Indications for ERT in Civilian Trauma

In the setting of civilian trauma, ERT is generally indicated only for penetrating trauma with either witnessed cardiac arrest or recent loss of vital signs. These indications were formalized by a working group of the American College of Surgeons Committee on Trauma after collectively reviewing the results of over 4,500 ERT procedures.3 There was an overall survival rate of only 5% for ERT, although survival was over 30% in patients with low velocity penetrating cardiac injury. When ERT was limited to penetrating trauma and appropriate indications, it is associated with an 8.8% survival rate. Although this remains a very low rate of success, ERT is a true salvage procedure, without which survival is essentially zero even in indicated scenarios. The working group formulated the following recommendations (Class II):

1. ERT is best applied to patients sustaining penetrating cardiac injuries that arrive at trauma centers after a short scene and transport time with witnessed or objectively measured signs of life (pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, or organized cardiac activity).
2. ERT should be performed in patients sustaining penetrating non-cardiac thoracic injuries, but these patients generally experience a low survival rate. Because it is difficult to ascertain whether the injuries are non-cardiac thoracic versus cardiac, ERT can be used to establish the diagnosis.
3. ERT can be performed in patients sustaining exsanguinating abdominal vascular injuries, but these patients generally experience a low survival rate. Judicious selection of patients should be exercised. REBOA may be an equally appropriate salvage procedure. This procedure should be used as an adjunct to definitive repair of the abdominal-vascular injury.
4. ERT should rarely be performed in patients sustaining cardiopulmonary arrest secondary to blunt trauma because of its very low survival rate and poor neurologic outcomes. It should be limited to those that arrive with vital signs at the trauma center and experience a witnessed cardiopulmonary arrest.

The Western Trauma Association (WTA) algorithm recommends ERT for patients with prehospital arrest and CPR duration of less than 10 minutes for blunt trauma and less than 15 minutes for penetrating injury.5-11 ERT is also recommended for patients undergoing CPR with signs of life (respiratory or motor effort, organized cardiac activity, or pupillary reflexes) or with profound shock (systolic pressure < 60 mmHg). WTA’s recommendation for ERT in blunt trauma patients with prehospital arrest and CPR<10 minutes is more liberal than others who recommend against ERT in this cohort; it is noteworthy, however, that this is based on only 5 patients (4 who arrived with organized electrical activity and 1 with tamponade from an atrial laceration).

Most recently, the Eastern Association for the Surgery of Trauma (EAST) Practical Management Guidelines for ERT analyzed 72 relevant studies utilizing the GRADE methodology for assessing the strength of the evidence, but also taking likely patient preferences into account.12 They defined “signs of life (SOL)” as presence of any of the following: pupillary reactivity, spontaneous breathing, palpable carotid pulse, measurable blood pressure, motor movement, or organized electrical activity. They identified 6 pre-defined patient categories depending of 3 conditions (penetrating or blunt mechanism, thoracic or extra-thoracic location and presence of SOL), and made either strong or conditional recommendations for ERT in pulseless patients, as following:

1. Penetrating thoracic trauma with signs of life but pulseless on arrival (Strong).
2. Penetrating thoracic trauma without signs of life and pulseless on arrival (Conditional).
3. Penetrating extra-thoracic (non-cranial) trauma with signs of life but pulseless on arrival (Conditional).
4. Penetrating extra-thoracic (non-cranial) trauma without signs of life, pulseless on arrival (Conditional).
5. Blunt injury with signs of life but pulseless on arrival (Conditional).
6. For the sixth category of blunt trauma patients without signs of life and pulseless on arrival they gave a conditional recommendation against proceeding with ERT.

Results from prehospital thoracotomy has been reported by a few authors.13,14 These studies concerned only the subgroup of stab wounds to the chest and described a 10 to 18% survival rate. This experience remains strictly limited to very few experienced teams acting within a trauma system with well-established training and quality assurance.

Recently, the prospective observational multicenter Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery study reported the outcomes of 310 patients undergoing ERT from 2013 to 2017 after either blunt or penetrating trauma.15 Survival rate was 12.3% beyond 24h and 5.2% to discharge. The authors discuss the fact that neither practice nor outcomes following ERT have changed in the last 40 years.