Background

Resuscitative thoracotomy (RT) performed in the Emergency Department (ED) is a potentially life-saving procedure in patients with traumatic cardiac arrest. However, the procedure does have the potential to harm providers (i.e. fluid exposure). Therefore, it is important to weight two different perspectives: the patient is dead and will remain so if an RT is not performed so why not try it as a last ditch effort and that RT is low yield so why expend resources and create a potential risk of harm to providers.  The Focused Assessment Using Sonography for Trauma (FAST) has a high sensitivity and specificity for identifying hemopericardium and cardiac activity in a matter of seconds.  Since there is really no good way to discriminate between which patients with traumatic cardiac arrest would benefit from RT, maybe adding a bedside FAST could help make this distinction.

Clinical Question

What is the ability of a FAST examination to predict between survivors and non-survivors undergoing RT for traumatic cardiac arrest?

Population

All patients with cardiac arrest from trauma deemed to be appropriate for RT by the attending trauma surgeon.

Intervention

FAST examination looking for the presence of pericardial effusion and cardiac activity

Outcomes

Overall survival or survival to organ donation

Design

Prospective cohort study

Excluded

Patients with non-traumatic cardiac arrest

Primary Results

Critical Findings

  • Survival in patients with the absence of both pericardial fluid and cardiac motion was zero
  • If no cardiac motion seen on US 0/126 survived
  • If cardiac motion seen on US 9/45 survived or became organ donors
    • Only 6 patients (3.2%) survived
    • Only 3 patients (1.6%) became organ donors

Primary Results

  • 187 patients with traumatic arrest and underwent FAST
    • 3.2% Survived
    • 1.6% Organ Donors
    • 95.2% Expired
  • Demographics:
    • Median Age 31 years
    • 84.5% Male
    • 51.3% Penetrating Trauma
  • The presence of cardiac motion on FAST was 100% sensitive and 73.7% specific for the identification of survivors and organ donors
  • Addition of pericardial effusion did not improve sensitivity for the identification of survivors or organ donors

Strengths

  • This study included a large number (n = 187) of RTs
  • All patients with traumatic arrest who had an US and progressed to RT were included

Limitations

  • Providers performing FAST examinations completed a 2 day, 16 hour ultrasound course and had 2 weeks of proctored training in point of care ultrasound
  • 16.1% of RTs were excluded because an US was not performed prior to the procedure
  • The authors do not discuss the number of patients with traumatic arrest that the senior clinician excluded from RT

Discussion

  • This group from LA County hospital performs a large number of ED RTs (223 over 3.5 years = > 1/week!) and so their outcomes are likely to represent a “best case scenario” in expert hands. It is unlikely that most level 1 trauma centers will be as skilled with the procedure due to lower numbers.
  • ED RT is already a relatively rare procedure in most institutions and a further decreased in the number of procedures will make it difficult to maintain the skills necessary for this procedure.

Author's Conclusions

“With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.”

Our Conclusions

In this large, prospective study, no patient with a traumatic cardiac arrest and absence of both cardiac motion and pericardial effusion survived ED RT.

Bottom Line

In patients with traumatic cardiac arrest, consider not performing an ED RT on patients with absence of cardiac activity and absence of pericardial fluid on FAST examination.

Read More

REBEL Cast: October 2015 REBEL Cast: The All Thoracotomy Episode