Recommendations

A recommended algorithm for ERT in traumatic arrest in the combat or operational environment is presented in Appendix A.

Penetrating Injuries

- Resuscitative thoracotomy at an MTF in the combat or operational environment is most strongly indicated and warranted in patients with penetrating injuries who present to an MTF in extremis or with a recent witnessed loss of vital signs, especially those with penetrating thoracic injuries. Although there is controversy on the exact definition of “recent” loss of vital signs, the majority of data supports up to 10-15 minutes as a cutoff for pre-hospital arrest with penetrating truncal or extremity trauma.
- Though most of these casualties will not survive, up to 25% of penetrating trauma patients who undergo ERT at a forward military facility can be salvaged with acceptable neurological outcomes.

Blunt Trauma

- In the deployed setting, victims of blunt trauma are less common but most commonly present after vehicle crashes or falls from height. The previously noted study from a combat trauma setting found no ERT survivors after blunt injury, although the blunt cohort was small.
- In the operational setting, ERT for blunt trauma should be based upon clinical judgment, recognizing that the data from civilian studies has demonstrated a very low survival rate. It should be limited to those who have either witnessed in-hospital arrest, pending arrest, or those with definite vital signs in the field and who arrive with clear and present signs of life (organized narrow complex EKG and/or organized cardiac contractile activity on bedside cardiac ultrasound).
- Blunt trauma patients with no vital signs at the scene of injury and during transport, or with reported vital signs during transport but who arrive in arrest should NOT have ERT performed.

Special Circumstances

- Patients with injuries that have a low likelihood of salvage, such as traumatic brain injury or high total body surface area burns, should be either declared expectant on arrival or at most managed with non-operative resuscitation and interventions (intubation, chest tubes, fluid/blood resuscitation) and then reassessed.
- In patients with arrest or impending arrest with severe blunt or penetrating traumatic brain injury, ERT is generally contraindicated unless there is evidence of preserved neurologic function and a potentially salvageable and survivable brain injury.

REBOA to control life-threatening sub-diaphragmatic hemorrhage in surgically capable theater facilities may be a selective alternative to ERT, as detailed in the JTS REBOA CPG.20