Is 30 minutes the golden period to perform emergency room thoratomy (ERT) in penetrating chest injuries?

BACKGROUND

Emergency room thoracotomy (ERT), a controversial procedure, was introduced to improve resuscitation of trauma patients. No study has been conducted to evaluate the importance of the time in the field (down time) in the initial survival of penetrating chest trauma requiring ERT. In addition to this, many factors have been considered to predict the success of ERT, but they are multiple and are not easy to assess in the brief period of decision making to perform an ERT. We decided, therefore, to see if the pre hospital time could be used as the principal parameter to predict whether TERT in emergency Department (ED) with the arrival of penetrating chest trauma is useful.

METHODS

Records of the Howard University Hospital Emergency Department (ED) were reviewed for all trauma patients between June 1992 and January 1995. The pre-admission data were obtained from Emergency Medical Service (EMS) reports, including the "down time". All patients who underwent ERT had vital signs documented by EMS in the field. Forensic autopsies were performed within 48 hours after death following practice standards already described.

RESULTS

Between January 1987 and June 1994, 58 adult patients presented with penetrating chest trauma at the Howard University Hospital Emergency Department. Pre-admission data were available for 49 of 58 chest trauma patients. Sixteen patients (33%), with no documented vital signs in the field, were pronounced dead on arrival in the ED, and no ERT was performed on them. The remaining thirty-three patients (57%) underwent ERT. In all patients with chest injury, the Revised Trauma Score (RTS) was below 4 on arrival to the ED. Considering only the patients (n=33) that underwent ERT 82% (n=27) of patients had vital sings upon arrival in ED, 19% (n=6) had no vital signs until arrival to the ED. Patients with multiple wound GS or SW (more than four) died on arrival (18%; n=6). The patients with single gun shot wounds or stab wounds (GSW/SW) survived initially and underwent ERT (82%; n=27). Of the patients who underwent ERT, (n=6; 18%) had GSW and (12%), (n=4) had SW. Among those patients that died in ED, 12% (n=4) had a drop of SBP of more than 50 mmHg and only 24% (n=8) presented with a SBP less than 70 mmHg. Average scene time was 11.2+/-8.1 min, the transit time was 7.9+/-5.6 min and the average ED resuscitation time was 10+/-3.2 min. Of the patients that arrived in ED within 30 minutes 63% (n=20) survived the first 24 hours, and of these only 9% (n=3) had no vital signs upon arrival. The remaining 28% (n=6), who arrived in ED after half hour, either died during the transportation or upon arrival to the ED; none of them had vital signs upon arrival. All the patients transferred to the ICU died within 24 to 78 hr, secondary to severe arrhythmia or cerebral hypoxia. Autopsy was performed in all the patients. Among the patients that died upon arrival in the ED, the most common injury responsible for death was ventricular injury with exanguination in the first 24 hours. Of the 9% of patients that died in the ED after ERT, the injury was caused by a 9 mm caliber gun, which created a major laceration to the ventricle which was not possible to repair during the ERT. In the patients that died after stab wound (12%; n=4), the patients were stabbed at least 3 times in the chest and they died of arrhythmia. Among the survivors of ERT that were transported in ICU, uncontrollable arrhythmia and acute lung injury was the cause of death within 24-72 hours in 45% (n=15) of patients while cerebral hypoxia complicated irreparably the life expectancy with death at 72 hours in 60% (n=20) of patients.

CONCLUSIONS

The only role of ERT in our opinion is in patients who arrive within 30 minutes of pre hospital time, with a witnessed vital signed in the field. Multiple wounds, low SBP and higher caliber bullet injuries are also negative prognostic factors.