An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma

Mark J. Seamon, Elliott R. Haut, Kyle Van Arendonk, Ronald R. Barbosa, William C. Chiu, Christopher J. Dente, Nicole Fox, Randeep S. Jawa, Kosar Khwaja, J. Kayle Lee, Louis J. Magnotti, Julie A. Mayglothling, Amy A. McDonald, Susan Rowell, Kathleen B. To, Yngve Falck-Ytter, Peter Rhee

    Research output: Contribution to journalReview article

    110 Scopus citations

    Abstract

    BACKGROUND: Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival? METHODS: All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest. RESULTS: The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825). CONCLUSION: We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury. LEVEL OF EVIDENCE: Systematic review/guideline, level III.

    Original languageEnglish (US)
    Pages (from-to)159-173
    Number of pages15
    JournalJournal of Trauma and Acute Care Surgery
    Volume79
    Issue number1
    DOIs
    StatePublished - Jul 3 2015

    Keywords

    • Emergency department thoracotomy
    • evidence-based medicine
    • practice management guideline
    • resuscitative thoracotomy

    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

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  • Cite this

    Seamon, M. J., Haut, E. R., Van Arendonk, K., Barbosa, R. R., Chiu, W. C., Dente, C. J., Fox, N., Jawa, R. S., Khwaja, K., Lee, J. K., Magnotti, L. J., Mayglothling, J. A., McDonald, A. A., Rowell, S., To, K. B., Falck-Ytter, Y., & Rhee, P. (2015). An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 79(1), 159-173. https://doi.org/10.1097/TA.0000000000000648