Dennis Bradley M, Medvecz Andrew J, Gunter Oliver L, Guillamondegui Oscar D
Division of Trauma and Acute Care Surgery, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, 1211 21st Avenue S, 404 Medical Arts Building, Nashville, TN, 37212, USA.
Department of General Surgery, Vanderbilt Medical Center, Vanderbilt University School of Medicine, Nashville, TN, USA.
Am J Surg. 2016 Sep;212(3):440-5. doi: 10.1016/j.amjsurg.2015.10.031. Epub 2016 Jan 9.
There continues to be significant debate in the trauma community regarding the indications for emergency department thoracotomy (EDT). Numerous studies have focused on the duration of arrest in EDT, whereas few have examined other factors that influence surgeon decision-making. We hypothesize that there is continued variability among surgeons in the use of EDT.
A 13-question web-based survey was distributed to the membership of a large, national trauma association, examining demographics, trauma fellowship completion, trauma center designation, professional organization membership, and annual EDTs performed. Consideration of patient's age, comorbidities, total injury burden, and the use of technological adjuncts-such as ultrasound-was assessed. Respondents were asked when they would perform the procedure after loss of vital signs for blunt and penetrating trauma. Logistic regression determined factors influencing consideration of EDT.
Overall 540 of 1,485 surveys were completed (36.4%). Patient age, total injury burden, and comorbidities are considered by 38.5%, 29.1%, and 55.7% of respondents, respectively. Technological adjuncts are used always or most of the time by 64% of respondents. A majority of respondents (51.9%) would perform an EDT for penetrating trauma with loss of vital signs 5 to 10 minutes before arrival. For blunt trauma, the largest group of respondents (47.0%) would perform an EDT only when loss of vital signs occurred in the ED. In addition, 20.6% would never perform EDT for blunt traumatic arrest.
EDT decision-making is more nuanced than previously described. Variation continues in the use of thoracotomy after loss of vital signs, in both blunt and penetrating trauma. For both mechanisms, there remains little consensus on the appropriate duration of arrest before performing EDT after arrest despite published guidelines. A large proportion of surgeons consider other factors such as patient age, total injury burden, and comorbidities in addition to vital signs when deciding to perform an EDT. Technological adjuncts are frequently used by surgeons to determine the need for EDT.
创伤学界对于急诊开胸手术（EDT）的适应症仍存在重大争议。众多研究聚焦于急诊开胸手术中患者心跳骤停的持续时间，而很少有研究探讨影响外科医生决策的其他因素。我们推测外科医生在急诊开胸手术的使用上仍存在差异。
向一个大型全国性创伤协会的成员发放了一份包含13个问题的网络调查问卷，调查内容包括人口统计学信息、创伤专科培训完成情况、创伤中心指定情况、专业组织成员身份以及每年进行的急诊开胸手术数量。评估了对患者年龄、合并症、总损伤负担以及技术辅助手段（如超声）的使用情况的考量。询问受访者在钝性和穿透性创伤导致生命体征丧失后何时会进行该手术。逻辑回归分析确定了影响急诊开胸手术考量的因素。
总共1485份调查问卷中，有540份完成（36.4%）。分别有38.5%、29.1%和55.7%的受访者会考虑患者年龄、总损伤负担和合并症。64%的受访者总是或大部分时间使用技术辅助手段。大多数受访者（51.9%）会在穿透性创伤导致生命体征丧失且在到达前5至10分钟时进行急诊开胸手术。对于钝性创伤，最大比例的受访者（47.0%）仅在急诊室出现生命体征丧失时才会进行急诊开胸手术。此外，20.6%的受访者永远不会对钝性创伤导致的心跳骤停进行急诊开胸手术。
急诊开胸手术的决策比之前描述的更为细致入微。在钝性和穿透性创伤导致生命体征丧失后，开胸手术的使用仍存在差异。对于这两种创伤机制，尽管有已发表的指南，但在心跳骤停后进行急诊开胸手术前的适当心跳骤停持续时间方面仍几乎没有共识。很大一部分外科医生在决定进行急诊开胸手术时，除了生命体征外，还会考虑其他因素，如患者年龄、总损伤负担和合并症。外科医生经常使用技术辅助手段来确定是否需要进行急诊开胸手术。
