A guest post by Matthew DeLaney, Assistant Program Director of the University of Alabama at Birmingham Emergency Medicine residency.
For most providers, there is a limited but well delineated role for emergency department thoracotomy (EDT) in patients with penetrating trauma. The potential role for EDT in blunt trauma patients is much less clear. In a recent meta-analysis, Slessor et al. included 13 studies consisting of 1369 patients who underwent EDT after blunt trauma.
Overall most of the patients who underwent a thoracotomy did poorly, with only 21(1.5%) patients having a good neurologic outcome. The highest rate of survival was found in patients who had vital signs either in the field or in the emergency department. All patients who experienced good neurologic outcomes had vital signs in the emergency department. Patients who have vital signs in the field but he did not have vital signs in the emergency department had lower rates of survival and worse neurologic outcomes compared to the patients who had signs of life in the ED.
Time to EDT seemed to play a role in terms of improving patient outcomes. The authors note one instance where an EDT was performed after 136 minutes of CPR, not surprisingly this patient did not have a good outcome. When looking at patient’s who underwent CPR, all patients who experienced good outcomes received less than 15 minutes of CPR before undergoing an EDT. Patients with no signs of life at any point did poorly with a reported survival rate of 0.4% with a 100% rate of bad neurologic outcomes.
While authors of the study concluded that the chances of survival with a good outcome were approximate 1.5%, this may not be applicable to most emergency medicine trained providers. Most of the included studies involved procedures performed by surgeons at large trauma centers, in fact only 1 study included EDT performed by emergency medicine providers. Unfortunately this study included a small number of cases with no reported survivors. Even under ideal circumstances if we look at cases where we as emergency department providers could be expected to make a critical intervention, (cardiac tamponade / penetrating cardiac injury) the rate of survival with good outcomes is closer to 0.07% (4/1369).
When performed by surgeons in large trauma centers, the EDT may be a reasonable “hail-mary” for a blunt trauma patient who is actively dying. Despite being the largest study to date on this subject, this study provides essentially no evidence to support the use of EDT by emergency trained providers. Given the invasive nature of the EDT, there is a very real risk of harm to the providers and staff from needle/scalpel injuries and exposure to broken ribs and blood. As with other seldom performed heroic procedures, there may be a clinical scenario where EDT by an emergency medicine provider is effective.When treating a patient in cardiac arrest from a blunt trauma, providers need to balance the potential risk of harm to provider and staff before performing an invasive procedure with a very low chance of success.
“To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis.”
http://www.ncbi.nlm.nih.gov/pubmed/25443990