Futility indications in resuscitative thoracotomy: A retrospective observational study evaluating practice guidelines

Abstract

Background

Resuscitative thoracotomies (RTs) are controversial interventions that heavily consume resources and can pose risks for the surgical team. Increasingly limited resources and risk to healthcare teams have encouraged the continued refinement of RT guidelines. We evaluated RT futility indicators amid institutional RT practice guideline changes.

Methods

Thoracotomies conducted at our Level 1 Trauma Center from January 2017 to July 2023 were reviewed and classified as either RT or non-resuscitative (non-RT). Injury characteristics, patient demographics, procedure details, and mortality outcomes were collected through chart review.

Results

Of 78 thoracotomies, 56 (71.8 %) were RTs, predominantly on patients with penetrating injuries (55.4 %), specifically gunshot wounds (46.4 %). Most RTs (87.5 %) complied with Eastern Association for the Surgery of Trauma guidelines. The procedure mortality rate was 4.6 % for non-RT and 67.9 % for RT, and hospital mortality was 13.6 % for non-RT and 89.3 % for RT. Thus, 10.7 % of RT patients survived to discharge, including 5 (16.2 %) with penetrating injuries and 1 (4.0 %) with blunt injuries. Ten (17.8 %) RT patients arrived with fixed and dilated pupils, 11 (19.6 %) arrived with no signs of life, and 4 (10.7 %) received pre-hospital CPR, all of whom did not survive to discharge. Changes in institutional practice guidelines decreased the frequency of total thoracotomies, but not RT numbers.

Discussion

RT utilization and mortality rates remained consistent after implementing stricter institutional guideline policies. Improving odds of survival may require further refinement to RT practice guidelines regarding patient selection criteria. We recommend adding witnessed cardiac arrest and prioritizing pupillary response to RT futility guidelines regardless of injury pattern.