A.J. Greene1, H.E. Kim1, J. Cyprich1, J.A. Keeley1, A.H. Kaji2, G.A. Singer1, A.C. Schwed1 1Harbor-UCLA Medical Center, Trauma, Acute Care Surgery, & Surgical Critical Care, Torrance, CA, USA 2Harbor-UCLA Medical Center, Emergency Medicine, Torrance, CA, USA
Introduction: Guidelines for resuscitative thoracotomy (RT) from the Eastern Association for the Surgery of Trauma (EAST) and the Western Trauma Association (WTA) differ; EAST’s are primarily mediated by signs of life (SOL) while WTA’s primarily rely on duration of prehospital CPR. Our goal was to assess WTA and EAST guidelines’ ability to predict “surgical rescue,” (SR) defined as survival to the operating room, in patients undergoing RT.
Methods: RTs performed in the emergency department at a Level 1 trauma center between April, 2014 and December, 2022 were included. Patient demographics, mechanism of injury (MOI), prehospital course, and details of ED resuscitation were analyzed. The primary outcome was SR. Secondary outcomes included overall survival. Bivariate analyses compared WTA and EAST indications for RT.
Results: 309 patients underwent RT during the study period. 198 (64.1%) had a penetrating MOI and 134 (43.4%) presented with at least 1 SOL. 11 (3.6%) patients survived to discharge. Comparing WTA vs EAST defined indications for RT, 234 (75.7%) patients underwent RT following WTA guidelines and 108 [46.2%] achieved SR. 158 patients (51.1%) underwent RT according to EAST guidelines and 71 of these patients [44.9%] achieved SR. Among patients without SOL, 126/175 (72%) underwent RT according to WTA guidelines, and of those who underwent RT 48/126 (38.1%) achieved SR. Among this cohort, 59/175 (33.7%) did not meet EAST criteria, of whom 21 (35.6%) achieved SR. Among those presenting with SOL (met EAST guidelines), RT performed within WTA time guidelines was more likely to achieve SR than RT outside of WTA guidelines (60/108 [55.6%] versus 8/26 [30.8%], OR 2.8, 95% CI: 1.1-7.0, p=0.027).
Conclusion: WTA guidelines offer an improved opportunity for SR in those presenting with and without SOL. WTA guidelines also offer potential salvage to patients without SOL who may not be offered RT via EAST guidelines. Given the subjective nature of some SOL, WTA guidelines provide clearer indications as to when to perform RT. Additional prospective data is needed to improve these guidelines.