Emergency department thoracotomy following injury: Critical determinants for patient salvage

The role of emergency department (ED) thoracotomy in resuscitation of the moribund trauma patient remains ill-defined. The purpose of this article is to analyze our experience during the past decade in order to elucidate prognostic features enabling a more cost-effective application of this heroic measure. Injury mechanism in the 632 ED thoracotomies performed in our trauma consortium consisted of blunt (BLT) in 50%, gunshot wounds (GSW) in 35%, and stab wounds (SW) in 15%. Mean patient age was 31 years, and 76% were men. Twenty-nine (5%) of the patients were ultimately discharged alive from the hospital. Outcome was analyzed on the basis of physiologic status at presentation to the ED: group I, n=481 (76%), presented without signs of life (SL); group II, n=38 (6%), presented with SL (pupillary response), but without vital signs (VS); and group III, n=113 (18%), presented with VS. Survival without SL was 10% of SW, 1% of GSW, and 1% of BLT. When VS were present, patient salvage was 32% following SW, 15% following GSW, and 5% after blunt trauma. Five of 15 survivors without SL had irreversible cerebral damage; whereas, 13 of the 14 survivors with VS had no permanent neurologic sequelae. This experience underscores the rationale for selective application of ED thoracotomy done for postinjury resuscitation; functional salvage of the blunt trauma victim arriving lifeless is nil while nearly one-third of patients in extremis from a thoracic SW can be returned to their preinjury state.