Introduction

The incidence of trauma has been increasing across several Caribbean countries. (₁,₂,₃,₄,₅,₆,₇) In 2006, the Caribbean Epidemiology Centre reported that 23% of emergency room visits were trauma related and inter-personal assaults had become the eighth commonest cause of mortality. (₇) The surge in inter-personal violence has increased the proportion of emergent operations for trauma and the number of resuscitative thoracotomies being performed in emergency rooms in some Caribbean countries. (₈)

Discussion

A resuscitative thoracotomy may be life saving in selected trauma patients. The primary rationale is the preservation of life by releasing cardiac tamponade, controlling hemorrhage and allowing access for internal cardiac massage. (₉) Secondary aims include clamping the descending thoracic aorta to isolate circulation to the upper torso and allow for damage control surgery. (₉)

The first reported successful procedure was performed on a 13 year old boy by Hill in 1902. (₁₀) This success boosted the popularity of resuscitative thoracotomies and they were soon performed indiscriminately in many moribund trauma victims. The statistical outcome was poor without appropriate patient selection. (₁₁,₁₂,₁₃,₁₄) There was a significant clinical shift over the past five decades when several exclusion criteria were defined once it was recognized that the low salvage rates and high cost could not justify its routine utility. (₉,₁₁,₁₂,₁₃,₁₄,₁₅) With better patient selection and concomitant advances in critical care, modern centers now report between 7.4% (₁₃) and 30% (₁₁) survival after this procedure.

Numerous advisory bodies have proposed selection criteria for resuscitative thoracotomy. Because of the nature of these injuries, no prospective randomized trials have been conducted. Most of the data comes from retrospective studies from large trauma centers in developed countries. (₉,₁₁,₁₂,₁₃,₁₆,₁₇,₁₈)

Many of the developing countries within the Caribbean operate under different health care environments. (₄,₅,₁₉,₂₀,₂₁,₂₂,₂₃) Their under-funded health care systems cannot always afford the degree of support that is needed to ensure survival after resuscitative thoracotomy. Post-operative intensive care support is not universally available. (₁₉,₂₀,₂₁,₂₂,₂₃) Blood and blood products are scarce resources and many times surgical instrumentation is inadequate. (₁₉,₂₀,₂₁,₂₂,₂₃) Several practicing Caribbean surgeons have questioned the value of resuscitative thoracotomies in this setting because they realize that even if the patients survive the emergency procedure, survival to discharge is uncommon with the current status of the heath care systems.

We believe that there is a place for emergency room resuscitative thoracotomy in the Caribbean. One retrospective report from the Caribbean revealed that 15% of patients with penetrating trauma were salvaged despite the health care system limitations. (₂₁) It is clear is that Caribbean territories cannot blindly adopt the selection criteria proposed by the developed world. The region may need to adopt more stringent selection criteria in order to achieve acceptable cost-benefit ratios from this procedure. Mature surgical judgment is needed to identify the patients who have a poor chance of survival in order to prevent a futile operation.

There is general consensus that a resuscitative thoracotomy is contraindicated in patients without signs of life at the injury scene. (₁₁,₁₃,₁₆,₁₇,₂₄,₂₅,₂₆) Some authorities have extended it to patients with penetrating injuries who arrive at hospital within five minutes of an arrest and have been resuscitated with a definitive airway. (₉,₁₃,₁₅,₂₆,₂₇,₂₈,₂₉) They base this on reports of survival ranging from 3% (₁₆) to 8% (₁₃) once there has been adequate resuscitation. In most Caribbean territories, pre-hospital emergency response services are not universally available. (₃₀,₃₁,₃₂) Most potential candidates are transported to hospital emergency rooms by non-medical personnel and without proper resuscitation. (₂₁) Previous reports from the region document 100% mortality when resuscitative thoracotomies are performed in patients who arrive at the emergency room without signs of life. (₈) Under these circumstances, we probably should not extend the procedure to patients with absent vital signs upon arrival in the emergency room.

Most authorities consider blunt chest trauma a contraindication. (₁₂,₁₃,₂₆) but some still advocate resuscitative thoracotomy for blunt trauma. (₉,₁₁) There are no reports of the procedure being performed in victims of blunt trauma in the Caribbean. The American College of Surgeons' Committee on Trauma has advocated “rare performance only in patients with blunt chest trauma who arrive to emergency rooms with vital signs and have a witnessed cardiopulmonary arrest.” (₁₁) They base this recommendation on a meta-analysis of 2,193 operations for blunt trauma that reported 1.6% overall survival. (₁₁) These results are still poor and are not easily reproducible, especially with the health care limitations in Caribbean countries. (₄,₅,₈,₁₉,₂₀,₂₁,₂₂,₂₃)

Consistently better outcomes have been reported when resuscitative thoracotomy is performed for penetrating trauma. (₁₁) The American College of Surgeons' Committee on Trauma reported 11.16% survival in their meta-analysis of 4,482 patients with penetrating chest trauma. (₁₁) The Caribbean experience is comparable, with 22% survival in patients with penetrating chest trauma and vital signs on presentation to hospital and 40% survival in patients with cardiac tamponade from thoracic stab wounds. (₈,₂₁)

Patients with multiple and/or significant organ injuries may require significant amounts of blood products if they survive operation. Our experience is that therapeutic outcomes are negatively affected by the chronic shortage of blood products in many Caribbean countries. (₁,₅,₁₉,₂₀,₂₁) This is supported by data from the region documenting 100% mortality after resuscitative thoracotomy in patients with significant organ injuries, multiple extra-thoracic injuries and high velocity thoracic gunshot wounds. (₈) The figures are similar to those in international reports where gunshot injuries (₁₆,₁₇,₂₆,₂₇) and multiple extra-thoracic injuries (₁₁,₁₃,₁₇,₂₇) have been recognized as independent predictors of mortality. We have to face the possibility that transfusion in these patients who have a poor chance of survival may amount to misappropriation of resources since transfusion may better serve other patients with better potential outcomes. In this light, emergency room resuscitative thoracotomies do not seem justified in patients with high velocity thoracic gunshot wounds or multiple extra-thoracic gunshot wounds if we cannot provide the necessary post-operative support to ensure survival.

Resuscitative thoracotomies are also not without complications. It puts the trauma team at risk for percutaneous injury and blood exposure. (₁₁,₁₂) These are likely to be high-risk exposures considering the highly invasive nature of the procedure. (₃₄) Moreover, the fast pace may not allow sufficient time to observe universal precautions that have been shown to decrease exposure. (₃₅) This is of concern with an estimated 3-30% risk of transmission of hepatitis B and C (₃₆) and 0.3% risk of HIV transmission. (₃₇,₃₈,₃₉,₄₀) The figures are put into perspective by the Pan American Health Organization biostatistics ranking the Caribbean second only to Sub-Saharan Africa in terms of the number of HIV cases per capita, with 2.4% of Caribbean adults living with HIV. (₄₁) The potential for exposure cannot be used as justification to withhold the procedure from appropriately selected patients, but it is impetus to define selection criteria.

In addition to disease transmission, a resuscitative thoracotomy is financially demanding. Most of these costs are never recovered because only small fractions of the population in Caribbean countries have health insurance. (₅,₂₀) The survivors require ICU admission and consume significant amounts of hospital resources that are already in short supply. (₂,₅,₂₀,₂₁) These patients “spill over” into the post-anaesthesia recovery room when our ICU is occupied, thereby slowing elective lists and leading to cancellation of major elective cases. (₁,₂₁)

The high demand on hospital resources and the heavy financial burden certainly cannot be used to justify denying appropriately selected patients of the procedure. Instead they highlight the importance of selection criteria to prevent futile operations in unsalvageable patients. While this principle is not unique to the Caribbean, we must acknowledge that the results of resource misappropriation are more devastating to Caribbean health care systems than in developed countries.

Quality of life is a valid concern in survivors. The American College of Surgeons' meta-analysis identified 226 survivors who had 15% incidence of significant neurologic deficits. (₁₁) Even when this occurs, EDT is not entirely futile because there may still be benefit through organ salvage and subsequent transplant. Transplant programmes are becoming more popular in several of the larger Caribbean islands. (₄₂,₄₃,₄₄,₄₅,₄₆)

Several large advisory bodies have shown that better patient selection can improve survival. (₁₁,₁₂,₂₂) It is now time for Caribbean countries to define selection criteria and implement protocols that are tailored to suit our own health care environments.

Conclusions

The health care environment in Caribbean countries differs from that in developed countries. With under-funded health care systems, we must ensure that resources are not misappropriated by performing futile procedures on unsalvageable patients.

In this setting, we believe that resuscitative thoracotomies should only be performed in patients with isolated penetrating chest trauma who arrive at hospital with vital signs and are in extremis, unresponsive to resuscitation or have a witnessed arrest. But it should be withheld from patients with blunt trauma, multiple extra-thoracic gunshot injuries and high velocity thoracic gunshot wounds. Patients presenting to hospital without vital signs are also not appropriate candidates in this setting.