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

References

Authors: