title: Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective.
abstract: BACKGROUND
  Since the promulgation of emergency department (ED) thoracotomy>40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival.
  
  
  METHODS
  Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively.
  
  
  RESULTS
  During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge.
  
  
  CONCLUSIONS
  Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.
authors.affiliation: Department of Surgery, Denver Health, Denver, Colorado 80204, USA. ernest.moore@dhha.org
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: M Margaret
authors.initials: MM
authors.lastname: Knudson
authors.forename: Clay C
authors.initials: CC
authors.lastname: Burlew
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Rochelle A
authors.initials: RA
authors.lastname: Dicker
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: Ajai K
authors.initials: AK
authors.lastname: Malhotra
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Browder
authors.forename: Raul
authors.initials: R
authors.lastname: Coimbra
authors.forename: Ernest A
authors.initials: EA
authors.lastname: Gonzalez
authors.forename: J Wayne
authors.initials: JW
authors.lastname: Meredith
authors.forename: David H
authors.initials: DH
authors.lastname: Livingston
authors.forename: Krista L
authors.initials: KL
authors.lastname: Kaups
mesh_terms: D000007:Abdominal Injuries / Q000401:mortality / Q000601:surgery; D000293:Adolescent; D000328:Adult; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods* / Q000401:mortality / Q000706:statistics & numerical data; D016019:Survival Analysis; D013898:Thoracic Injuries / Q000401:mortality / Q000601:surgery; D013908:Thoracotomy / Q000401:mortality / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014481:United States; D014947:Wounds and Injuries / Q000401:mortality / Q000601:surgery*; D014948:Wounds, Gunshot / Q000401:mortality / Q000601:surgery; D014951:Wounds, Stab / Q000401:mortality / Q000601:surgery; D055815:Young Adult