Pericardial Decompression - Resuscitative Thoracotomy

The Procedures Course Podcast

Most fatalities from blunt or penetrating cardiac injuries occur prior to hospital arrival. The main reversible pathology is acute cardiac tamponade, which may be present without external signs of injury, abnormal clinical signs, or ECG abnormalities. The cause of the tamponade is usually a laceration to a low-pressure cardiac cavity. In recent years the widespread use of ultrasound in the initial assessment of severely injured patients has facilitated the early diagnosis of cardiac tamponade and associated cardiac injuries. Trauma patients with no signs of life and pulseless electrical activity at the time of hospital arrival have a consistently poor outcome despite resuscitative thoracotomy performed in the Trauma Centre. Therefore, resuscitative thoracotomy is reserved for those unstable patients in extremis, with deteriorating physiology and proven cardiac tamponade on ultrasound.

Incidence

From 2008 to 2013 inclusive, there were 9 independent survivors of the 27 patients who underwent resuscitative thoracotomy in the Alfred Trauma Centre. Over this time period, Alfred Trauma Registry data shows that 89% of the resuscitative thoracotomies were for blunt trauma. Survival was 29% and 66% in blunt and penetrating trauma respectively.

The primary aims of resuscitative thoracotomy are:

• Release of cardiac tamponade
• Temporary control of haemorrhage
• Access for internal cardiac massage

Release of cardiac tamponade and digital control of cardiac bleeding is the primary procedure. There is no evidence that aortic cross clamping improves outcome.

Indications

A consensus-based indication for immediate resuscitative thoracotomy:

• Unresponsive hypotension with a systolic blood pressure of less than 70 mmHg and...
• FAST positive for pericardial tamponade and...
• Cardiac electrical activity must be present

Contraindications

• No signs of life and pulseless electrical activity (PEA) on hospital arrival
• Signs of life include:
  • Pupillary response
  • Spontaneous ventilation
  • Presence of carotid pulse
  • Extremity movement
• Severe multisystem injury
• Severe head injury
• Lack of training in the procedure
• Lack of timely cardiothoracic surgery back-up following the procedure

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Further Reading »

Schipper, P., Sukumar, M., & Mayberry, J. C. (2008). Pertinent Surgical Anatomy of the Thorax and Mediastinum. In Current Therapy of Trauma and Surgical Critical Care. (pp. 227-251). Elsevier Inc

Fitzgerald M, Newton-Brown E & Tan G, Martin K. The Alfred Emergency & Trauma Centre Resuscitative Thoracotomy and Pericardial Decompression Handbook. 3rd Edition, 2015

Fitzgerald M, Tan G, Gruen R, Smit de V, Martin K, Newton-Brown E, Luckhoff C, Maini A. Emergency physician credentialing for resuscitative thoracotomy for trauma. Emerg Med Australas. 2010 Aug;22(4):332-6

Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. Practice management guidelines for emergency department thoracotomy. J Am Coll Surg. 2001 Sep. 193(3):303-9

Fialka C, Sebök C, Kemetzhofer P, Kwasny O, Sterz F, Vécsei V. Open-chest cardiopulmonary resuscitation after cardiac arrest in cases of blunt chest or abdominal trauma: a consecutive series of 38 cases. J Trauma: Volume 57(4); 809-814.

Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma – a review. Injury (2006) 37; 1—19.

Wise D, Davies G, Coats T, Lockey D, Hyde J. A Good Emergency thoracotomy: how to do it. Emerg Med J 2005;22:22-24