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THORACIC TRAUMA
TRAUMA RESUSCITATION

 

 

Emergency Department Thoracotomy
Rationale

Overall survival of patients undergoing emergency thoracotomy is between 4 and 33% depending on the protocols used in individual departments.

The main determinants for survivability of an emergency thoracotomy are the mechanism of injury (stab, gunshot or blunt), location of injury and the presence or absence of vital signs.

Emergency Thoracotomy

Introduction
Indications
Rationale
Resuscitation
Operative technique
References
 

Mechanism of Injury

For penetrating thoracic injury the survival rate is fairly uniform at 18-33%, with stab wounds having a far greater chance of survival than gunshot wounds. Isolated thoracic stab wounds causing cardiac tamponade probably have the highest survival rate, approaching 70%. In contrast, gunshot wounds injuring more than one cardiac chamber and causing exsanguination have a much higher mortaility.

Blunt trauma survival rates vary between 0 and 2.5% and some authorities suggest that thoracotomy for blunt trauma should be abandoned altogether. However, this is an oversimplification of the literature. There is a distinct survival rate for patients with isolated blunt thoracic trauma who undergo emergency thoracotomy. This is highest for patients who are severely hypotensive in the emergency room and are exsanguinating from a chest injury. Blunt thoracic trauma causing traumatic arrest in the emergency department should also undergo thoracotomy. Whether this should be extended to those patients arresting in the presence of prehospital emergency services is debatable.

Location of Injury

Almost all survivors of emergency thoracotomy suffer isolated injuries to the thoracic cavity. Cardiac injuries have the highest survival rates, with improved outcome for single chamber versus multiple chamber injuries. Injuries to the great vessels and pulmonary hila carry a much higher mortality. Injuries to the chest wall rarely require emergency thoracotomy but tend to have a good outcome.

The rationale for performing thoracotomy for injury to other parts of the body, such as the abdomen or pelvis, is to cross-clamp the descending aorta and so control exsanguination and redistribute blood flow to the vital organs. Penetrating injury to the abdomen may benefit from this manoeuver but thoracotomy for multiple blunt trauma has an almost universally poor outcome.

Presence of vital signs

The presence of cardiac activity, or the amount of time since loss of cardiac activity is consistently related to the outcome following emergency thoracotomy. In one study of 152 patients (Tyburski) survival rates were 0% for those patients arresting at scene, 4% when arrest occurred in the ambulance, 19% for emergency department arrest and 27% for those who deteriorated but did not arrest in the emergency department.

Survival for blunt trauma patients who never exhibited any signs of life is almost uniformly zero. Survival for penetrating trauma patients without signs of life is between 0 and 5%.

Resuscitation
Karim Brohi, trauma.org 6:6, June 2001