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):
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:
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.