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Emergency Department Thoracotomy: Survival of the Least Expected

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Abstract

Although emergency department thoracotomy (EDT) is often considered a controversial “last chance” method of resuscitation, we hypothesized that EDT performed in a busy urban Level I trauma center has significant salvage rates despite the absence of traditional survival predictors. A retrospective review revealed that 180 patients underwent EDT after traumatic arrest for penetrating injury between 2000 and 2005. All were deemed nonsalvageable by other resuscitation methods. Injury mechanism and location, signs of life (SOLs), initial cardiac rhythm, and presence of vital signs were analyzed. In total, 23 patients survived hospitalization neurologically intact. Compared to nonsurvivors, survivors more often suffered multiple stab wounds (21.7% vs. 1.9%, p = 0.001), presented with field (95.7% vs. 72.6%, p = 0.016) and ED (87.0% vs. 60.5%, p = 0.014) SOLs, had sustainable cardiac rhythms (sinus tachycardia, 43.5% vs. 10.2%, p = 0.001; normal sinus rhythm, 17.4% vs. 4.5%, p = 0.037), and had measurable vital signs (65.2% vs. 25.5%; p = 0.001). However, only 3 of 23 (13.0%) survivors had all survival predictors, and one survivor had none. Frequent predictors in survivors were field SOLs (95.7%), ED SOLs (87.0%), salvageable initial cardiac rhythms (78.3%), and obtainable vital signs (65.2%). Stabbing mechanism (30.4%) and cardiac injury location (30.4%) were least common. Had a strict policy of EDT performance based solely on the presence of survival predictors been followed and EDT withheld, several patients who ultimately survived would have died. Our study suggests that EDT is a technique that should be utilized for patients with critical penetrating injuries even in the absence of many traditional survival predictors.

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References

  1. Beall AC Jr, Diethrich EB, Cooley DA et al (1967) Surgical management of penetrating cardiovascular trauma. South Med J 60:698

    PubMed  Google Scholar 

  2. Ledgerwood AM, Kazmers M, Lucas CE (1976) The role of thoracic aortic occlusion for massive hemoperitoneum. J Trauma 16:610

    PubMed  CAS  Google Scholar 

  3. Baker CC, Thomas AN, Trunkey DD et al (1980). The role of emergency room thoracotomy in trauma. J Trauma 20:848–855

    PubMed  CAS  Google Scholar 

  4. Flynn TC, Ward RE, Miller PW (1982) Emergency room thoracotomy. Ann Emerg Med 11:413–416

    Article  PubMed  CAS  Google Scholar 

  5. Branney SW, Moore EE, Feldhaus KM et al (1998) Critical analysis of two decades of experience with post injury emergency department thoracotomy in a regional trauma center. J Trauma 45:87–95

    PubMed  CAS  Google Scholar 

  6. Rosemurgy AS, Norris PA, Olson SM et al (1993) Prehospital traumatic cardiac arrest: the cost of futility. J Trauma 35:468–473

    Article  PubMed  CAS  Google Scholar 

  7. Powell DW, Moore EE, Cothren CC et al (2004) Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg 199:211–215

    Article  PubMed  Google Scholar 

  8. Pasquale MD, Rhodes M, Cipolle MD et al (1996) Defining “dead on arrival:” impact on a level I trauma center. J Trauma 41:726–730

    PubMed  CAS  Google Scholar 

  9. Esposito TJ, Jurkovich GJ, Rice CL et al (1991) Reappraisal of emergency room thoracotomy in a changing environment. J Trauma 31:881–887

    PubMed  CAS  Google Scholar 

  10. Cogbill TH, Moore EE, Millikan JS et al (1983) Rationale for selective application of emergency department thoracotomy in trauma. J Trauma 23:453–460

    PubMed  CAS  Google Scholar 

  11. Mazzorana V, Smith RS, Morabito DJ et al (1994) Limited utility of emergency department thoracotomy. Am Surg 7:516–521

    Google Scholar 

  12. Velmahos GC, Degiannis E, Souter I (1995) Outcome of a strict policy on emergency department thoracotomy. Arch Surg 130:774–777

    PubMed  CAS  Google Scholar 

  13. Boyd M, Vanek VW, Bourguet CC (1992) Emergency room resuscitative thoracotomy: when is it indicated? J Trauma 33:714–721

    PubMed  CAS  Google Scholar 

  14. Lorenz HP, Steinmetz B, Lieberman J et al (1992) Emergency thoracotomy: survival correlates with physiologic status. J Trauma 32:780–788

    PubMed  CAS  Google Scholar 

  15. Clevenger FW, Yarbrough DR, Reines HD (1988) Resuscitative thoracotomy: the effect of field time on outcome. J Trauma 28:441–445

    Article  PubMed  CAS  Google Scholar 

  16. Gervin AS, Fischer RP (1982) The importance of prompt transport in salvage of patients with penetrating heart wounds. J Trauma 22:443–448

    PubMed  CAS  Google Scholar 

  17. Ivatury RR, Nallathambi MN, Roberge RJ et al (1987) Penetrating thoracic injuries: in-field stabilization vs. prompt transport. J Trauma 27:1066–1072

    Article  PubMed  CAS  Google Scholar 

  18. Schwab CW, Adcock OT, Max MH (1986) Emergency department thoracotomy (EDT): a 26 month experience using an “agonal” protocol. Am Surg 52:20–28

    PubMed  CAS  Google Scholar 

  19. Ivatury RR, Kazigo J, Rohman M et al (1991) “Directed” emergency room thoracotomy: a prognostic prerequisite for survival. J Trauma 31:1076–1082

    PubMed  CAS  Google Scholar 

  20. Roberge RJ, Ivatury RR, Stahl W et al (1986) Emergency department thoracotomy for penetrating injuries: predictive value of patient classification. Am J Emerg Med 4:129–135

    Article  PubMed  CAS  Google Scholar 

  21. Moreno C, Moore EE, Majure JA et al (1986) Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds. J Trauma 26:821–825

    PubMed  CAS  Google Scholar 

  22. Baxter BT, Moore EE, Moore JB et al (1988) Emergency department thoracotomy following injury: critical determinants for patient salvage. World J Surg 12:671–675

    Article  PubMed  CAS  Google Scholar 

  23. Stratton SJ, Brickett K, Crammer T (1998) Prehospital pulseless, unconscious penetrating trauma victims: field assessments associated with survival. J Trauma 45:96–100

    PubMed  CAS  Google Scholar 

  24. Seamon MJ, Fisher CA, Gaughan J et al (2007) Prehospital procedures before emergency department thoracotomy: “scoop and run” saves lives. J Trauma 63:113–120

    PubMed  Google Scholar 

  25. Rhee PM, Acosta J, Bridgeman A et al (2000) Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg 190:288–298

    Article  PubMed  CAS  Google Scholar 

  26. Battistella FD, Nugent W, Owings JT et al (1999) Field triage of the pulseless trauma patient. Arch Surg 134:742–746

    Article  PubMed  CAS  Google Scholar 

  27. Anonymous (2001) Working group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons’ Committee on Trauma: practice management guidelines for emergency department thoracotomy. J Am Coll Surg 193:303–309

    Article  Google Scholar 

  28. Hobson LR, Hirsh E, Delgado J et al (2003) Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest: joint position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg 196:475–481

    Article  Google Scholar 

  29. Pickens JJ, Copass MK, Bulger EM (2005) Trauma patients receiving CPR: predictors of survival. J Trauma 58:951–958

    PubMed  Google Scholar 

  30. Miglietta MA, Robb TV, Eachempati SR et al (2001) Current opinion regarding indications for emergency department thoracotomy. J Trauma 51:670–676

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Temple University School of Medicine, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA, 19104, USA

    Mark J. Seamon

  2. Department of Surgery, Temple University School of Medicine, Philadelphia, PA, 19104, USA

    Carol A. Fisher, Heather Kulp, Daniel T. Dempsey & Amy J. Goldberg

  3. Biostatistics Consulting Center, Temple University School of Medicine, Philadelphia, PA, USA

    John P. Gaughan

Authors
  1. Mark J. Seamon
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  2. Carol A. Fisher
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  3. John P. Gaughan
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  4. Heather Kulp
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  5. Daniel T. Dempsey
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  6. Amy J. Goldberg
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Corresponding author

Correspondence to Mark J. Seamon.

Additional information

This work was presented at the International Association of Trauma Surgery and Intensive Care Meeting, August 2007.

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Seamon, M.J., Fisher, C.A., Gaughan, J.P. et al. Emergency Department Thoracotomy: Survival of the Least Expected. World J Surg 32, 604–612 (2008). https://doi.org/10.1007/s00268-007-9392-9

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  • DOI: https://doi.org/10.1007/s00268-007-9392-9

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