Very good paper, especially in assuming that the final response will never come to us, due to the impossibility in performing controled trials. In my opinion: in non penetrating trauma cases there could be some space of ED Thoracotomy in cases of cardiac arrest WITH elecrtical cardiac activity, after excluding problems in pleural space (pneumothorax and hemothorax). This is because we can have cardiac tamponade in thses patients. In other cases, I think it is futile.

I believe there is merit in performing EDRT for blunt trauma if vital signs were lost within 5 minutes of arrival, and particularly if ED ultrasound is available and there is any sign of cardiac activity. Clearly the presence of pericardial effusion, cardiac activity and no pulse (tamponade physiology) would merit immediate needle pericardiocentesis if not full-out EDRT. Hope this helps...

Agree 100% with Fabrizio.

In general I agree with the high leveled comments expressed here by surgeons, deeply engaged in EDT. Usually the scenario of presumable IA bleeding in blunt trauma is in a CA situation; if the time frame gap in reasonable as stated, or signs of life are present, I keep doing EDT for CPR and aortic crossclamping, followed then by crash lap. If the IA hemorrage was during an already opened abdomen, the procedure is damage control, compression and packing, for either injury, venous or arterial, and reevaluate further moves, including if necessary aortic crossclamping, by supraceliac access or anterolateral left thoracotomy. Arterial injuries should be controlled before leaving the OR (usually by damage control vascular techniques, i.e. shunts).

Spangaro's paper was published in 1906, commented by Beck in 1926:

Spangaro S: Sulla tecnica da seguire negli interventi chirurgici per ferite del cuore e su di un nuovo processo di toracotomia. Clin Chir 14:227, 1906. As quoted by Beck CS: Wounds of the heart. The technic of suture. Arch Surg 13:205-227, 1926

I enjoyed very much this discussion, thank you.

...we are talking about the same issues... I believe you misinterpret my argumentation. In trauma management you must have an open minded systemic approach, not only in the isquemic reperfusion side. In the blunt trauma/deep shock seetting with CA, (with assumption of IA hemorrage by kynematics, US or signs/symptoms), you should first do CPR and then focus on the hemorrage control (crash lap). Whether to do CPR, closed or open chest (EDT), is more than just an option , Sometimes crash lap, (which is very fast indeed), for IA hemorrage, encounters massive hemorrage of venous or arterial origin, and again sometimes effective temporary bleeding control, compression and packing, takes more than a few seconds, and might end in exanguination. TACC is another surgical technique that every trauma surgeon should have in his armamentarium.

As I mentioned some days ago, we are on the same side of the road; as trauma surgeons, we both see the same critical patients, as in any hospital/emergency room worldwide. What I also believe is that when a modern trauma critical care surgeon places a clamp across a vessel, he should bear in mind the IR, microcirculation, cytokine activation cascades, hypothermia issues, as well as the technical aspects of the surgical manouvers. Every surgeon managing trauma cases should read (and train) Ken Boffard's DSTC manual, which is exactly what we are doing in Buenos Aires, since three years ago, when the DSTC programme was started in our country, and others in south America follow. If I have a word for DSTC is: outstanding. USA has its own L Jackob's ATOM programme; I believe it is similar, American style, and I am looking forward to do it as well, as soon it will arrive in Argentina.

The initial question was EDT for non penetrating traumatic CA; worthwhile?. I keep doing it, for exactly the same reason as you tackle the crash lap first (which I do immediately after EDT): stop the bleeding and tissue hypoperfussion.

I am very happy to have these high level discussions on trauma, shock and critical care management with you and I look forward to to have them personnally in a academic meeting, to exchange our experience and views, but now my concern is that this forum is browsed by residents and young unexperienced surgeons, that one day will recieve in their ER, as surely both of us once did, their first blunt trauma CA victim and they should be prepared to engage with their management, and in few seconds decide what to do: nothing, or follow to tackle the origin of the shock/hemorrage. How do you know that this case has arrested due to an exanguinating IA hemorrage, due to a massive PV or illiac artery laceration? You don't. You act as you have trained to do so, with a protocol. Yes you might pressume it by trauma kinematics, and yes you can do a US, but you perform it while you at the same time also doing RCP by EDT, to start the pump working, and then decide which cavity to access, thoracic or abdominal (crash lap).

In the rest of the damage control moves, I absolutely agree with you Fabrizio.

Evidence data shows very scarce small survival by performing EDT in blunt trauma, compared to EDT for penetrating trauma. It is for this small survival gap, that I keep pursuing EDT in closed trauma as well; only then come the damage control manouvers for hemorrage management, (you need blood circulating and pump started).

The controversy on what to do in the scenario of blunt trauma cardiac arrest, today is an open issue, with arguments in favour and against EDT, and probably will endure until a larger series clearly shows a significant survival chance opposed, and balanced, to the cost/benefit and bad outcome of doing so. Till then, each surgeon should decide what he believes is the best action for his individual patient., and when to withheld from doing something.

Yes ... EDT can salvage critically injured patients following non-penetrating trauma

All injury patterns, but certainly most favorable for penetrating thoracic wounds.

J Trauma 70:334, 2011 While REBOA is attractive for hypotensive pateitns, I believe it is inferior for those patients arriving with PEA

We have an established ED thoracotomy protocol as trauma surgeons in Adelaide.

I use my protocol we developed in cape Town. We have 2 thoracotomy sets in our ED, and we use the Lebschke knife/chisel for the sternum.

For ED thoracotomies to work the surgeon is present when the patient arrives.

In a 9 year setting, we have 65% survival for penetrating trauma and 35% for blunt ED thoracotomy. We now use a clam-shell technique as exposure is excellent.

This is effective for both thoracic and non-thoracic cardiovascular arrests.

We open the chest when the systolic falls below 70, or when the carotid pulses disappear. We routinely occlude the aorta above the diaphragm until the circulation is restored. Using the protocol we have about 85% of ED thoracotomies leaving the ED with a spontaneous circulation, ie 15% are unsuccessful.

We have had 1 patient with a post thoracotomy CVA. Many patients also end up with damage control laparostomies and thoracostomies where the chest and abdomen are open using the same temporary covers in usually the commercial vacuum dressing.

So yes, we think it worthwhile in blunt trauma 35% survival.

Peter Bautz, Royal Adelaide hospital, Adelaide, Australia.

Not surprisingly, agree with Prof Moore.

PSB publication:

The Journal of Trauma and Acute Care Surgery 74 (3), 825-829

I do it, as the last resort.

However the indication(s) may differ from one center to another, the procedure is major, and the efficacy debated.

I presume you are referring to exsanguination... so will provide an answer accordingly.

When suspecting exsanguinating injury, key factor is time to definitive therapy and hemostasis. Literature shows that rushing patients to the closest trauma center / hospital is better than trying to do any procedures in the field. There is also some support for resuscitative thoracotomy (e.g., ED Thoracotomy) but this continues to be somewhat controversial. In many studies, survival after blunt traumatic arrest continues to be so dismal as to pretty much reinforce the futility of this high-risk and high-cost intervention. In carefully selected penetrating trauma patients, there may be some justification to perform an ED thoracotomy, but I do not think that this should be done lightly... read below about "physiologic debt".

Following successful restoration of vital signs at the trauma resuscitation area, it is important not to provide excessive resuscitative effort in terms of fluid or therapy -- you need to provide "enough" to get the patient to the operating room or some other definitive hemostatic maneuver. If you pump tons of IV fluids into an actively bleeding patient, it will just increase the rate of exsanguination! The terms "permissive hypotension" and "hemostatic resuscitation" have been used to describe this type of resuscitation.

Once the patient is in the operating room (or embolization suite, etc) and is undergoing definitive therapeutic hemostasis, it is important to maintain adequate end-organ perfusion, ensure normothermia, correct acidosis, and avoid any coagulopathy. The last three constitute the "lethal triad". Damage control (both surgical and medical) has been utilized in such scenarios.

it is pretty well documented in the literature that if you maintain appropriate FFP:PRBC (and platelet:PRBC) ratios, patients tend to do better up front, but this may be (in a way) trading mortality for morbidity (e.g., survivors have more ARDS, infectious complications).

Depending on how much (e.g., quantity and duration) blood loss there was, the patient will end up incurring a "physiologic debt". The quicker the hemostasis is achieved, the less "physiologic debt" is there to pay (e.g., morbidity, mortality, lengths of stay, functional outcomes, etc).

This is just a short version of the more "general" approach to an exsanguinating patient, with or without trauma-related cardiac arrest (or, more properly, loss of vital signs).

Regards,

Stan.

The rate of patients with blunt chest ERT surviving neurologically intact is 3%, but it is solely the decision of the surgeon on call. He carries the ultimate responsabiliy. In busy situations, save your reserves. If you have time and Team and Training - think about it carefully.  Sometimes people survive. Think about the time of CPR intubated/not intubated before as well.

Always do if the CA was witnessed and in the very first few minutes (within 5 min if not oxygenated with ETI). If within 10 min and intubated I would do it as well (See ED, EEM et al).

You have in any case to consider several factors like for example duration of mydriasis, presence of a central pulse, cause of the arrest if known or highly suspected, presence of severe head injury et al factors or variables or contexts.

Watch also if the ETT is actually oxygenating and not causing a TPNX

Idem for LMA as they do a good job in oxygenation and maintaining oxygenation.

We know now that the heart-pump can be re-established even after 20-30 min with highly 'heroic and complex settings' like the EPR/CAT, which suggests the critical factor in this kind of resuscitation, nonetheless, cost-effectiveness is oxygenation rather than pressure.....RE-EDITED AND PUNCTUALIZED ON APRIL 7TH, 2021

EDT for blunt trauma is beneficial if CPR , 10 min. An alternative is REBOA, with the same survival when performed by experienced trauma surgeons in the US

Prof Moore, thanks. I have no exposure or experience with REBOA but it is obvious to me - at first glance instinctive comment - that can only work if the bleeding is arterial and technically allowing the passage of the catheter; if the bleeding is venous it can only accelerate exitus of a critical patient as it worsens ie decreases the amount of venous return already decreased by the venous blood loss. The time of execution should also make it worthy. I do not have a clue or experience of the method but in principle feel it is better to address directly the bleeding cavity rather than to embark on a far to near attempt to stop the bleeding. ADDENDUM 12.03.21 I see REBOA as more a tool for physicians where is no surgeon or surgical facility reachable within the hour and with a proven arterial source.

We have some survivors with REBOA and personal experience with one survivor when blunt. For penetrating/heart, different story ofcourse. THe ABOTrauma registry of REBOA in trauma showed survival better than expected in cases with pending arrest or arrest. The Bias is obviousely not clear when patient arrested/10minutes time limit. I would not open on more than tem minutes, but would use REBOA. would eliminate tamponad ofcourse. as mentioned, extreme rare success in EDT.

we have a child 15 minutes CPR on blunt, total collapse, arrythmias and REBOA/open abdominal surgery. Intact. #EVTM....

http://www.jevtm.com/journal/images/v3n3/09_jevtm_99/09_JEVTM_99.html

Article Feasibility and Clinical Outcome of Reboa in Patients with I...

Article Successfully REBOA performance: does medical specialty matte...

....Sorry but I do not think REBOA should be promoted more than necessary and logical. REBOA can only be useful in a medical facility without a surgeon and with a haemorrhage is known with certainty to come from an arterial source below the aortic arch. Otherwise, it has got high probability of deteriorating even killing faster the patient if bleeding has a venous origin because to the ongoing decreased venous return about to lead to a Card Shock/CA from exsanguination you are adding an extra crucial insult by further decreasing that progressively fading venous return, hence you fasten the deterioration by exsanguination and the exitus. This because less blood will pass from the arterial system to the venous one within organs so venous return already in decline will lead to CS/CA sequence or to a direct CA. Whereas instead if you use it - in a medical facility with no surgeon - in arterial bleeding then less blood will be lost as the bleeding rate will be slowed by less blood passing from the arterial to the venous system, which will make you spare vital time for the direct source control.## About the rescued cases you mention, do you think you could have got the same result and positive outcomes if not better and faster, had you aggressed the bleeding cavity directly? I think so! In how many minutes you put in and set up the REBOA and how many minutes you think a crash laparotomy and source control would take??!! !!?? 07.04.2021

THank you and i agree. it should be very carefully used. Depends again on injury, where u are etc. REBOA in place in our expereinces within two minutes (or faster), and in different studies within 3-4 minutes. I agree fast Laparatomy you get to the aorta within 3-5 minutes (maybe i am slow...). thoracotomy, at least if not longer times. Not to mention in UNEXPEREIENCED hands...

THats why REBOA should be used with in the EVTM concept, and not replace surgery. just facilitate. Using pREBOA might be of some solution as a bridge. It is a fact that almost ALL thoracotomies for blunt trauma dies...even in very expereinced centers... and we should check carefully adjunct solutions..

In other words, i agree with you comments FAbrizio! Would not promote wrong using of REBOA!

Coming to this a bit late in the discussion, but a fantastic discussion none the less! Another option to consider, especially in the pre-hospital EMS world (with the appropriate training), is bi-lateral finger thoracotomy in the traumatic arrest. We have had great success with this, although like anything else it comes with its own risk factors. Even as recently as several years ago, traumatic cardiac arrests were being left as dead in the street literally, as the mantra was "If they went into cardiac arrest from blunt trauma, there is nothing we can do." Now, at least where we are located, a traumatic cardiac arrest victim 2nd to blunt trauma, is not "dead" until they have either a tube or bi-lat finger thoracotomy, a unit of blood, and were intubated.

To touch on the REBOA, and the thoracotomy topic at the same time...military medics (not even referring to physicians or mid-level providers) are utilizing these skills in the field at the point of wounding or during extraction. I was trained on REBOA and thoracotomy among other interventions, while active duty. I agree with what is said previously that when used at the wrong time i.e. venous bleeds, it can be deleterious, but especially with the advent and increased availability of POCUS ultrasound in the field, we are coming leaps and bounds from the days of simply flooding someone with as much saline as possible "just because."

Going off on a tangent, but on a related topic, the US 75th Ranger Regiment (Army) is finishing up a year-long project/study on rapid IV bolus of 2G TXA at point of wounding, with very optimistic results, in an effort to prove that the benefits far outweigh the risks. Keep your eyes open for the results soon!