Resuscitative Thoracotomy: An Update

Abstract

Background:

Resuscitative thoracotomy is a heroic procedure that may offer the only survival hope for trauma patients in extremis. However, this operation has been the subject of much debate and its use, feasibility, outcomes, and cost are being continuously re-evaluated.

Methods:

This is a review of the most current (after 2000) literature on resuscitative thoracotomy, based on computer database searches for studies on resuscitative thoracotomy, emergency department thoracotomy, and emergency thoracotomy. Studies were selected for inclusion in this review based on their relevance and contribution to our understanding of resuscitative thoracotomy.

Results:

A total of 37 studies were included, and the following resuscitative thoracotomy–related topics were critically discussed: indications, biochemical profile, long-term outcome, organ donation, pre-hospital use, military use, international aspects, intra-aortic balloon occlusion, suspended animation, and cost and occupational exposure.

Conclusions:

This review demonstrates that the indications for resuscitative thoracotomy become clearer and that new information is available regarding its use in the pre-hospital urban environment and military settings. Furthermore, it points to new strategies to supplement resuscitative thoracotomy including intra-aortic balloon occlusion and suspended animation. Finally, it sheds light on the long-term outcomes, organ donation, and cost and occupational exposure following resuscitative thoracotomy.

Methods

This study aimed to review the most updated information on selected topics related to resuscitative thoracotomy (RT). To that end, an electronic search of MEDLINE from 2000 to the present was conducted using PubMed and OvidSP. Search included all papers published in the English language on RT, emergency department thoracotomy, or emergency thoracotomy. Searched papers were then selected for inclusion in this review based on their relevance and contribution to the literature. The following RT-related topics were critically discussed: indications, biochemical profile, long-term outcome, organ donation, pre-hospital use, military use, international aspects, intra-aortic balloon occlusion, suspended animation, and cost and occupational exposure.

Introduction

Trauma patients in extremis are in a state of profound or complete neurological, respiratory, and cardiovascular collapse. As the severity and dynamic of these physiological derangements are overwhelming, standard Advanced Trauma Life Support (ATLS) protocols are insufficient to address patient needs, and only a dramatic out-of-the-box intervention can lead to survival. The paradigm of such intervention is RT. This operation has several distinct objectives. First, it allows the drainage of cardiac tamponade as well as control of bleeding from cardiac, lung, and great vessel injury. Second, it facilitates resuscitation through open cardiac massage, diversion of blood into the cerebral and coronary circulation only (clamping of the descending thoracic aorta), intravenous access (placement of a right atrial line), and intra-cardiac administration of drugs. Finally, aortic cross-clamping may slow down major bleeding due to intra-abdominal or pelvic injury.

If enacted in a timely manner, RT can offer a chance for survival in carefully selected seemingly hopeless patients. The continuous challenge for the trauma surgeon is to improve outcome, avoid unnecessary use of resources, and minimize exposure to blood burn pathogens by better anticipating which patients would benefit from RT. The present review describes the most recent advances to achieve these objectives.

Review

Indications

Establishing evidence-based indications for performing RT is problematic, as the literature related to this procedure suffers from major limitations. First, most reports lack relevant information and use ambiguous nomenclature. For example, frequently, there is no clear description of the indications, settings, and technique used. Second, the physiologic state of the patient just prior to surgery is commonly not described, and vaguely defined pseudo-physiologic terms such as “no signs of life,” “no vital signs,” “lifeless,” and “agonal” are frequently utilized. Third, many of the reports are selective and describe long-term inconsistent practices. These inconsistencies were recently confirmed by a survey that queried 304 members of the Eastern and American Associations for the Surgery of Trauma (1). The survey reported a lack of agreement regarding the indications for RT in multiple clinical scenarios as well as in defining “signs of life.” Fourth, the high-stress nature and ethical issues surrounding the care of moribund trauma victims present a significant obstacle to the performance of high-quality prospective studies.

Despite the limitations described above, Level II and Level III evidences allow for two solid conclusions. Most importantly, RT is supported in patients who present to the emergency room (ER) with any sign of life (SOL) or deteriorate shortly after arrival (2, 3). This is especially true for trauma victims with thoracic stab wounds (SWs) and cardiac tamponade, in whom survival may reach 40% (2). The case for performing RT in moribund blunt trauma patients with in-house loss of SOL is less clear, and some advocate performing RT only in the presence of cardiac tamponade or loss of SOL in the ER. The available data also support refraining from RT in both penetrating and blunt trauma patients who never had witnessed SOL (3). Thus, most of the debate regarding the indications for RT is focused on patients who develop cardiopulmonary arrest prior to arrival to the hospital.

Multiple studies demonstrated a dismal chance for survival in patients undergoing pre-hospital cardiopulmonary resuscitation (CPR), especially in the blunt trauma population. Consequently, many trauma centers do not perform RT in this group of patients. This practice has been recently challenged by the Western Trauma Association (WTA), which published guidelines partially based on short transit times (4). According to the WTA recommendations, RT should be performed in blunt and penetrating trauma patients who present in the ER with no SOL if CPR time is <10 min or 15 min, respectively. This paradigm is supported mainly by two key studies. The first study was conducted in 2004 and examined 959 RT patients admitted to a single institution during a 26-year period (5). In this study, 26 of the 65 survivors underwent pre-hospital CPR. Of these, six patients, all with SW to the heart and tamponade, had asystole on arrival to the ER. Four of the six survivors who presented with asystole were discharged with either mild or severe neurologic deficit. The CPR time for patients without admission electrical activity upon arrival was not described, although for all survivors it varied from 3 to 15 min. None of the blunt trauma patients who presented with asystole survived. The second study supporting the WTA paradigm was initiated by the same organization. In 2011, it launched a multicenter study (n = 18), which identified 56 RT survivors of whom 37% underwent pre-hospital CPR (6). Some of the survivors with blunt torso injuries had CPR up to 9 min and some with penetrating torso injuries up to 15 min. In the SW group, CPR time was 2–10 min, and in the gunshot wound (GSW) patients, it lasted 1–15 min. Only one patient (cardiac laceration with tamponade) survived with 15-min CPR. Upon hospital discharge, 10 of the 56 survivors had moderate to severe anoxic brain injury.

Although the two studies provided novel information, several concerns cast doubt on the validity of their recommendations and challenge the WTA guidelines for performing RT in patients with pre-hospital arrest. Both studies have a very small number of surviving patients presenting without SOL (asystole). Combined, the 2004 and 2011 reports had only 12 SW patients (all with cardiac laceration and tamponade), one patient with blunt traumatic injuries, and no GSW patients. Also, the CPR time for each patient is not provided, and the total number of patients and analysis of nonsurvivors is not provided in the WTA multicenter study. Finally, as in all other studies, pre-hospital information may be incomplete or inaccurate.

Although the main WTA guidelines are in question, one solid conclusion emerged from the above two studies—RT should be performed in patients who arrive in the hospital with asystole and suspected cardiac injury and tamponade. It would therefore be prudent to include focused assessment sonography for trauma (FAST) for diagnosing pericardial effusion in this well-defined group of chest SW patients. Indeed, many trauma centers do not perform RT in patients who arrive in the ER without cardiac electrical activity and palpable pulse unless they sustained SW to the chest with suspected tamponade (7). It is therefore prudent to include FAST for diagnosing pericardial effusion in this subset of patients.

Another debate on the indications for RT focuses on its performance in moribund patients with extra-thoracic exsanguination. The American College of Surgeons (ACS) 2001 guidelines for RT (2) suggest that “Emergency department thoracotomy should be performed in patients sustaining exsanguinating abdominal vascular injuries, but these patients generally experience a low survival rate. Judicious selection of patients should be exercised.” This recommendation is supported by a recent retrospective review of 50 patients (98% GSW, 84% SOL in the field, 78% SOL in the ER) who underwent RT for abdominal exsanguination (8). In this article, eight (16%) survived hospitalization, neurologically intact. One survivor had asystole, two presented with pulseless electrical activity (PEA), and the remaining five had some form of organized rhythm. These data suggest that pre-laparotomy RT provides surviving benefits to penetrating trauma victims dying from intra-abdominal hemorrhage and should be performed in this group of patients. Weaker support for performing RT for nonthoracic injuries was provided by another study, which reviewed 27 patients in extremis due to nontorso injuries (9). The authors reported three survivors (11%). Two of these survivors hemorrhaged from neck vessel injuries and one from a radial artery laceration. All three patients underwent pre-hospital CPR of unknown duration.

The performance of RT in patients with thoracic GSW has also been the subject of much debate. The most recent information regarding this issue is derived from a 2009 study that combined data from two high-volume urban Level I trauma centers (10). The study reviewed 283 patients with penetrating injuries to the heart and great vessels, mostly (n = 250, 88%) from GSW. In that study, survival from a single GSW was 5% (6/117) and from multiple GSW it was 0.8% (1/133). Furthermore, 6 out of 49 patients (6%) with a single GSW presenting in the ER without SOL survived. In contrast, there were no survivors among the 47 multiple GSW victims who presented with no SOL in the ER. Thus, based on the best available data, RT should not be performed in moribund patients with multiple GSW to the chest, while patients suffering from a single GSW may benefit from RT mostly when SOL is present.

Biochemical Profile

A recent study, admirably performed under the stressful conditions of RT, shed some light for the first time on the biochemical profile of patient undergoing this dramatic operation (11). In this report, intra-cardiac blood samples from the right ventricle were collected in 22 patients undergoing RT for chemical, coagulation, hematological, and blood gas analysis. As expected, 91% of patients presented with severe acidosis (pH < 7.20) secondary to the severe hypoperfusion that follows cardiac arrest or profound shock. The pCO₂ was <45 mmHg in 68% of patients, and the pO₂ level was >75 mmHg in 77% (17/22) of cases. Thus, oxygenation and ventilation during RT are adequate in most patients. This is surprising, as the cardiopulmonary arrest and acidosis-induced shift of the oxygen–hemoglobin dissociation curve are expected to worsen blood gas levels.

When compared to patients with a return of cardiac rhythm, those who never regained cardiac activity had higher lactate, sodium, and potassium levels. Severe hyperkalemia occurred more often in the latter group of patients. Thus, one can conclude that these abnormalities are associated with decreased probability of return of cardiac function. Although the exact causative mechanism is unknown, it is likely that the prolonged hypoperfusion in patients who never regained cardiac activity causes irreversible hypoxic cellular injury, which accounts for the above abnormalities.

Coagulopathy (international normalized ratio (INR) > 1.2 and/or prothrombin time > 15 s and/or platelet count < 100,000/µL) was noted in 96% of patients. This coagulopathy may be secondary to hemodilution as well as the early initiation of the activated protein C pathway. Finally, calcium and magnesium levels were not significantly different between the two groups, making the therapeutic role of these electrolytes questionable.

It should be noted that the interpretation of the above information must be made with caution, as the number of patients sampled is small, inclusion criteria of patients may have led to a potential selection bias, and times of intra-cardiac blood sampling potentially affected the results.

Long-Term Outcome

Survival without neurological deficits is considered the ultimate outcome of RT. However, the long-term social, cognitive, functional, and psychological consequences of this operation were evaluated for the first time only very recently (12). Review of 448 RT cases in an urban Level I trauma center revealed 37 survivors (98% penetrating trauma) to hospital discharge. Of those, 16 were available for a comprehensive evaluation using a variety of functional scoring systems, at a median 59-month follow-up period. Most patients (75%) had normal cognition and returned to normal activity, 81% were freely mobile and functional, and 75% had no evidence of posttraumatic stress disorder. Nevertheless, unemployment (75%) and daily alcohol (50%) and drug use (38%) were common. These observations should be interpreted cautiously for several reasons. First, they represent a very small group of penetrating trauma patients in a single institution, and thus, generalization to blunt trauma or other geographical areas may be deficient. Second, only 16 of the 37 survivors were interviewed, which suggests that study participation was not uniformed. Finally, the study did not include a control group of non-RT patients with similar injuries, which is impossible to establish for practical and ethical considerations. In spite of these limitations, the report demonstrated that in contrast to the intuitive suggestion that RT survivors often live with significant physical, emotional, and social dysfunction, most of these patients have no long-term impairment. This conclusion incentivizes the performance of RT.

Organ Donation

Organ shortage is the most significant rate-limiting factor for meeting the global growing demand for organ transplantation. Consequently, the number of patients on the transplant waiting lists as well as the number of patients dying while on the waiting list has dramatically increased. Theoretically, in the right settings, RT may be one procedure that could provide precious organs to alter the survival and quality of life of many recipients. Thus, proponents of the liberal use of RT argue that organ donation and brain-dead potential organ donations should also be considered when deciding whether to pursue this dramatic operation. To establish this notion, donor organ procurement was examined in an urban high-volume Level I trauma center that uses RT very liberally (all patients who arrive with an unobtainable pulse). That group reviewed 263 RT patients (71% penetrating trauma, 66% in full cardiac arrest on arrival) and reported 48 survivors to the surgical intensive care unit (SICU) and five to hospital discharge (13). Of the 48 patients, 11 (22.9%) who reached the SICU alive became potential organ donors. Of these, five patients had lost their vital signs in the field, four en route, and two in the ER. Five patients were injured in blunt motor vehicle collisions and six sustained a penetrating mechanism of injury. Mean transportation time to the hospital for these patients was 13.4 min. Only 3 of the 11 potential donors were harvested and donated a total of 11 organs (6 kidneys, 2 livers, 2 pancreases, and 1 small bowel). Reasons for nonprocurement included decline by family (n = 4), poor organ function (n = 3), and pre-injury conditions (n = 1). Time interval from admission to meeting brain death criteria ranged from 31 to 33 h. Although only 3 patients out of 263 (1.1%) donated organs, the number of recipients whose survival was positively altered was greater than the number of RT survivors. Although this valid information should be considered when analyzing the value of RT, more comprehensive studies are needed to determine the ultimate cost–benefit ratio of this operation.

Pre-Hospital RT

Prognosis following RT is greatly affected by the length of time between loss of cardiac output and surgery. Consequently, most RT survivors arrest in-house or shortly before arrival to the ER, and cardiac arrest at the scene is associated with very poor outcomes. These observations led several trauma systems, where pre-hospital physicians are part of the dispatched team, to pursue field RT (FRT) when the nearest trauma center is more than 10 min away (14). In 2001, The London Helicopter Emergency Medical Service (HEMS) reported 39 FRT for penetrating trauma, with 4 survivors (15). The mechanism of injury was SWs (25 patients), handgun (12 patients), and glass (2 patients), and the predominant condition was exsanguination (21 patients) and cardiac tamponade (18 patients). Nine patients had no SOL after injury, 23 patients lost SOL prior to doctor’s arrival, and 7 lost SOL after team arrival. Emergency medicine physicians (n = 23), anesthesiologists (n = 13), and surgeons (n = 3) performed the procedures with survival rates of 9%, 15%, and 0%, respectively. The time between emergency call and arrival of doctor on scene was less than 10 min for 16 patients, between 11 and 20 min for 19 patients, and greater than 20 min for 2 patients. The same group published several additional studies (15, 16), some of which overlapped, with a total of 89 FRT and 8 survivors (8%). Three other reports from various countries (17–19) described additional 41 FRT patients.

Although conceptually attractive, extending RT to the field is extremely difficult and nontrivial. The ability of any physician, regardless of his or her specialty, to perform RT (including opening of the pericardium, aortic cross-clamping, and repair of injury) under suboptimal conditions is severely compromised. Consequently, it exposes the patient to the risk of iatrogenic injuries and the emergency medical team to the risk of blood-borne diseases. In an editorial comment (20), Dr Kenneth Mattox supports FRT as an expeditious damage control procedure provided it is overseen by an established trauma program, approved by an institutional review board (IRB), and performed by well-trained and well-equipped physicians who can communicate with the trauma center’s surgeons.

RT in Military Settings

Survival following RT is closely related to the mechanism of injury, time from injury to the trauma room, and the physiology of the patient upon arrival to the hospital. As military trauma commonly involves high-energy weapons, hostile environments, and long distances from a hospital, the use of RT in combat casualties is inherently limited. However, the recent advancements in military damage control surgery, hemostatic resuscitation, medical logistics, forward critical care and transfusion capabilities, and evacuation times made this procedure a viable option for a selected group of exsanguinating combat victims.

A review of 101 RT performed in an American combat-support hospital demonstrated an overall 12% survival to evacuation (21). In the penetrating and blunt trauma patients, survival was 12.7% and 0%, respectively. Most patients sustained thoracic (40%), abdominal (30%), or extremity (22%) injuries. All survivors presented to the hospital with SOL had a higher plasma: red blood cell (RBC) ratio and were discharged neurologically intact. Interestingly, there was no difference in survival seen in either injury mechanism or primary injury location. The vast majority of patients (92%) underwent CPR and mean transfusion requirements for all patients were 15.0 U of RBC and 7.3 U of fresh frozen plasma during the initial resuscitation. Thus, RT can save combat casualties with penetrating injury, arriving at a forward surgical hospital with SOL, and receiving CPR.

The British experience with RT in combat environments supports the American military reports, which favor performing this operation in appropriately selected wounded soldiers. An analysis of 65 patients who underwent RT reported 14 survivors (21.5%) (22). Ten patients (15.4%) had an arrest in the field with no survivors, 29 (44.6%) had an arrest en route with 3 survivors, and 26 (40.0%) had an arrest in the emergency department with 11 survivors. There was a difference in Injury Severity Scores (ISSs) between survivors and fatalities, and survivors had a significantly shorter time to RT than did fatalities.

Finally, a review of eight British combat casualties who underwent a pre-hospital RT suggests that this early procedure has no role in the military environment (23).

Taken together, the articles reviewing the performance of RT in combat settings suggest that RT done in a forward surgical facility with critical care capabilities yields survivors in spite of the different injury patterns. Similar to the civilian experience, best outcomes were observed in patients who had an in-hospital arrest and in penetrating trauma victims. Indeed, the Joint Theater Trauma System Clinical Practice Guideline (24) published by the US military reflect this notion. In addition, surgeons deployed in war zones should be familiar with the indications for RT and its technical aspects.

International Aspects

RT is performed globally and reviews from several countries emerged recently. Interestingly, the reported survival in the European series is higher than in the United States. For example, a study of 121 RT patients in Switzerland (25) documented 63 survivors (52%). It should be noted that in this study, RT was performed in both the operating room (OR) and ER, and that survival in patients who underwent this procedure in the OR was higher than in patients who had RT in the ER (74% vs 10%). Correspondingly, blood pressure was higher, and the incidence of profound shock and head injury was lower in patients with an OR RT. As these data suggest that not all patients in the Swiss study were in profound shock, it is likely that the indications for RT in the OR in Switzerland were more liberal and that some of the reported patients would have not qualified for a RT in the United States. Thus, given the dissimilar indications and technique, differences in outcome between these two countries cannot be accurately compared.

Another European study analyzed the results of RT performed for blunt chest and abdominal injuries in an urban Austrian Level I trauma center (26). In that study, the authors reported 12.5% survival, which is higher than the dismal survival rates observed in the United States for blunt trauma patients. This difference is even more pronounced since inclusion criteria included patients with a long pre-hospital CPR of up to 20 min. One main difference from the American literature has been the technique employed. While in the United States, RT is uniformly performed through a left anterolateral approach, the Austrian study also included patients who underwent midsternotomy and trans-diaphragmatic thoracotomy after laparotomy. Furthermore, similar to the Swiss study, a large portion of RT was performed in the OR rather than the ER. Thus, again, comparisons with the American data cannot be accurately done.

Data from Denmark demonstrated overall 59% survival in a group of RT patients who sustained blunt (n = 16) or penetrating (n = 28) trauma (27). Interestingly, in that study, the anesthesiologist was always the team leader deciding whether RT is indicated, and the most senior cardiothoracic surgeon performed the operation. Moreover, RT was performed in the OR rather than the ER in more than half of the cases. When performed in the ER, survival was 33%, and when done in the OR, survival was 83%. The authors suggest that outstanding pre-hospital and intensive care unit (ICU) care may explain their superior results. It should be noted that this Danish report also includes patients who underwent midsternotomy, right anterolateral thoracotomy, or a combined approach. This suggests that RT in the United States and Denmark is not necessarily similar, and thus, comparisons are not possible.

Another Scandinavian study, originating from Norway, reported 27% (10 of 27) survival in blunt trauma patients undergoing RT and 12% (10 of 82) survival in penetrating trauma victims who underwent this operation (28). In this report, both midsternotomy and left anterolateral thoracotomy were performed. Some of the indications for performing RT were vague and may explain the improved survival compared with the American reports. For example, RT was performed in “exsanguinated patients without immediate response to fluid resuscitation” and in “obviously large abdominal bleeding and decreasing blood pressure with no response to fluid resuscitation before laparotomy.”

In Iceland, an overall 56% survival rate was reported in 9 patients who underwent RT (29). Survival for blunt trauma patients was 60% (3 of 5) and for penetrating trauma 50% (2 of 4). Thoracotomy was performed in five patients, sternotomy in two and other two underwent both procedures. One patient had a thoracotomy in the ambulance, four in the ER, and four in the OR. Pre-hospital CPR was required for four patients and for two others in the emergency room. Three patients never had any SOL, none of whom survived. All of the five survivors had Glasgow Coma Scale (GCS) ≥ 10 (range: 10–15) and systolic blood pressure (SBP) ≥ 100 mmHg (range: 100–144 mmHg) at first medical contact in the ambulance.

In summary, there is discrepancy between the American and European RT survival data. Analysis of the various studies suggests that these data cannot be compared due to several factors. First, although one cannot rule out the possibility that the European results are indeed better than those reported in the United States, the indications for RT are different and favor improved survival in Europe. This is because some European trauma centers may be using too liberal indications, so that RT is occasionally performed in patients who would have survived without it. In addition, other centers may avoid performing RT on some severely injured patients who would have qualified for this procedure in the United States. Second, although practice variations exist in the United States, RT in that country almost always entails left anterolateral thoracotomy with open cardiac massage and clamping of the descending thoracic aorta, whereas in Europe, it frequently includes right anterolateral thoracotomy or midsternotomy as well. Third, the vast majority of RT in the United States is performed in the ER, whereas in Europe, it is frequently done in the OR. Finally, a high degree of publication bias, that is, only studies with good outcomes tend to be published, cannot be ignored. However, there is no reason to assume that this bias is different in Europe and the United States. In the future, it would be ideal if the indications for RT and the surgical technique employed were standardized globally. This will allow better understanding of the data and productive discussions to improve all aspects related to RT.

Endovascular Balloon Occlusion

One of the main components of RT is temporary clamping of the descending aorta to divert blood into the most vital cerebral and coronary circulation and to decrease bleeding from subdiaphragmatic sources. The idea of obtaining a similar objective by percutaneous placement of an intra-aortic occlusive balloon was entertained for decades (30). However, it never gained popularity, likely due to latent technology, a poorly understood skill set, and anticipated poor efficacy. Recently, with the evolution of endovascular balloon and stent technology, the idea of using resuscitative endovascular balloon occlusion of the aorta (REBOA) resurfaced. Animal studies in large animal models of hemorrhagic shock from noncompressible torso injuries demonstrated efficacy and even superiority to RT (31). Furthermore, favorable results were reported using REBOA in patients with nontraumatic ruptured aortic aneurysm (32) and a few unpublished cases of combat casualties. Special catheters were developed for placement without fluoroscopic guidance (33), and the technique for REBOA placement in patients was described in detail (34). Although currently at a developmental phase only, it is possible that REBOA may replace or serve as an adjunct to RT in the future.

Suspended Animation

RT is performed in trauma patients with total or severe cardiovascular collapse, and unless tissue perfusion is restored within minutes, irreversible cell death occurs. Thus, cell protection strategies, which allow valuable time to control of bleeding and repair of injuries, could theoretically improve outcome of trauma patients undergoing RT. One such strategy is early application of profound hypothermic arrest (suspended animation). This approach raises a conceptual concern, as shock-induced hypothermia in trauma patients is an ominous sign and an established independent risk factor for death. Nevertheless, pre-clinical studies have demonstrated that rapid induction of “controlled” hypothermia in profound shock can protect cells during both ischemia and reperfusion, decrease organ damage, and improve survival (35). Furthermore, it has been shown that long-term survival in animals subjected to uncontrolled lethal hemorrhagic shock is influenced by the rate of reversal of hypothermia (36), and that hypothermic arrest is possible in an animal model of RT (37). No clinical trials testing suspended animation in trauma victims were reported so far, but a multicenter study examining its therapeutic efficacy in patients undergoing RT was recently approved by the United States National Institute of Health. This study will hopefully provide the much-anticipated data, which will determine whether suspended animation would evolve into a viable adjunct to RT in the future.

Cost and Occupational Exposure

The main driving forces promoting a selective approach to RT are optimization of costs and reduction of the risk to provider posed by occupational exposure to blood-borne pathogens. Although these factors surfaced decades ago, they were more accurately defined only recently. In 2007, a detailed decision-analytic cost-utility analysis of RT in both penetrating and blunt trauma patients was performed using acceptable published rates of survival, impairment, and occupational exposure (38). This study reported that the incremental cost-effectiveness ratio of RT for penetrating trauma was US$16,125 per quality-adjusted life year (QALY), and <US$50,000 per QALY with a 93% probability. The incremental cost-effectiveness ratio for blunt trauma was US$163,136 per QALY, and <US$50,000 per QALY with a 37% probability. Neither model was sensitive to provider exposure. The penetrating model was insensitive to the probability of neurologically intact survival, the utility adjustment, procedure costs, and long-term care. The blunt model was sensitive to the probabilities of survival and of neurologic impairment. Based on these data, the authors concluded that RT is cost-effective for penetrating, but not for blunt trauma, given current rates of survival and impairment. They also concluded that occupational exposure does not significantly impact the cost-effectiveness of the procedure.

A 2012 report investigated the frequency with which RT was performed for inappropriate indications and the resulting societal costs (39). After reviewing 123 RT patients, the authors found that 63 (51%) were inappropriately operated on. In this group, there were no survivors, none became organ donors, three cases of needlesticks to health care providers occurred, and 335 units of blood products were used. Also, only 4 of the 63 patients undergoing a none-indicated RT survived to the OR, and required a total of six separate OR visits. Three of these patients had an ICU stay of 1 day and one died on day 5. Taken together, these observations suggest that inappropriate use of the procedure resulted in substantial costs and wasted resources, exposure of health care providers to possible blood-borne infections, while offering no survival benefit. One main limitation of this study was determining the appropriateness of RT, which inherently introduced some biases.

The prevalence of HIV, hepatitis B virus, and hepatitis C virus (HCV) in penetrating trauma patients was recently determined. A prospective analysis of 314 such patients admitted to an urban Level I trauma center identified 4 patients (1.2%) who tested positive for anti-HIV, 2 (0.6%) who were positive for HBsAg, and 26 (7.6%) who were seropositive for anti-HCV antibodies (40). Of these 32 patients, only 25% were diagnosed prior to enrollment. Further analysis demonstrated that age and intravenous drug use independently increased the likelihood of all positive markers. These data suggest that the prevalence of potential virally transmitted diseases in victims of urban penetrating trauma approaches 10%. In addition, most patients were unaware of their seropositive status at the time of admission. The actual exposure risk for the trauma team is likely higher, as the anti-HIV and anti-HCV tests may have missed recent infections, as antibodies may take up to 6 months to reach detectable levels. Also, many patients are unwilling or unable to convey this critical information due to altered mental status. Although the study did not specifically analyzed RT patients, it is conceivable that the prevalence of viral infections in this subgroup of patients is similar to the overall penetrating trauma group.

Examination of the costs associated with provider exposure to HIV and hepatitis during RT was performed in 2004 (41). To perform this analysis, the authors assumed 7.1% and 18% prevalence of HIV and HCV, respectively, and a 10% provider percutaneous injury rate. Using these assumptions, they reported a probability of 0.0004% for HIV and 0.0027% for chronic hepatitis seroconversion. The additional cost per RT was US$1377.

The above studies suggest that developing a better understanding of the RT-associated risks and costs will allow the provision of this procedure with greater efficiency, resource utilization, and safety. In addition, these studies emphasize the need for universal precautions when performing RT and suggest that exposure to virally transmitted diseases should be considered when deciding to perform this operation in patients with very low survival probability or for teaching purposes in nearly futile cases.

It is clear that the cost analyses described above are system-specific and may not be relevant to other states or countries. Nevertheless, as resource utilization and cost containment are central to the discussion surrounding the indications for RT, these embryonic reports may serve as a platform for further investigation of this important topic.

Summary

Although RT has been utilized for more than half a century, it remains a hotly debated procedure. Despite of the inherent fact that RT offers the only chance for survival to patients in extremis, a selective approach emerged as the optimal treatment paradigm. One firm conclusion derived from the RT literature is that best results are obtained in patients with thoracic SWs who present in the trauma bay with cardiac tamponade and SOL. Another reasonable conclusion is that RT should not be performed in patients who never had witnessed SOL. A third conclusion, contested by the WTA data, suggests that RT is a futile effort in blunt trauma patients who arrive in the hospital without SOL.

Recent studies shed light into the metabolic and biochemical events during RT, its long-term outcome, and the potential for organ donation following this operation. Furthermore, data from the last decade supports using RT in military settings and possibly in the pre-hospital urban environment. New adjuncts to RT including endovascular balloon occlusion of the aorta and profound hypothermia are being considered for future application. Finally, the risk of exposure to virally transmitted diseases and the cost of RT are better defined.