
Discussion:
This case illustrates a challenging, peri-arrest trauma, managed initially at a non-trauma center. The Emergency Department, while large, lacks resuscitation bays or a staff familiar with protocolized trauma management. Strong communication was maintained, though during the resuscitation, the unfamiliar nursing team placed five large bore IVs, and the order of events (Primary Survey, IV, Fluids, O2, Monitor, Adjunct Imaging and Ultrasound, Secondary Survey) occurred in disjoint fashion due to frequent interruptions and role confusion. This case brings to mind a point of worry for community and non-trauma emergency physicians – management of codes from penetrating trauma: “To do or not to do an ED thoracotomy.”
Resuscitative Thoracotomy
By way of review, when cardiac arrest occurs following penetrating trauma to the neck, chest, abdomen, or pelvis, a resuscitative thoracotomy may be indicated if signs of life were present within 15 minutes of the arrest event. The Eastern Association for the Surgery of Trauma (EAST)[1] guidelines recommend thoracotomy as follows:
| Condition: Absent pulses plus… | Recommendation to perform |
|---|---|
| Penetrating Thoracic, with signs of life* | Strong |
| Penetrating Thoracic, without signs of life | Conditional |
| Penetrating Extrathoracic (excluding isolated cranial), with signs of life | Conditional |
| Penetrating Extrathoracic (excluding isolated cranial), without signs of life | Conditional/weak evidence |
| Blunt, with signs of life | Conditional/moderate evidence |
| Blunt, without signs of life | Not recommended |
*Signs of life: pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, or cardiac electrical activity.
A resuscitative thoracotomy controls hemorrhage in the thorax (by direct compression/hemostasis maneuvers), in the abdomen (by proximal aortic cross clamping), or in the pericardial space (by pericardiocentesis). It further permits internal cardiac massage instead of external chest compressions. In this manner, circulation to vital organs can be restored while the patient is prepared for definitive operative management. A resuscitative thoracotomy is only appropriate if a patient can survive long enough and with low enough morbidity to permit definitive surgical management. EAST additionally recommends that thoracotomy only be performed when the correct equipment, a trained team, and downstream surgical resources are available[1].
A concern shared by many non-trauma center emergency medicine practitioners relates to how to manage situations similar to this case – a peri-code patient who would otherwise meet an indication for thoracotomy. Imagine yourself in a single-coverage department with few resources. What would you do if a peri-code or coding trauma patient arrived?
There are alternatives.
REBOA
Retrograde Endovascular Balloon Occlusion of the Aorta (REBOA)[2] is an alternative that involves cannulating the femoral artery and passing an inflatable balloon through it into the proximal aorta. The balloon is then inflated, blocking distal flow. Not every center has the equipment to perform REBOA; without trained staff, the conditions in which it is appropriate are limited. Further, for distal aortic trauma or aortoiliac trauma, it may be impossible to pass a catheter proximal to the lesion. REBOA is only as temporizing as proximal internal cross-clamping of the aorta for abdominopelvic/femoral arterial exsanguination, and much of the morbidity is similar (renal hypoperfusion, mesenteric ischemia). The same downstream trauma team must be available to prevent prolonged ischemia. At a small hospital, no such care may exist, and transfer times may be hours. This makes REBOA impossible, impractical, or potentially contraindicated in the same manner as resuscitative thoracotomy.
Abdominal Aortic Tourniquet
This device is a pneumatic compression band that wraps around the patient at the level inferior to the costal margin. It is inflated to 150-300 mmHg, compressing the aorta against the spine. In tests, such devices completely occluded distal flow in nearly all subjects. The time to apply a device is 30-60 seconds, whereas the time to cross clamp an aorta via thoracotomy averages over 400 seconds, and the time to REBOA is typically between 200 and 300 seconds. The image demonstrates the device and procedure, from Major David M. Taylor et. Al., Royal Army Medical Corps, during testing of the device[3].
Proximal External Aortic Compression (PEAC)
In the pre-hospital and battlefield setting, kneeling or placing a fist onto the proximal aorta in a supine patient (image at right) has also proven to slow distal flow. In cases of lower limb exsanguination and pelvic junctional exsanguination, combat medics frequently kneel into the wounded patient’s proximal aorta, just below the xiphoid, while applying a tourniquet and attempting to gain source control. These maneuvers work best on thin persons; habitus may limit the application in morbidly obese persons. The time to achieve control is typically seconds. Douma et. Al have written three studies on these techniques in pre-hospital medicine, all showing that PEAC can halt distal flow in as little as 12.5 seconds. Limitations were noted for body habitus of patient and for strength of provider [4,5,6,7,8].
Ultrasound-Guided PEAC
Applying the study by Douma, Michel and team[9] showed that ultrasound could be used to locate the proximal aorta during a penetrating trauma resuscitation with exsanguination involving the abdomen and pelvis. In a similar situation to our case, they also work in a non-trauma center, and a patient with multiple abdominopelvic gunshot wounds arrested in their department. They attempted resuscitation using guided PEAC instead of thoracotomy. With administration of blood products, external CPR, and PEAC guided by and applied with a curvilinear transducer, they achieved ROSC in the patient without the need for invasive control of distal hemorrhage. Additionally, they could focus their compression via image guidance which limited the requirement for large habitus of the operator, and reduced the disseminated pressure required on the patient. They maintained aortic pressure manually, and the resuscitation succeeded, temporizing the bleeding for the patient to be transferred to operative management. This technique also allowed direct visualization of ROSC with returning pulsatility of the aorta.
Conclusion
While resuscitative thoracotomy and REBOA are often viewed as heroic procedures, both carry an exorbitant amount of mortality and morbidity, and few centers around the country are able to competently offer these options. It seems appropriate to consider alternatives, especially with the emergence of bedside ultrasound and its increasing applicability in the emergency setting. PEAC or US-guided PEAC may be more feasible, performable by mostly untrained staff, and may temporize bleeding to permit transfer to definitive care.
Faculty Reviewer: Dr. Lindquist
References
Seamon MJ, Haut ER, Van Arendonk K et. Al. Emergency Department Thoracotomy. Eastern Association for the Surgery of Trauma. J Trauma. 79(1):159–173, July 2015
Brenner M,Teeter W,Hoehn M et. Al. Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Proximal Aortic Control in Patients with Severe Hemorrhage and Arrest. JAMA Surg. 2018 Feb 1;153(2):130-135.
Taylor DM, Coleman M, Parker PJ. The evaluation of an abdominal aortic tourniquet for the control of pelvic and lower limb hemorrhage. Mil Med. 2013 Nov;178(11):1196-201.
Douma MJ, O’Dochartaigh D, Brindley PG. Bi-manual proximal external aortic compression after major abdominal-pelvic trauma and during ambulance transfer: A simulation study. Injury. 2017 Jan; 48(1):26-31.
Douma MJ, Picard C, O’Dochartaigh D, Brindley PG. Proximal External Aortic Compression for Life-Threatening Abdominal-Pelvic and Junctional Hemorrhage: An Ultrasonographic Study in Adult Volunteers. Prehosp Emerg Care. 2019 Jul-Aug;23(4):538-542.
Keogh J, Tsokos N. Aortic compression in massive postpartum haemorrhage--an old but lifesaving technique. Aust N Z J Obstet Gynaecol. 1997 May;37(2):237-8.
Soltan MH, Faragallah MF, Mosabah MH, Al-Adawy AR. External aortic compression device: the first aid for postpartum hemorrhage control. J Obstet Gynaecol Res. 2009 Jun;35(3):453-8.
Riley DP, Burgess RW. External abdominal aortic compression: a study of a resuscitation manoeuvre for postpartum haemorrhage. Anaesth Intensive Care. 1994 Oct;22(5):571-5.
Michel WB, Lachance A, Turcotte AS, Morris J. Point-of-Care Ultrasonographically Guided Proximal External Aortic Compression in the Emergency Department. Ann Emerg Med. 2019 Nov;74(5):706-710.