I must admit, this has been an interesting discussion regarding the usefulness of ER thoracotomies. I was also gald to see that someone finally began to look at the data available on the subject. Since I am a surgical resident in one of the busiest trauma centers in the country, I thought I might throw in my two cents worth.
Several points need to be emphasized. There are some clear cut things in medicine and surgery, however, the use of emergency department thoracotomy is not one of them. Usually when there are multiple studies over many years with widely varying results one can be sure there will be no clear answer. However, as the review by Rhee et al. indicates, there may be a way to break the patients down. Clearly, mechanism of injury and signs of life are the two key factors across the board for all studies involved. The person with the highest chance of walking out of the hospital after an ED thoracotomy is one who dies in the ED and has suffered a stab wound to the chest. This low energy mechanism makes repair of this type of injury much easier. The least likely person to survive is one who suffered blunt trauma, no matter the mechanism, who had signs of life in the field but died close to the hospital. The fact that patients suffering blunt trauma may have many more reasons to die (pelvic bleeding, severe head injury, etc) other than an isolated thoracic injury amenable to ED thoracotomy is the reason ED thoracotomy is less effective in this patient population. A recent study published in the Journal of Trauma by Tyburski et al from Wayne State University at the Detroit Receiving Hospital brings out another point. Of the 152 patients with an ED thoracotomy, 93 suffered gunshot wounds and none survived to walk out of the hospital. Of the remaining 59 patients, all of whom had stab wounds, 20% survived. Gunshot wounds are a high energy penetrating injury. This combination is likely to be lethal in a shot to the heart where the myocardium can suffer a severe contusion as well as penetration resulting in unsalvagable arrhythmias.
So, when discussing this subject it is important to stratify patients based on the mechanism of injury. Based on these and other data the indications for ED thoracotomy at our institution currently are:
1. Penetrating injury to the chest (either gunshot or stab) with signs of life within 5 minutes of arrival to the ED.
2. Blunt trauma with signs of life on arrival to the hospital and in whom cardiac rupture is suspected (either by signs of tamponade on physical exam or by ultrasound). In 99.9% of other cases, blunt trauma does not warrant an ED thoracotomy.
Two other brief points. When examining the literature one must look at it critically. With regard to that, in the reference sited from the Japanes journal of Thoraic and Cardiiovascular Surgery, the thoracotomies were performed in the OR not in the ED. This is much different. The patients were in shock on arrival and not yet dead. Second, there are cases in which the performance of an ED thoracotomy is not likely to result in a good outcome, however, it is undertaken anyway, especially at a teaching institution so that residents may learn the procedure. This, in my opinion, is justified since without practice when a patient arrives who is likely to survive an ED thoracotomy, he or she may die as a result of the ignorance to the procedure of their doctor.