Patients experiencing severe penetrating or blunt-force trauma have an increased risk of cardiac arrest, and ultimately, death. Consequences of trauma include hemorrhage, damage to vital organs, and shock – all of which exacerbate one another – leaving the patient in rapidly deteriorating, critical condition. Unfortunately, pre-hospital medicine does not possess the tools to adequately treat these patients and first responders must prioritize transport to the closest, well-equipped hospital for the best chance of survival.
One procedure that can be performed by emergency physicians/surgeons upon arrival includes a resuscitative thoracotomy; this technique involves opening the chest cavity for direct access to the heart. The indications to complete this invasive procedure are incredibly specific: the patient actively in witnessed cardiac arrest, ongoing CPR for <10 minutes in blunt injuries and <15 minutes in penetrating injuries, evidence of pericardial tamponade, and exhibiting signs of life (Pust and Namias, 2016). Pericardial tamponade occurs when fluid fills the pericardial sac, creating pressure on the heart and decreasing its ability to pump blood – resulting in decreased perfusion and shock (Shashko and Meer, 2023). To diagnose pericardial tamponade, physicians utilize an ultrasound machine to examine the heart and can distinguish any surrounding free fluid, as well as check for cardiac activity (Pust and Namias, 2016).
If all the necessary qualifications are met, a resuscitative thoracotomy takes place in attempt to save the patient’s life. Physicians will make an incision on the patient’s left, fifth intercostal space, using rib spreaders to gain access to the chest cavity (Pust and Namias, 2016). To relieve pericardial tamponade, the pericardium is manually separated from the heart and physicians clear any obvious clots in the space, allowing further examination and interventions for other cardiac injuries. (Pust and Namias, 2016). Common injuries include lacerations to cardiac tissue that are treated with sutures, but more severe injuries causing massive blood loss, require more intensive intercessions; to divert perfusion to vital organs – and prevent further loss from lower extremities – surgeons cross-clamp the descending aorta and expedite transport to the OR (Pust and Namias, 2016).
This controversial practice maintains a dismal survival rate, influenced by patient condition upon arrival – signs of life present, degree of shock, and mechanism of injury. Penetrating thoracic injuries exhibiting signs of life hold the most optimistic chance of survival, between 21.3-35%, while blunt injury survival rests between 4.6-15% (Pust and Namias). A relatively new medical intervention, resuscitative thoracotomies require continual criteria and method evolution. While heavily debated, the alternative to this procedure reveals assured death.
Lifesaving procedures in trauma patients is an interesting and important topic. Your explanation of resuscitative thoracotomies was very well done. Near the end of your post you mentioned how patient condition upon arrival can influence outcomes, and how shock impacts the survival of trauma patients. Thinking about shock really emphasizes the importance of blood flow throughout the body which we just learned about in class. It is important to screen patients in an emergency room, using triage to identify which patients may need attention before others. I found an article (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193151/) which discusses the benefits of the use of a Modified Shock Index during triage. I think it is incredibly important that triage methods be constantly improved to ensure better patient outcomes, and perhaps give a little more time for lifesaving procedures like resuscitative thoracotomies to be effective.
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