Abstract
Purpose
Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world.
Methods
Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications.
Results
Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012).
Conclusions
Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.
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References
Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, Fox N, Jawa RS, Khwaja K, Lee JK, Magnotti LJ, Mayglothling JA, McDonald AA, Rowell S, To KB, Falck-Ytter Y, Rhee P. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159–73.
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):288–98.
Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: objectives, indications, and outcomes. World J Emerg Surg. 2006;1:4.
Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015;108(1):11–6.
Lockey DJ, Lyon RM, Davies GE. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation. 2013;84(6):738–42.
Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015;65(3):297–307.e16
Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma—a review. Injury. 2006;37(1):1–19.
Powell DW, Moore EE, Cothren CC, Ciesla DJ, Burch JM, Moore JB, Johnson JL. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg. 2004;199(2):211–5.
Seamon MJ, Shiroff AM, Franco M, Stawicki SP, Molina EJ, Gaughan JP, Reilly PM, Schwab CW, Pryor JP, Goldberg AJ. Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. J Trauma. 2009;67(6):1250–7.
Tyburski JG, Astra L, Wilson RF, Dente C, Steffes C. Factors affecting prognosis with penetrating wounds of the heart. J Trauma. 2000;48(4):587–90.
Karmy-Jones R, Nathens A, Jurkovich GJ, Shatz DV, Brundage S, Wall MJ, Engelhardt S, Hoyt DB, Holcroft J, Knudson MM, Michaels A, Long W. Urgent and emergent thoracotomy for penetrating chest trauma. J Trauma. 2004;56(3):664–8.
Passos EM, Engels PT, Doyle JD, Beckett A, Nascimento B, Rizoli SB, Tien HC. Societal costs of inappropriate emergency department thoracotomy. J Am Coll Surg. 2012;214(1):18–25.
Mollberg NM, Glenn C, John J, Wise SR, Sullivan R, Vafa A, Snow NJ, Massad MG. Appropriate use of emergency department thoracotomy: implications for the thoracic surgeon. Ann Thorac Surg. 2011;92(2):455–61.
Pahle AS, Pedersen BL, Skaga NO, Pillgram-Larsen J. Emergency thoracotomy saves lives in a Scandinavian hospital setting. J Trauma. 2010;68(3):599–603.
Schnüriger B, Talving P, Inaba K, Barmparas G, Branco BC, Lam L, Demetriades D. Biochemical profile and outcomes in trauma patients subjected to open cardiopulmonary resuscitation: a prospective observational pilot study. World J Surg. 2012;36(8):1772–8.
Kennedy F, Sharif S. Emergency room thoracotomy: a single surgeon’s thirteen-year experience. Am Surg. 2000;66(1):56–60.
Gomez G, Fecher A, Joy T, Pardo I, Jacobson L, Kemp H. Optimizing outcomes in emergency room thoracotomy: a 20-year experience in an urban level I trauma center. Am Surg. 2010;76(4):406–10.
Edens JW, Beekley AC, Chung KK, Cox ED, Eastridge BJ, Holcomb JB, Blackbourne LH. Longterm outcomes after combat casualty emergency department thoracotomy. J Am Coll Surg. 2009;209(2):188–97.
Okoye OT, Talving P, Teixeira PG, Chervonski M, Smith JA, Inaba K, Noguchi TT, Demetriades D. Transmediastinal gunshot wounds in a mature trauma centre: changing perspectives. Injury. 2013;44(9):1198–203.
Molina EJ, Gaughan JP, Kulp H, McClurken JB, Goldberg AJ, Seamon MJ. Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective. Interact Cardiovasc Thorac Surg. 2008;7(5):845–8.
Capote A, Michael A, Almodovar J, Chan P, Skinner R, Martin M. Emergency department thoracotomy: too little, too much, or too late. Am Surg. 2013;79(10):982–6.
Ladd AP, Gomez GA, Jacobson LE, Broadie TA, Scherer LR III, Solotkin KC. Emergency room thoracotomy: updated guidelines for a level I trauma center. Am Surg. 2002;68(5):421–4.
Huber-Wagner S, Lefering R, Qvick M, Kay MV, Paffrath T, Mutschler W, Kanz KG. Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest. Resuscitation. 2007;75(2):276–85.
Rabinovici R. Sixty-seven consecutive resuscitative thoracotomies by a single surgeon. Scand J Surg. 2014;103(2):156–60.
Paydar S, Moghaninasab A, Asiaei E, Sabetian Fard Jahromi G, Bolandparvaz S, Abbasi H. Outcome of patients underwent emergency department thoracotomy and its predictive factors. Emergency (Tehran, Iran). 2014;2(3):125–9.
Berg R, Okoye O, Teixeira P, Inaba K, Demetriades D. The double jeopardy of blunt thoracoabdominal trauma. Arch Surg. 2012;147(6):498–504.
Asensio JA, Arroyo H, Veloz W, Forno W, Gambaro E, Roldan GA, Murray J, Velmahos G, Demetriades D. Penetrating thoracoabdominal injuries: ongoing dilemma—which cavity and when? World J Surg. 2002;26(5):539–43.
Lustenberger T, Labler L, Stover JF, Keel MJB. Resuscitative emergency thoracotomy in a Swiss trauma centre. Br J Surg. 2012;99(4):541–8.
Aihara R, Millham FH, Blansfield J, Hirsch EF. Emergency room thoracotomy for penetrating chest injury: effect of an institutional protocol. J Trauma. 2001;50(6):1027–30.
Matsumoto H, Mashiko K, Hara Y, Kutsukata N, Sakamoto Y, Takei K, Kanemaru K, Tomita Y, Saito N, Yagi T, Tetsu S, Iida H, Masuda Y, Koami H, Yokota H. Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system. Resuscitation. 2009;80(11):1270–4.
Sheppard FR, Cothren CC, Moore EE, Orfanakis A, Ciesla DJ, Johnson JL, Burch JM. Emergency department resuscitative thoracotomy for nontorso injuries. Surgery. 2006;139(4):574–6.
Kaljusto M, Skaga N, Pillgram-Larson J, Tonnessen T. Survival predictor for penetrating cardiac injury; a 10-year consecutive cohort from a scandinavian trauma centre. Scand J Trauma Resusc Emerg Med. 2015;23(41):1–7.
Kandler K, Konge L, Rafiq S, Larsen CF, Ravn J. Emergency thoracotomies in the largest trauma center in Denmark: 10 years’ experience. Eur J Trauma Emerg Surg. 2012;38(2):151–6.
Burack JH, Kandil E, Sawas A, O’Neill PA, Sclafani SJA, Lowery RC, Zenilman ME. Triage and outcome of patients with mediastinal penetrating trauma. Ann Thorac Surg. 2007;83(2):377–82.
Cawich SO, Mitchell DIG, Williams EW, Mcfarlane ME, Martin A, Plummer JM, Blake G, Newnham MS, Brown H. Emergency department thoracotomy in Jamaica: a case controlled study. Int J Surg. 2007;5(5):311–5.
Van Waes OJF, Van Riet PA, Van Lieshout EMM, Hartog DD. Immediate thoracotomy for penetrating injuries: ten years’ experience at a Dutch level I trauma center. Eur J Trauma Emerg Surg. 2012;38(5):543–51.
Huerta S, Bui TD, Nguyen TH, Banimahd FN, Porral D, Dolich MO. Predictors of mortality and management of patients with traumatic inferior vena cava injuries. Am Surg. 2006;72(4):290–6.
Alanezi K, Milencoff GS, Baillie FGH, Lamy A, Urschel JD. Outcome of major cardiac injuries at a Canadian trauma center. BMC Surg. 2002;2:4.
Martin SK, Shatney CH, Sherck JP, Ho C-C, Homan SJ, Neff J, Moore EE. Blunt trauma patients with prehospital pulseless electrical activity (PEA): poor ending assured. J Trauma. 2002;53(5):876–81.
Balkan ME, Oktar GL, Kayi-Cangir A, Ergül EG. Emergency thoracotomy for blunt thoracic trauma. Ann Thorac Cardiovasc Surg. 2002;8(2):78–82.
Ferris JD, Smith I, Robertson CE. Emergency department at the cutting edge. Eur J Emerg Med. 2008;15(2):67–70.
Soreide K, Soiland H, Lossius HM, Vetrhus M, Soreide JA, Soreide E. Resuscitative emergency thoracotomy in a Scandinavian trauma hospital—is it justified? Injury. 2007;38(1):34–42.
Johannesdottir BK, Mogensen B, Gudbjartsson T. Emergency thoracotomy as a rescue treatment for trauma patients in Iceland. Injury. 2013;44(9):1186–90.
Morrison JJ, Midwinter MJ, Jansen JO. Ballistic thoracoabdominal injury: analysis of recent military experience in Afghanistan. World J Surg. 2011;35(6):1396–401.
Lyn-Sue J, Siram S, Williams D, Mezghebe H. Epidemiology of trauma deaths in an urban level-1 trauma center predominantly among African Americans—implications for prevention. J Natl Med Assoc. 2006;98(12):1940–4.
Morgan BS, Garner JP. Emergency thoracotomy—the indications, contraindications and evidence. J R Army Med Corps. 2009;155(2):87–93.
Smith RM, Conn AK. Prehospital care—scoop and run or stay and play? Injury 2009;40(suppl. 4):S23–6.
Esposito TJ, Jurkovich GJ, Rice CL, Maier RV, Copass MK, Ashbaugh DG. Reappraisal of emergency room thoracotomy in a changing environment. J Trauma. 1991;31(7):881–5.
Sloan EP, McGill BA, Zalenski R, Tsui P, Chen EH, Duda J, Morris M, Sherer R, Barrett J. Human immunodeficiency virus and hepatitis B virus seroprevalence in an urban trauma population. J Trauma. 1995;38(5):736–41.
Sikka R, Millham FH, Feldman JA. Analysis of occupational exposures associated with emergency department thoracotomy. J Trauma Injury Infect Crit Care. 2004;56(4):867–72.
Boyd M, Vanek VW, Bourguet CC. Emergency room resuscitative thoracotomy: when is it indicated? J Trauma. 1992;33(5):714–21.
Branney SW, Moore EE, Feldhaus KM, Wolfe RE. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma. 1998;45(1):85–7.
Mazzorana V, Smith RS, Morabito DJ, Brar HS, McCarthy MC, Lechner GW, Ledgerwood AM, Reed DN, Bachulis B. Limited utility of emergency department thoracotomy. Am Surg. 1994;60(7):516–21.
Danne PD, Finelli F, Champion HR. Emergency bay thoracotomy. J Trauma. 1984;24(9):796–802.
Hoyt DB, Shackford SR, Davis JW, Mackersie RC, Hollingsworth-Fridlund P. Thoracotomy during trauma resuscitations—an appraisal by board-certified general surgeons. J Trauma. 1989;29(10):1318–21.
Cogbill TH, Moore EE, Millikan JS, Cleveland HC. Rationale for selective application of emergency department thoracotomy in trauma. J Trauma Injury Infect Crit Care. 1983;23(6):453–60.
Velmahos GC, Degiannis E, Souter I, Allwood AC, Saadia R. Outcome of a strict policy on emergency department thoracotomies. Arch Surg. 1995;130(7):774–7.
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. 2001;193(3):303–9.
Brown TB, Romanello M, Kilgore M. Cost-utility analysis of emergency department thoracotomy for trauma victims. J Trauma. 2007;62(5):1180–5.
Hopson LR, Hirsh E, Delgado J, Domeier RM, McSwain NE, Krohmer J, Weldon C, Friel M, Hoyt DB. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. J Am Coll Surg. 2003;196(3):475–81.
Kortbeek JB, Al Turki SA, Ali J, Antoine JA, Bouillon B, Brasel K, Brenneman F, Brink PR, Brohi K, Burris D, Burton RA, Chapleau W, Cioffi W, Collet e Silva FDS, Cooper J, Cortes A, Eskesen V, Fildes J, Gautam S, Gruen RL, Gross R, Hansen KS, Henny W, Hollands MJ, Hunt RC, Jover Navalon JM, Kaufmann CR, Knudson P, Koestner A, Kosir R, Larsen CF, Livaudais W, Luchette F, Mao P, McVicker JH, Meredith HW, Mock C, Mori ND, Morrow C, Parks SN, Pereira PM, Pogetti RS, Ravn J, Rhee P, Salomone JP, Schipper IB, Schoettker P, Schreiber MA, Smith RS, Svendsen LB, Taha W, van Wijngaarden-Stephens M, Varga E, Voiglio EJ, Williams D, Winchell RJ, Winter R. Advanced trauma life support, 8th edition, the evidence for change. J Trauma. 2008;64(6):1638–50.
Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014;98(3):1134–40.
Carr JA, Buterakos R, Bowling WM, Janson L, Kralovich KA, Copeland C, Link R, Roiter C, Casey G, Wagner JW. Long-term functional and echocardiographic assessment after penetrating cardiac injury: 5-year follow-up results. J Trauma Injury Infect Crit Care. 2011;70(3):701–4.
Tarmey NT, Park CL, Bartels OJ, Konig TC, Mahoney PF, Mellor AJ. Outcomes following military traumatic cardiorespiratory arrest: a prospective observational study. Resuscitation. 2011;82(9):1194–7.
Moore EE, Knudson MM, Burlew CC, Inaba K, Dicker RA, Biffl WL, Malhotra AK, Schreiber MA, Browder TD, Coimbra R, Gonzalez EA, Meredith JW, Livingston DH, Kaups KL. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011;70(2):334–9.
Nevins EJ, Moori PL, Smith-Williams J, Bird NTE, Taylor JV, Misra N. Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma? Eur J Trauma Emerg Surg. 2018. https://doi.org/10.1007/s00068-018-0937-4
Miglietta M, Robb T, Eachempati S, Porter B, Cherry R, Brause J, PS B. Current opinion regarding indications for emergency department thoracotomy. J Trauma Injury Infect Crit Care. 2001;51(4):670–6.
Dennis B, Medvecz A, Gunter O, Guillamondegui O. Survey of trauma surgeon practice of emergency department thoracotomy. Am J Surg. 2016;212:440–5.
Anderson I, Cripps M, Cromwell D, Emma M, Ms D, Drake S, Grocott M, Kuryba A, Lourtie J, Moonesinghe R, Murray D, Oliver M, Papadimitriou D, Peden C, Walker K. The first patient report of the national emergency laparotomy audit (NELA) executive summary. R Coll Anaesth. 2015:1–149.
Seamon MJ, Chovanes J, Fox N, Green R, Manis G, Tsiotsias G, Warta M, Ross SE. The use of emergency department thoracotomy for traumatic cardiopulmonary arrest. Injury. 2012;43(9):1355–61.
Keller D, Kulp H, Maher Z, Santora TA, Goldberg AJ, Seamon MJ. Life after near death: long-term outcomes of emergency department thoracotomy survivors. J Trauma Acute Care Surg. 2013;74(5):1315–20.
Morrison JJ, Poon H, Rasmussen TE, a Khan M, Midwinter MJ, Blackbourne LH, Garner JP. Resuscitative thoracotomy following wartime injury. J Trauma Acute Care Surg. 2013;74(3):825–9.
Eastridge BJ, Hardin M, Cantrell J, Oetjen-Gerdes L, Zubko T, Mallak C, Wade CE, Simmons J, Mace J, Mabry R, Bolenbaucher R, Blackbourne LH. Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma. 2011;71(1 Suppl):S4–8.
Mercer S, Park C, Tarmey N. Human factors in complex trauma. Contin Educ Abaesthesia Crit Care Pain. 2014;15(5):231–6.
Arul G, Pugh H, Mercer S, Midwinter M. Human factors in decision making in major trauma in Camp Bastion, Afghanistan. Ann R Coll Surg Engl. 2015;97:262–268.
Coats TJ, Keogh S, Clark H, Neal M. Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series. J Trauma. 2001;50(4):670–3.
Dayama A, Sugano D, Spielman D, Stone ME, Kaban J, Mahmoud A, Mcnelis J. Basic data underlying clinical decision-making and outcomes in emergency department thoracotomy: tabular review. ANZ J Surg. 2016;86(1–2):21–26.
Narvestad JK, Meskinfamfard M, Soreide K. Emergency resuscitative thoracotomy performed in European civilian trauma patients with blunt or penetrating injuries: a systematic review. Eur J Trauma Emerg Surg. 2016;42(6):677–85.
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Nevins, E.J., Bird, N.T.E., Malik, H.Z. et al. A systematic review of 3251 emergency department thoracotomies: is it time for a national database?. Eur J Trauma Emerg Surg 45, 231–243 (2019). https://doi.org/10.1007/s00068-018-0982-z
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DOI: https://doi.org/10.1007/s00068-018-0982-z