FAST THORACOTOMY

Penetrating arrestUltrasound is being used for procedures and decision making everywhere. Now, someone’s evaluated it for decision making in penetrating trauma cardiac arrest emergent thoracotomies. Is there a place (and time) for ultrasound in this setting? A new article in Annals of Surgery looks into this. What we can take home is that cardiac standstill on ultrasound is always a bad sign.

Prospective study on penetrating arrest
Coming from a country with very little penetrating trauma, I’m pretty impressed that a hospital can gather 187 arrested penetrating trauma patients in a 3.5 years in a prospective study! What they did was to FAST scan all these before doing the thoracotomy, and in retrospect see how FAST did – and could’ve performed – if used for decision making.

Still, this is less than 200 patients, from one center, and even though the numbers are convincing, they should be interpreted with caution. With that in mind, read on.

Results
They found that NONE of the 126 pts with cardiac standstill on ultrasound were saved by the thoracotomy. Only pts with sign of cardiac motion on ultrasound survived – although only 9 out of 54. And by survived, they mean surviving patients, and pts who get ROSC, but end up as organ donors. So, overall, 9 out of 180 pts “survived” the penetrating arrest. Following the numbers of this paper, more than tripling that survival rate by patient selection and getting this number to 9 of 54 could make emergency thoracotomies more acceptable. Sounds intriguing.

Ultrasound in arrest
Now, is a penetrating traumatic arrest situation the right place to use ultrasound? This is a high stress situation where the team leader needs to make a decision quickly. And in this setting, the mortality is 100% if you don’t do the thoracotomy. Although a trained sonographer will get a heart image in seconds, I don’t think I would reach for the ultrasound probe in this situation in my hosptial.

But maybe. If you’re team is streamlined, someone could place the probe as the the person doing the thoracotomy starts with bilateral finger thoracostomies, and then proceed if there is still cardiac movement.

Many centers have an aversion against thoracotomies. Seeing cardiac movement might encourage the team to push ahead instead of declaring the patient. At the other end of the spectrum, one might think about doing the thoracotomy even after the 10 min window if there’s still cardiac activety on ultrasound, although the weak part of that scenario is brain survival.

Cardiac standstill=lost case
Despite these musings, the decision criteria are still clinical: penetrating trauma to the thorax or upper abdomen with cardiac arrest within the last 10 mins.

In this article, we find the interesting part is that – just as in medical arrests – cardiac standstill on ultrasound is a very bad sign. Generally a sign that this is a lost case. The patient is dead. If the heart has run out of oxygen, the brain is surely fried.

FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation., Ann Surg, sept, 2015.

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4 Responses to FAST THORACOTOMY

  1. Pingback: FAST THORACOTOMY | Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds

  2. Pete Finnegan says:

    Hi Thomas,
    Great sunmary.
    I think there’s still valuable info to be gained from looking at the small number of survivors as all had witnessed cardiac motion on FAST.
    We can infer that cardiac activity on ultrasound does select potential survivors by looking at likelihood ratios instead of predictive values reported in the study.
    As the number of survivors with cardiac motion on ultrasound are low the prevalence is therefore low.
    Predictive value as a statistical test performs less well the lower the prevalence.
    Likelihood ratios are independent of disease prevalence, unaffected by population and can be applied to an individual patient level.

    Calculating the likelihood ratios from Table 4 gives us a +ve of 3.84 and a -ve of 0 therefore the likelihood of a patient surviving RT following cardiac motion on FAST is increased nearly 4-fold whereas the likelihood of survival with no motion on FAST is 0!
    Game changing?
    Pete Finnegan,
    ED Registrar,
    Alfred Emergency and Trauma Centre,
    Melbourne

  3. Pingback: FAST exam predicts futile resuscitative thoracotomy | EMUGS – Emergency Medicine Ultrasound Group Sydney

  4. Pingback: October 2015 REBELCast: The All Thoracotomy Episode - R.E.B.E.L. EM - Emergency Medicine Blog

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