Article 1
Futility indications in resuscitative thoracotomy: A retrospective observational study evaluating practice guidelines. Kalantar GH, Villalta CI, West M, Ragsdale M, Grossman Verner HM, Krezczowski RM, Amos JD, Shifflette V. Injury. 2025 Oct;56(10):112673.
This single-center retrospective observational study reviewed six years of resuscitative thoracotomies (RT) (n=56) performed at a US Level 1 trauma center with the aim to evaluate predictors of high mortality or “futility indicators”. Most RTs were performed for penetrating trauma (55.4%), with gunshot wounds the most common injury etiology (46.4%). Key findings were that most RTs (87.5%) were EAST guideline-concordant, and outcomes remained consistent with previous studies: procedure mortality was 67.9% for RT and in-hospital mortality 89.3%, with 10.7% surviving to discharge (penetrating 16.2% vs blunt 4.0%). With regards to futility factors, all patients with fixed/dilated pupils, no signs of life on arrival, or prehospital CPR expired prior to discharge. The authors conclude that refinement in thoracotomy patient selection may be possible and recommend incorporating witnessed arrest and prioritizing initial pupillary response in RT futility guidance.
This retrospective piece meaningfully contributes to ongoing discussions of prognostication in resuscitative thoracotomy. This work reinforces the prioritization of specific signs of life, particularly pupillary response. Reported survival to discharge mirrors outcomes cited in the EAST PMG, suggesting that current RT practice is guideline-concordant and that survival expectations remain consistent without changes to protocol. While the study demonstrates 100% mortality among patients meeting proposed futility indicators (fixed/dilated pupils, absence of SOL, or prehospital CPR), these observations are limited by small subgroup sizes and retrospective documentation, solidifying these signs as reinforcement of existing caution. Although the authors suggest taking these futility predictors into consideration for RT indication, these signs can continue to serve as postmarks for when resuscitative attempts have become futile. This work does not contraindicate the current EAST guideline driven patient selection for when RT should be initiated.
Article 2
Prehospital needle thoracostomy and the need to implement objective criteria for intervention: A retrospective study. Boever JC, Ott MJ, Muldiiarov V, Barmettler N, Veatch J, Chaplin R, Waibel B, Buesing KL, Tierney J. Injury. 2025 Dec 13:112973.
This single-center retrospective study evaluated the indications and physiologic impact of prehospital needle thoracostomy (NT) among adult trauma patients treated by EMS and transported to a US Level I trauma center between 2015 and 2024 (n=214). The results reveal that the cohort who received field NT were severely injured (median ISS 33; 83% ISS >15) with high overall mortality (52%). In a majority of cases NT was documented to be performed for subjective clinical indications, namely reduced or absent breath sounds (55%). Overall, 30% of patients demonstrated a positive response to NT defined as improved oxygenation by 10% or prompt ROSC. NT was associated with a significant reduction in presence of hypoxia (from 68% to 48%), while no significant changes were observed in systolic blood pressure or heart rate. Complications were noted in 14% of patients, including serious events related to mispositioned needles.
The findings of this piece highlight both the potential benefit of NT but also flag the high-risk nature of this procedure. This is an important consideration in the pre-hospital setting when complications cannot be as quickly acted upon. For these reasons, the authors urge for a refined use for NT. This is investigated through their subgroup analysis in which they demonstrated that the highest rate of physiologic improvement occurred in patients with both hypoxia and reduced or absent breath sounds, with about two-thirds showing improvement in oxygenation. This is in contrary to the cohort undergoing CPR en route who had the lowest likelihood of a positive response. These ultimately suggest that objective physiologic derangements, particularly hypoxia, may be more predictive of benefit from prehospital NT than subjective findings alone. The heterogeneity in NT indications in the pre-hospital setting remain a valid and newly researched concern by the authors and open the door to continued refinement of prehospital protocols, especially those of emergent NT towards objective indications.
