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
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