Resuscitation, 15 (1987) 59-66 Elsevier Scientific Publishers Ireland Ltd.

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RESUSCITATIVE THORACOTOMY SYMPOSIUM* - PANEL DISCUSSION

February 21st, 1986

Program Committee Ralph Altman; Jose M. Davilla; Douglas Migden; Harold H. Osborn; Paul

van Niewerburgh; Michael Radeos; Bruce Sanderov; Diane Sauter; Mitchell Strand

Program D irec tor Harold H. Osborn

Proceedings Editors John B. McCabe; Harold H. Osborn; Douglas Migden; Michael Radeos

Panel James K. Alifimoff; Charles Babbs; Louis Del Guercio; Karl B. Kern;

Harold H. Osborn; Michael Rohman; Blaine White

Part I Question: Do you think the literature supports the use of open cardiac massage after

ten to fifteen minutes of unsuccessful closed-chest CPR (CCCPR)? If not then what additional studies are needed?

Answer (Rohman): Yes Alifimoff: I agree completely. I feel that once you have proven inadequate perfusion

with external CPR, then you should open the chest. Rohman: I’ll go a step further, you may not be found guilty of it, but you will prob-

ably be sued if you don’t. Kern: I’d like to make a comment on the opposite side. In an isolated case you could

find a lawyer to defend your side, but I would hate to see that as a general policy it would be adopted nation wide, because there is still some work to be done, as I mentioned before, I think an actual prospective study needs to be performed in a very careful manner to find the real answer. An isolated case could be defended. He could also go against you. But overall, for the best good, I think we still need, in fact, some animal data and then some preliminary human clinical study.

*Sponsored by the Emergency Medical Residency Training Program of Metropolitan Hospital Center and Lincoln Medical and Mental Health Center (affiliated with New York Medical College). Abbreviations: BLS, basic life support;CCCPR, closed-chest cardiopulmonary resuscitation; E.D., Emergency Department; EMS, Emergency Medical System; OCCPR, open-chest cardiopulmonary resuscitation.

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White: I would agree. I would think you could adequately defend yourself if you in fact did open chest massage after the failure of closed chest, and as a matter of fact, the language of the ACLS treatment standard this time is going to be strengthened substan- tially in that regard. I would certainly agree, I would encourage you that if you want to do that, then the way to do it is to set up a careful controlled prospective study with a well controlled EMS system and get us the data. If you’r going to sort of go off willy-nilly trying to save lives one at a time this thing is going to have advanced from dogma to chaos.

Rohman: But I think we have to deal with the realities of our hospitals our floors and our Emergency Department. Today, it is virtually impossible to end the mortality report without the wards cardiac arrest, and I think that obviously that is not what we mean in general terms when we’ve talked about cardiac resuscitation. It seems to me totally meaningless to take a patient who is dying of terminal cancer, or to take a patient who is in irreversible septic multisystem failure and to pull out all the plugs in trying to resusci- tate that individual. Not only does it seem to me cruel and unreasonable treatment, but it misleads us in terms of the success of our resuscitation. When I answered the question, that we should open the chest as early as possible, when closed chest is not effective, without any fear of legal concern, I’m speaking about the patient who truly fits into the category of cardiac arrest, or the patient who has a sudden aspiration pneumonia, and is hypoxic for a moment, a young patient in particular, I think you don’t open the chest to try to get resuscitation if closed chest doesn’t work in a patient who is terminally ill. I think you let the patient die. That’s my personal opinion.

Osbom: Regarding the medicolegal aspects of using thoracotomy for resuscitation in non traumatic arrests we are indebted to Dr. Del Guercio for calling our attention to the indications for internal cardiac compression in medical patients in his editorial in the American Journal of Medicine (Am. J. Med., 2 (1984) 565-566). Failure to establish sufficiently effective artificial circulation is an indication irrespective of trauma or tamponade (Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), J. Am. Med. Assoc., 227 (1974) 855.). So at least the support for doing this, in terms of medicolegal considerations, is there. The intriguing question is why open thoracotomy was ignored, why it was abandoned, and how can be reverse the trend when presently most training programs and medical schools don’t even teach their people how to do the procedure?

We can look at Stephenson’s classic report of 1200 arrest cases treated by thoraco- tomy and OCCPR in the Annals of Surgery (Ann, Surg., 137 (1953) 731-744). The interesting thing about this data is that the survival rate was better then (28%) than the recent Beth Israel data in the New England Journal (14%) (iV. Engl. J Med., 309 (1983) 569-576). The other interesting thing about the Stephenson report is the fact that 86% of the cases arrested in the O.R., essentially right under the eye of surgeons who could perform thoracotomy without delay. If you look at the patients arresting outside the O.R. in the same study the survival rate was only 17%. Therefore, the sooner you open the chest to do OCCPR, the better. In addition, Stephenson reports that if the patient was arrested more than 4 minutes until resuscitation was initiated then the success rate was very poor (6%). This 4 minute number is remarkably similar to the data from Seattle regarding time to BLS intervention. Thus, we are dealing with some hard numbers here.

Dr. White mentioned the study from San Francisco General Hospital (N. Engl. J. Med., 314 (1986) 1189). Where they found no difference with OCCPR in the E.D. But if you go back and look at the study, although they performed resuscitative thoracotomy within 4 minutes of arrival to the E.D. the “down time” before thoracotomy was exceedingly long (down time before CPR for the OCCPR group was 6.4 f 5.4 min., total time until arrival at the E.D. was 18.0 ?r 7.3 min., time to thoracotomy was 3.9 * 2.39 min. and the thoracotomy itself took time to perform), It’s no wonder that the San Francisco group failed to show a beneficial effect from OCCPR.

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Is it possible to construct a study that deals with pre-hospital cardiac arrest using OCCPR in the E.D. that will also provide a fair chance to study the question? Unless you have very rapid EMS response times and transit times I’m not sure. Should we be studying out-of-hospital arrests at all or should we fist study in-hospital arrests? Although obvi- ously in-patients are already ill by definition, wouldn’t this give us a better chance to study the usefulness of OCCPR without dooming it to failure?

Babbs: I don’t think we can design a new protocol here on the panel, but there are some reasonable ways to set limits on some of the protocols. You mentioned some of Stephenson’s data, where he showed that 96% of the successful open chest resuscitation were done with a down time of 4 minutes or less. I think that sets a limit on designing a study. It’s going to depend on local circumstances whether you think we need in-hospital or out-of-hospital. I think it will be in-hospital. I think Dr. Kern’s study sets a limit on how long closed chest technique should be done before open chest is tried. It’s 15 min- utes. Now it would be interesting to repeat that kind of a study in a animal model of myocardial infarction. I think the most likely outcome of such a study would be that both in the open chest and in closed chest survival rate would go down and the difference would be preserved, and I feel comfortable today in saying that’s a reasonable limit to set, and we could look through the literature and probably find one or two more limits and then you look at the local constraints at your particular institution and it’s not all that difficult to come up with a reasonable protocol.

Kern: My bias is that an in-hospital study is much easier to perform. Nevertheless, I think that is possible as Dr. Babbs has said, to carefully design a protocol that would be feasible in an emergency department setting, But I think that it will take a long time to gain adequate numbers to make it a worthwhile study. It may take three or four genera- tions of young investigators who are seeking tenure for seven years, but nonetheless I think it could be done.

Part II Question: What expertise is needed to perform open chest resuscitation (OCCPR)?

What about the Emergency Room physician who perhaps can open a chest but doesn’t have any thoracic surgery experience?

Answer (Del Guercio): As I said in my editorial on the subject every physician includ- ing medical students, should be capable of performing a thoracotomy, As I’ve pointed out, I think the only time closure is a problem is when you have a survivior. If the patient isn’t resuscitated, then anybody can do a baseball stitch and close the patient up, the undertaker included. If you’re in a hospital that doesn’t have thoracic surgeons, then, obviously, there are general surgeons that are doing thoracotomy and closures. The only time that it becomes an infectious proposition and requires great skill to do open chest massage is when you have a survivor and you’ve got to put in a chest tube and then make sure it’s working properly, and properly close the chest. The interesting thing is that it’s been shown in thousands of cases studied who were resuscitated, that the incidence of empyema in thoracotomies in unprepared chests, was less than 10%. Infection very seldom becomes a real problem.

Kern: For those who saw the video, you may recall, that at least in the animals that I’ve worked with after successful resuscitation with a wide open thoracotomy, there’s actually very little problem with bleeding, depending on your technique. If you make an incision in a fashion where most of your actual dissection will be blunt once you get to the pleura. then pull and tear instead of slicing with a blade, it’s not going to be an exsanguinating problem.

White: Technically what we do in the laboratory is that we stay right on top of the lower rib, and then we enter the pleura by poking through with something blunt, put a finger in the hole, then use a pair of scissors and very carefully dissect the intercostals off of the top of the lower rib, and we don’t get into trouble with bleeding in our laboratory,

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and we try not to go more than an inch and a half away from the internal mammaries, and we try not to go all the way around the shoulder muscle. In the Emergency Depart- ment, we almost never did sternal splits, and the reason was that, in our hands, at least, it was more difficult to get in, it took more time. What we would do, if we thought we had a right chest wound, was we would cut across the sternum and open up the right side, sort of like a clam shell, from top to bottom. If you do that you’re going to have to have someone in there to ligate the internal mammaries. The mistakes you can make, arc that you can cut into the arteries underneath the rib, you can cut through the internal mammary and not recognize it and not ligate it, but if you tie it off it’s usually not a problem. You can cut a lung;. . . , and you can punch a hole in the heart if you’re not careful about how you go through the intercostals, and with a little bit of care and think- ing about the structures that are there, I don’t think you’ll have any problem, we don’t have much bleeding problem with the incision at all.

Part III Question: Feeling for pulses during CCCPR is not a good test of the effectiveness of

CPR because pulse cannot be equated with blood flow. How then do you evaluate effec- tiveness of CCCPR during resuscitation and how do you decide when OCCPR is needed?

Answer (Babbs): What I say is that if you have an arterial line, and the diastolic blood pressure is substantially less than 40 mmHg (which is the value identified by Redding as necessary for restoration of spontaneous circulation in arrested animals) (Anesth. Analg., 50 (1971) 668-675) then I would consider that an indication to perform a thoracotomy.

Kern: I think one of the reasons why that has laid there since 1974, is this very problem. It is extermely difficult to assess the effectiveness of CPR and there’s research in that realm. In fact, we’re looking at some non invasive methods, none of which appear to be a great step forward. We’ve looked at expired carbon dioxide and over a very large range, it correlates well, but there is no magic answer, and that’s why it will probably remain in a very nebulous area even in 1986.

Del Guercio: Well, I think that Stephenson really has pointed out where in his mind the accepted signs of perfusion beyond the palpation of a pulse, capillary refill, some signs of pupillary activity, and there are even some, as I pointed out in my book, that I’ve seen moving and looking around in a coma vigil fashion, signs of cerebral activity, and that, to my mind, indicates some flow to the brain, which is what you’re after. If you don’t see some of those, that’s when I open the Chest, and in any patient that I have control over, I’ve got to really see convincing signs of perfusion during closed chest massage, otherwise we open the chest right away, even if it’s only a couple of minutes. In actual fact, it practially never, is less than 10 minutes from the time of arrest, just on a logistical standpoint, it’s impossible to get a chest open that fast.

Rohman: I think there’s no way of looking at it other than that way. If you’re not getting effective perfusion by the signs that you can look at clinically, because you can’t always get an A-line to monitor it. One time, when a chest is being opened, stand there and time it. All of us look at it as though “all right, we’ve had,three minutes of closed chest massage, and then we opened the chest,” as if that is when we started cardiac compression. There’s an interval where nothing’s happening, except maybe the patient’s being ventilated. I’ve never seen a chest opened in less than two minutes, and often longer.

Kern: In my animal experiments, I have seen animals that are actively gagging, and open their eyes and who could even respond to closed chest if their pressures were good enough. On the other hand, I’ve seen a majority of animals where the pressures are reasonable, 30 to 40, who have no signs such as these gross clinical findings. I would suggest maybe one other criterion and that would be response to defibrillation. Is that not where we started? If you cannot defibrillate them successfully, perhaps that’s the main indication as to when to go in.

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Part IV Question: If OCCPR is more effective than CCCPR, can you defend not performing

it even with a terminal rhythm like asystole? Answer (Kern): It’s been apparent that there is a striking difference, per cause of

cardiac arrest. If the patient is a healthy, young person who fibrillates for unknown reasons, as in a primary electrical event, all efforts should be given to that patient as he has a wonderful chance especially if the defibrillator is nearby. On the otherhand, if YOU look closely at what asystole in most cases actually represents, it’s the end of the road for a fellow who had andther reason for collapsing on the scene, but now after 30 minutes of inadequate perfusion, has a terminal rhythm and I think that it would be very important for animal studies to separate those out. In the individual case, I agree with Dr. White that thus far the data support no treatment as being effective for asystole, open chest or whatever, and I would personally hate to see open chest looked at in that subgroup first, for again we’ll condemn it to an under the t.able therapy for another twenty years before it surfaces again.

Osbom: Yes I think you can. First, OCCPR has not yet been proven better than CCPR in a carefully controlled study although all the animal work cited and the early excellent results in humans when OCCPR was routinely used suggest that it is. Second, as Dr. White has pointed out, with asystole (provided the patient is not hypothermic) the likelihood of a successful resuscitation is virtually nil. I think you can look the family of the patient in the eye if that patient has been in asystole for several minutes (provided they are normothermic) and say “I’ve done everything I can” even without opening the chest.

On the other hand I think if we’re dealing with young people with a relatively short down time who are in refractory V-fib, then we’re talking about a very different category of patients. And I guess I would concur with everybody that we have to be clear who we’re talking about when we’re talking about clinical studies or mounting clinical studies. I also would reiterate the point that if we’re really going to look for positive results that we look for people who arrested very close to us, in the hospital or very near the hospital, so that we can give ourselves the best opportunity to show a difference between CCPR and OCCPR.

Rohman: We heard a number of people allude to the inability to resuscitate an asystolic arrest, and I suspect that’s probably reasonably true in the spontaneous arrest but isn’t so in the traumatic arrest, particularly in the arrest with a penetrating cardiac injury, I think you should know that before leaving this room. You cannot use asystole as a reason for not opening the chest in a penetrating cardiac injury. Now, it’s quite true that those patients will resuscitate with great difficulty and they may not resuscitate with increasing frequency versus those who are fibrillating, but we have documented, here in this institution, a number of patients, who clearly on objective evidence, eyebal- ling the heart, and on EKG evidence, to be in arrest, asystole, who have been resuscitated, and who have survived. So you cannot use EKG evidence of asystole as a reason not to open the chest in a traumatic arrest.

White: I want to add to that, I’m sort of interested in the studies here of prolonged inadequate perfusion ruining the heart for resuscitation. We have done potassium induced cardiac arrests for 15, 20 and 30 minutes over the last six years in our laboratory and if you let them all lay there dead, they’re going to all be in asystole when you start the resuscitation.

Now, we do not rush restarting the heart when we’re doing it because we measure brain blood flow and we know we can buy some time like that, correct the acidosis, get the epinephrine on board, get the perfusion pressures up good, and by protocol we stand there and massage them for five minutes before we even try to shock them. This is a real change in emphasis, and the reason for this change of emphasis, is because I know that the cerebral blood flow is 80-90% while we’re doing that and there is no further brain

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ischemia involved. Those animals and those kind of arrest times are 100% in asystole and unless we’re having a real bad day, we’re going to resuscitate every single one of them by open chest. But they had nothing done during the arrest period, a complete anoxic ischemic arrest rather than a severe incomplete ischemia.

Bobbs: While we’re on the subject of asystole, I’d like to point out Gordon Ewy’s paper from Arizona entitled “Ventricular Fibrillation Masquerading as Asystole” where he finds that in fine VF and coarse VF, it is possible in some leads to record something that looks very much like asystole. It was Aprahamian in Milwaukee who had studies of patients with out-of-hospital arrests who were in asystole, and you know what the most effective treatment associated with the most successes. . . defibrillation. Because it wasn’t really asystole, it was pseudo-asystole. When you see a straight line, that doesn’t mean you quit, and I think maybe we gave the wrong impression earlier in the day.

Part V Questions: I think a lot of what we’re trying to do today, is defining the indications

for thoracotomy in a nontraumatic arrest. Are we pretty much agreed that a patient who comes in V-fib refractory to defibrillation, that is a suitable indication for open thoraco- tomy?

Answer (Alifmof#: In my opinion, yes. Del Guercio: I would agree. Rohman: You already heard me, Kern: My only reservation would be, as Dr. White just mentioned, there are times

when you need to actually be sure that you’ve gotten the best perfusion you can, and if that requires open chest, for sure,

Babbs: I would agree, without reservation. I would add only that the best way to do that is a controlled study so we can get the data for it.

Part VI Question (Osborn): One final question for people to consider is, what kind of training

program do we need, building on the existing ones, or creating new ones, to allow the vast majority of us who aren’t on trauma teams to feel confident and capable of doing this procedure?

Answer (Alifimoff): I think if you look at the data that came from McNulty, when he spoke to people who had done a lot of open chest CPR, 20-30 years ago, Physicians were a lot more aggressive in terms of this, simply, I think because of training. And I think that you can train medical students, internists, Emergency physicians and certainly surgeons to be capable of opening the chest quickly and safely and effectively. I don’t think it takes much special training beyond a concentrated effort on the part of a resi- dency training program

Del Guercio: I would certainly agree, and I think that the video films and the dog labs can go a long way in improving and should be an integral part in CPR training. I don’t think it should be limited to surgeons. I think that every physician should be skilled in the full spectrum of CPR and just as the American Heart Association and all the others have pointed out, that open chest massage is part of the general practice of cardio pulmo nary resuscitation. Their indications were just a little vague from that original Washington Conference and it took a great deal of doing for us to get even that one statement in and to have them mention open chest massage at all. But they finally all did agree. NOW we have to pin them down even more.

Rohman: I concur. Before, when I was pointing out how long it might take to really get into the chest if you timed it, if you then decide to do that procedure later on in the course of CPR, what you get is that much longer a delay in getting adequate pumping than what you think you do. Therefore’ all of us who are going to take care of such patients have to know how to do it appropriately and that includes the training in open

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chest resuscitation. In terms of setting up a program, I think it’s a team approach. I think that you really don’t learn it too well as medical students‘ because you have too many other things to do to become a doctor. But, I think in your residency program, there should be combined training activity in this area, not just for the emergency medical physicians but for the surgeons as well, because I can assure YOU there are many surt3eons who do not know how to open a chest and they should learn it together, cooperatively led by someone who is really skilled, and it could be a medical person, it could be a surgeon, but it ought to happen in the spirit of cooperative, creative learning. And it should start in the morgue, where you can’t do any damage then it should move to the dog lab where you can actually work on a moving heart, and then you should be in the emergency room for enough of your training so that when it does happen in the emer- gency room, you’re there to help, and there to learn.

Bobbs: I agree with everything that’s been said. There should be an organized program. It should be interdisciplinary. The people in the programs should not fuss with each other. Don’t underestimate the importance of the dog lab. And in doing your dog labs please record your arterial pressures. And in doing the cardiac massage, get the trainees to look at the arterial pressure record with the following instructions: maximize the area under the blood pressure curve, not just the peak height, but the area under the pressure curve, because it’s pressure multiplied by time equals stroke volume, Most common mistake - failure to relax the hands, open up wide and let the ventricle fill. People get panicky and start squeezing harder and harder and say “I’m squeezing as hard as I can, but I’m only getting 30 mm of mercury.”

We’ve got to let the heart fill, before it can empty, and as the training progresses, the trainee should learn to measure the stroke volume by feel, and then pretty soon they don’t have to look at the blood pressure tracing any more to know they’re doing well. But initially they must get the idea to vary their style and learn how to grip those ventri- cles so they can maximize the area under that pressure curve, They ought to be able to get systolics over 100 and diastolics over 60 if they do it right.

Osborn: Well, I really want to thank everyone, first of all our speakers, for coming here and sharing their thoughts with us, and certainly the Program Committee, and the residents from the Metropolitan and Lincoln Residencies who really helped put this conference together. I think although we haven’t really answered all of our questions, certainly we’ll come away much better informed than when we started.

Thank you for coming and thank you all for participating.

Find Statement of the Program Committee

Controversy surrounds every aspect of Medicine, and nowhere is this more apparent than in life and death decisions. The issue of open chest CPR in non traumatic cardiac arrest may be the most difficult to resolve.

Should we be performing thoracotomies in non-traumatic arrests? The panelists all agree that there is a place for this procedure but differ as to when, where, how, and by whom it should be done.

Time is valuable and is a major factor to be considered in open chest CPR. As we know, there is an unavoidable delay in the delivery of arrested patients to our ED’s, with most patients having had closed chest CPR. Cardiac arrest patients are a heterogenous group, and present to us with varying periods of non flow, or inadequate flow. Even if thoracotomy were performed immediately, we are still faced with significant delay in affecting adequate perfusion. If closed chest CPR truly creates inadequate perfusion, then should we be discouraging our paramedics from doing any more than immediate defibril- lation and rapid transport with CPR en route? In the interest of time, this may be neces- sary. One method of studying open chest CPR under conditions of optimizing time of delivery of the arrest patient would be to use in-hospital cardiac arrest patients.

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Another important point on which to focus is that of cerebral perfusion. If we believe that closed chest only gives us enough perfusion to injure the brain then by using closed chest massage, we may be dooming our patients to a tragic outcome. We need to know how open chest versus closed chest cerebral perfusion pressures compare in human subjects.

As for who should perform the thoracotomy when the need arises, it would behoove the emergency physician to be prepared and skillful in this technique. For most purposes, a left anterolateral approach would be satisfactory.

The preceding is a call for all physicians and researchers in cardiac resuscitation to commence objective double blind studies and compare notes in the area of open chest CPR. It is only through the committment of concerned members of the medical com- munity that we may give open chest a fair trial and perhaps revolutionize our approach to the cardiac arrest patient.

Ralph P, Altman, M.D. F.AC.E.P, Douglas Migden, D. 0.

Harold H. Osbom, M.D. Michael S. Rodeos, M.D.

Bruce Sanderov, M.D. Mitchell S. Stmnd, M.D.