From the Division of Traumatology (M.J.S.), Surgical Critical Care and Emergency Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Acute Care Surgery (E.R.H.), Department of Surgery (K.V.A.), the Johns Hopkins Hospital, Baltimore, Maryland; Trauma Services (R.R.B.), Legacy Emanuel and Randall Children's Hospitals, Portland, Oregon; R Adams Cowley Shock Trauma Center (W.C.C.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (C.J.D.), Emory University and Grady Memorial Hospital, Atlanta, Georgia; Division of Trauma (N.F.), Department of Surgery, Cooper University Hospital, Camden, New Jersey; Division of Trauma, Emergency Surgery, and Surgical Critical Care (R.S.J.), Stony Brook Medicine, Stony Brook, New York; Division of Trauma and Acute Care Surgery (K.K.), McGIll University Health Centre, Montreal, Quebec, Canada; Division of Trauma Surgery and Surgical Critical Care (J.K.L.), Department of Surgery, Advocate Christ Medical Center, Oak Lawn, Illinois; Department of Surgery (L.J.M.), University of Tennessee Health Science Center, Memphis, Tennessee; Departments of Emergency Medicine and Surgery (J.A.M.), Division of Trauma/Critical Care, Virginia Commonwealth University, Richmond, Virginia; Division of Trauma, Critical Care, Burns, and Acute Care Surgery (A.A.M.), Department of Surgery, Metrohealth Medical Center, Cleveland, Ohio; Division of Trauma, Critical Care and Acute Care Surgery (S.R.), Departments of Surgery and Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Division of Acute Care Surgery (K.B.T.), Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan; Division of Gastroenterology (Y.F.-Y.), Case and VA Medical Center, Case Western Reserve University, Cleveland, Ohio; and Division of Trauma, Critical Care, Burn, and Emergency Surgery (P.R.), Department of Surgery, University of Arizona, Tucson, Arizona.
J Trauma Acute Care Surg. 2015 Jul;79(1):159-73. doi: 10.1097/TA.0000000000000648.
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?
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.
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).
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.
Systematic review/guideline, level III.
在 GRADE（分级评估、制定与评价）框架内，我们进行了系统评价并制定了循证建议，以回答以下 PICO（人群、干预、对照、结局）问题：在出现危及生命的创伤（有和无穿透性胸部、胸外或钝性创伤后的生命迹象）后无脉的患者是否应接受急诊开胸手术（EDT）（与不进行 EDT 的复苏相比）以提高生存率和神经完整生存率？
所有接受 EDT 的患者均被纳入研究，而那些接受院前复苏性开胸手术或手术室开胸手术的患者则被排除在外。由于无法获得感兴趣的 PICO 问题的任何比较或对照组（即未接受 EDT 的类似患者的生存或神经完整生存数据），因此无法进行定量综合的荟萃分析。
72 项纳入的研究共纳入了 10238 名接受 EDT 的患者。在有生命迹象的穿透性胸部损伤后出现无脉的患者中，EDT 的结局最为有利（存活，853 例中的 182 例[21.3%]；神经完整存活，454 例中的 53 例[11.7%]）和无生命迹象（存活，920 例中的 76 例[8.3%]；神经完整存活，641 例中的 25 例[3.9%]）。在有生命迹象的穿透性胸外损伤后出现无脉的患者中，EDT 的结局更为有利（存活，160 例中的 25 例[15.6%]；神经完整存活，85 例中的 14 例[16.5%]）而无生命迹象（存活，139 例中的 4 例[2.9%]；神经完整存活，60 例中的 3 例[5.0%]）。有生命迹象的钝性损伤后出现无脉的患者接受 EDT 的结局有限（存活，454 例中的 21 例[4.6%]；神经完整存活，298 例中的 7 例[2.4%]），而无生命迹象的患者则预后不良（存活，995 例中的 7 例[0.7%]；神经完整存活，825 例中的 1 例[0.1%]）。
我们强烈建议有生命迹象的穿透性胸部损伤后出现无脉的患者接受 EDT。我们有条件地推荐 EDT 用于有生命迹象的穿透性胸部损伤后出现无脉和无生命迹象的患者，有或无生命迹象的穿透性胸外损伤后出现无脉的患者，或有生命迹象的钝性损伤后出现无脉的患者。最后，我们有条件地反对对无生命迹象的钝性损伤后无脉的患者进行 EDT。
系统评价/指南，III 级。
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