EBQ:Effective ED Thoracotomy Usage

Complete Journal Club Article

Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N.. "Survival After Emergency Department Thoracotomy: Review of Published Data From the Past 25 Years". J Am Coll Surg. 2000. 190(3):288-298.
PubMed

Clinical Question

What are the survival rates and indications for emergency department thoracotomy (EDT), and which patient populations are most likely to benefit?

Conclusion

• EDT is most effective in penetrating cardiac injuries with witnessed vital signs
• Overall survival after EDT is approximately 7.4%, but varies significantly by mechanism and patient presentation
• Patients with penetrating cardiac injuries who arrive with signs of life have the highest survival rates (up to 35%)
• EDT for blunt trauma has extremely poor outcomes (<2% survival) and should rarely be performed

Major Points

• This was the most comprehensive review of EDT outcomes at the time, analyzing over 7,000 patients from 42 studies
• Survival by mechanism: penetrating cardiac injuries 19.4%, penetrating non-cardiac thoracic 10.7%, penetrating abdominal/extremity 4.5%, blunt trauma 1.4%
• Signs of life (pupillary response, spontaneous ventilation, cardiac electrical activity) at presentation predict better outcomes
• The study established evidence-based guidelines for when EDT should and should not be performed
• EDT is futile in patients without vital signs after blunt trauma with >10 minutes of prehospital CPR

Study Design

• Systematic review of published literature on emergency department thoracotomy
• 42 studies reviewed spanning 25 years of published data
• N = 7,035 patients who underwent EDT

Population

Inclusion Criteria

• Published studies reporting outcomes of emergency department thoracotomy
• Studies with sufficient data to calculate survival rates by mechanism

Exclusion Criteria

• Case reports with insufficient outcome data
• Studies combining EDT with OR thoracotomy without separating outcomes

Interventions

• Emergency department thoracotomy (left anterolateral thoracotomy)
• Goals of EDT: release pericardial tamponade, control cardiac hemorrhage, cross-clamp aorta for hemorrhage control, internal cardiac massage

Outcomes

Primary Outcome

• Overall survival to discharge: 7.4% (521/7,035)

Secondary Outcomes

• Survival by mechanism:
  • Penetrating cardiac: 19.4%
  • Penetrating non-cardiac thoracic: 10.7%
  • Penetrating abdominal: 4.5%
  • Blunt trauma: 1.4%
• Neurologically intact survival: majority of survivors had good neurological outcomes

Criticisms

• Significant heterogeneity across studies in patient selection, technique, and outcome definitions
• Publication bias may overestimate survival rates (centers with better outcomes more likely to publish)
• Review included older studies with different prehospital care standards
• Definition of "signs of life" varied across studies
• Does not address the resource utilization or cost-effectiveness of EDT

Funding

• None reported

See Also

• Emergency department thoracotomy
• Penetrating chest trauma
• Cardiac tamponade