Kennedy F, Sharif S
Trauma Office, Sharp Memorial Hospital, San Diego, California 92123, USA.
Am Surg. 2000 Jan;66(1):56-60.
Our objectives were to elucidate the postoperative complications in patients who have had emergency room thoracotomy (ERT), to define anatomic and physiologic parameters that are compatible with survival and to document the evolution of management of these patients. A single surgeon's experience over a 13-year period was reviewed. All patients where he was the primary or supervising surgeon for the ERT were included. Data were analyzed for mechanism (penetrating/blunt), hospital where performed, survival to intensive care unit, survival to discharge, and postoperative complications. Among survivors, data were analyzed for the anatomic injuries and the patients' physiologic condition in the field and on arrival. There were a total of 102 patients; penetrating injury 94 (92 percent); blunt, 8 (8 percent). Ten patients (10 percent) reached the intensive care unit alive. Three of the ten (30 percent) died at 2 hours, 12 hours, and 7 days postoperatively. Seven patients survived to hospital discharge. All seven had penetrating chest injuries and were not in cardiac arrest when first examined by paramedics. Four of the seven survivors (57 percent) had major complications. Survival for the early period was 1.6 percent (1/62) and for the later period 15 percent (6/40); P < 0.05. During the study period, changes in patient management included 1) for penetrating torso injury, withholding ERT when survival was extremely unlikely; 2) increased use of blood- and fluid-warming measures; 3) elimination of aortic cross-clamping, instead judiciously using manual compression; 4) making the main purpose of ERT the relief of cardiac tamponade; and 5) immediately controlling any cardiac injury with a simple running suture on a large needle. We conclude the following: 1) The postoperative course after ERT carried significant mortality and morbidity. 2) Compatibility with survival required both the absence of cardiac arrest when initially evaluated in the field and the presence of penetrating chest injury. 3) Significant changes occurred in patient management during this 13-year period. Survival was higher in the latter part of this period.
我们的目标是阐明接受急诊室开胸手术（ERT）患者的术后并发症，确定与生存相容的解剖和生理参数，并记录这些患者的治疗演变。回顾了一位外科医生13年期间的经验。纳入所有他作为ERT主刀或指导医生的患者。分析了机制（穿透性/钝性）、手术医院、重症监护病房生存率、出院生存率和术后并发症的数据。在幸存者中，分析了现场和到达时的解剖损伤和患者生理状况的数据。共有102例患者；穿透性损伤94例（92%）；钝性损伤8例（8%）。10例患者（10%）存活至重症监护病房。这10例中的3例（30%）分别在术后2小时、12小时和7天死亡。7例患者存活至出院。所有7例均为穿透性胸部损伤，急救人员首次检查时未发生心脏骤停。7例幸存者中的4例（57%）出现严重并发症。早期生存率为1.6%（1/62），后期为15%（6/40）；P<0.05。在研究期间，患者管理的变化包括：1）对于穿透性躯干损伤，当生存可能性极小时不进行ERT；2）增加血液和液体加温措施的使用；3）取消主动脉交叉钳夹，改为谨慎使用手动压迫；4）将ERT的主要目的改为缓解心脏压塞；5）立即用大针连续缝合控制任何心脏损伤。我们得出以下结论：1）ERT术后病程死亡率和发病率均很高。2）与生存相容需要在现场初步评估时无心脏骤停且存在穿透性胸部损伤。3）在这13年期间患者管理发生了重大变化。这一时期后期生存率更高。
