Appropriate Use of Emergency Department Thoracotomy: Implications for the Thoracic Surgeon

Appropriate Use of Emergency Department Thoracotomy: Implications for the Thoracic Surgeon Nathan M. Mollberg, DO, Cavin Glenn, MD, Jobin John, MD, Stephen R. Wise, MD, Ryan Sullivan, MD, Amir Vafa, MD, Norman J. Snow, MD and Malek G. Massad, MD Department of Surgery, Divisions of Trauma and Cardiothoracic Surgery, Mount Sinai Hospital and the University of Illinois at Chicago, Chicago, Illinois Background. Practice guidelines for the appropriate use of emergency department thoracotomy (EDT) according to current national resuscitative guidelines have been developed by the American College of Surgeons Committee on Trauma (ACS-COT) and published. At an urban level I trauma center we analyzed how closely these guidelines were followed and their ability to predict mortality. Methods. Between January 2003 and July 2010, 120 patients with penetrating thoracic trauma underwent EDT at Mount Sinai Hospital (MSH). Patients were separated based on adherence (group 1, n 70) and nonadherence (group 2, n 50) to current resuscitative guidelines, and group survival rates were determined. These 2 groups were analyzed based on outcome to determine the effect of a strict policy of adherence on survival. Results. Of EDTs performed during the study period, 41.7% (50/120) were considered outside current guidelines. Patients in group 2 were less likely to have traditional predictors of survival. There were 6 survivors in group 1 (8.7%), all of whom were neurologically intact; there were no neurologically intact survivors in group 2 (p 0.04). The presence of a thoracic surgeon in the operating room (OR) was associated with increased survival (p 0.039). Conclusions. A policy of strict adherence to EDT guidelines based on current national guidelines would have accounted for all potential survivors while avoiding the harmful exposure of health care personnel to bloodborne pathogens and the futile use of resources for trauma victims unable to benefit from them. Cardiothoracic surgeons should be familiar with current EDT guidelines because they are often asked to contribute their operative skills for those patients who survive to reach the OR. (Ann Thorac Surg 2011;92:455 61) 2011 by The Society of Thoracic Surgeons Reported survival rates for emergency department thoracotomy (EDT) have varied significantly in the literature, ranging from 2% to 31%, as a result of the various circumstances under which it was considered appropriate [1 22]. Predictors of EDT survival were therefore described in order to maximize survival while minimizing the associated risks of EDT to health care workers and unnecessary costs to the hospital. The type of penetrating injury, injury mechanism, anatomic location of injury, the presence or absence signs of life in the field or emergency department (ED), obtainable vital signs, presenting cardiac rhythm, Glasgow Coma Scale score, and the severity of injury based on scoring systems have all been identified as predictors of survival after EDT [1 22]. A number of guidelines have since been published taking these predictors into account in order to direct the use of EDT toward those patients who are potentially salvageable [23 25]. Accepted for publication April 6, 2011. Presented at the Poster Session of the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31 Feb 2, 2011. Address correspondence to Dr Mollberg, Department of Surgery, Mount Sinai Hospital, 15th at California Ave, Chicago IL, 60608; e-mail: nathan.mollberg@gmail.com. However the ability of these guidelines to predict mortality has not been reported to our knowledge. The purpose of the current study was to determine whether a proposed EDT policy based on current resuscitative guidelines can predict mortality for patients arriving at the hospital in extremis from penetrating thoracic trauma. In addition we wished to determine if the presence of a board-certified thoracic surgeon in the operating room (OR) was associated with increased survival. Patients and Methods After Institutional Review Board approval (MSH-10-09) at our institution, a retrospective review of all patients undergoing EDT secondary to penetrating trauma at Mount Sinai Hospital (MSH) from January 1, 2003 to July 1, 2010 was conducted. Cases were identified by review of the prospectively managed MSH Trauma Registry. Only patients undergoing EDT for penetrating trauma were included in the analysis. Exclusion criteria included EDT for blunt trauma, EDT for extrathoracic trauma, resuscitative thoracotomies performed in the operating room (OR), and patients with incomplete prehospital informa- 2011 by The Society of Thoracic Surgeons 0003-4975/$36.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2011.04.042

456 MOLLBERG ET AL Ann Thorac Surg EMERGENCY DEPARTMENT THORACOTOMY GUIDELINES 2011;92:455 61 Table 1. Currently Accepted Indications and Contraindications for Use of EDT in Penetrating Thoracic Trauma Indications Contraindications Patients sustaining witnessed cardiac arrest from penetrating thoracic trauma with signs of life in the field and 15 minutes of unsuccessful prehospital CPR Patients sustaining witnessed cardiac arrest from penetrating thoracic trauma without signs of life in the field Patients sustaining witnessed cardiac arrest from penetrating thoracic trauma with signs of life in the field and 15 minutes of unsuccessful prehospital CPR CPR cardiopulmonary resuscitation; EDT emergency department thoracotomy. (Data from Schwab and associates [17].) tion. Data collected from prehospital records included patient demographics; mechanism of injury; injury location; elapsed time before the hospital was reached; use of cardiopulmonary resuscitation (CPR) before reaching the hospital; presence of signs of life, defined as spontaneous movement, spontaneous respirations, organized electrocardiographic activity, palpable pulse, or pupillary response; obtainable vital signs such as respiratory rate, measureable blood pressure, or palpable pulse; Glasgow Coma Scale score; use of epinephrine; and the number of patients intubated. Data collected from hospital records included initial electrocardiographic rhythm, presence of obtainable vital signs, presence of signs of life, New Injury Severity Score (NISS), time from loss of vital signs to EDT, units of packed red blood cells given, liters of crystalloid administered, dose of epinephrine given, location of injury, disposition from the ED, overall survival, and neurologically intact survival. Patients who had an operation that lasted 30 minutes or longer were considered to have survived to reach the OR. Patients were separated into 2 groups based on whether an EDT was performed within (group 1) or outside (group 2) the proposed guidelines for the appropriate use of EDT (Table 1) [26]. Group 1 consisted of patients who had signs of life in the field and presented within 15 minutes after the start of CPR or those presenting to the ED with signs of life who subsequently had EDT performed. Group 2 consisted of patients who were found by emergency medical services (EMS) personnel to be apneic and pulseless in the field and without other signs of life or patients who had 15 minutes or more of prehospital CPR and no signs of life on presentation to the ED who subsequently had EDT performed (Fig 1). Outcomes analyzed included survival to the hospital, overall survival, and neurologically intact survival at the time of hospital discharge. Mount Sinai Hospital is an inner-city, level I trauma center located in Chicago, Illinois. All thoracotomies were performed immediately on arrival to the ED for patients in prehospital traumatic cardiac arrest or on loss of pulse for those having cardiac arrest in the ED. In all cases the initial incision was a left anterolateral thoracotomy through the fourth or fifth intercostal space with selective transsternal extension to a bilateral thoracotomy (clamshell) if further exposure was needed. Patients saved with EDT were brought emergently to the OR for definitive repair. Consultation with a thoracic surgeon was based on the clinical judgment of the on-call general trauma surgeon. Data were entered into SPSS (Statistical Package for the Social Sciences, Version 16.0.0, SPSS, Inc, Chicago, IL). Comparisons among guideline groups were made using a Student s t test for continuous variables and a Fischer s exact test for categorical variables. A p value of less than or equal to 0.05 was considered statistically significant. Results During the study period, 201 patients undergoing resuscitative thoracotomy were identified from the MSH Fig 1. Emergency department thoracotomy (EDT) algorithm based on current resuscitative guidelines for penetrating trauma. (CPR cardiopulmonary resuscitation; ECG electrocardiogram)

Ann Thorac Surg MOLLBERG ET AL 2011;92:455 61 EMERGENCY DEPARTMENT THORACOTOMY GUIDELINES Trauma Registry. Of those patients, 120 met inclusion criteria. Exclusions were due to resuscitative thoracotomy performed in the OR in 16 patients, incomplete prehospital information in 13 patients, EDT secondary to blunt trauma in 5 patients, and EDT secondary to extrathoracic trauma in 47 patients. Patient demographic and clinical characteristics are depicted in Table 2. The majority of injuries were cardiac (76/120, 63.3%), with the left ventricle (45/120, 37.5%) being most commonly injured. Review of prehospital information from EMS personnel showed that 89 (74.2%) patients had signs of life and 58 (48.3%) had obtainable vital signs in the field, whereas 78 (65.0%) patients underwent prehospital CPR. Review of hospital data showed that 79 (65.8%) patients had signs of life and 37 (30.8%) had obtainable vital signs in the ED, respectively. The mean SD time from loss of vital signs to performance of EDT for the entire study population was 23.1 9.6 minutes. Overall 33 (27.5%) patients survived to reach the OR and 7 (5.8%) patients survived to hospital discharge, with 6 (5.0%) neurologically intact. Patients in group 1 and group 2 were compared regarding the prehospital and hospital parameters described earlier (Table 3). Group 2 patients were more likely to have cardiac injury (p 0.007) and a higher NISS (55.6 23.1 versus 42.7 23.2; p 0.003), and on average they received more epinephrine en route (p 0.005), whereas patients in group 1 were more likely to have a pulmonary hilar injury (p 0.019). With regard to outcome, patients in group 1 were more likely to survive to reach the OR (p 0.001). Furthermore there were 6 neurologically intact survivors in group 1 (8.6%) and no neurologically intact survivors in group 2 (p 0.040). There were 33 (27.5%) patients who survived to reach the OR. Clinical indicators for these patients were compared on the basis of whether a board-certified thoracic surgeon was present in the OR (16/33 patients, 48.5%) or not (17/33 patients, 51.5%) (Table 4). There was no difference between the 2 groups with respect to patient demographics, injury mechanism or location, prehospital physiologic status, ED resuscitation, or ED physiologic status. The presence of a thoracic surgeon in the OR was associated with increased survival to hospital discharge (p 0.039). Comment Table 2. Clinical Characteristics Overall Variable n (%) 120 Demographics Age, mean SD 28.2 10.0 Sex (male) 112 (93.3) Injury mechanism and anatomy Gunshot wound 99 (82.5) Cardiac injury 76 (63.3) Left ventricle 45 (37.5) Right ventricle 31 (25.8) Right atrium 20 (16.7) Left atrium 4 (3.3) Great vessel injury 26 (21.7) Superior vena cava 7 (5.8) Subclavian artery 9 (7.5) Aorta 10 (8.3) Lung hilum injury 31 (25.8) Prehospital physiologic status Field signs of life 89 (74.2) Obtainable field vital signs 58 (48.3) Prehospital CPR 78 (65.0) Prehospital CPR time, a mean SD 17.0 8.8 Field Glasgow Coma Score, mean SD 4.4 3.5 Time at scene of injury, mean SD 12.0 6.2 Transport time, mean SD 8.9 5.5 Prehospital care Intubation overall 92 (76.7) Intubation for those receiving prehospital CPR 67 (85.9) Advanced Cardiac Life Support drugs given to 72 (92.3) those receiving prehospital CPR ED physiologic status ED signs of life 79 (65.8) Obtainable ED vital signs 37 (30.8) Initial ED cardiac rhythms Sinus rhythms 24 (20.0) Pulseless electrical activity 52 (43.3) Asystole 44 (36.7) NISS, mean SD 48.1 23.9 ED resuscitation Time from loss of vitals to EDT 23.1 9.6 Units of packed red blood cells given 2.7 1.9 Liters of crystalloid given 3.2 1.7 Doses of epinephrine given 4.3 3.0 Outcomes Survival until OR 33 (27.5) Survival until hospital discharge 7 (5.8) Neurologically intact hospital survival 6 (5.0) a Mean times are only for patients who underwent prehospital CPR. 457 All values are given as n (%) or mean SD unless otherwise specified. CPR cardiopulmonary resuscitation; ED emergency department; EDT emergency department thoracotomy; NISS New Injury Severity Score; OR operating room. Guidelines that identify patients in whom mortality can be predicted were published as early as 2001 [23]. These early guidelines stipulate that EDT is best applied to patients sustaining penetrating cardiac injuries who arrive at trauma centers after a short scene and transport time with witnessed or objectively measured physiologic parameters (signs of life). These guidelines are vague however with regard to the definition of short scene and transport time, and what to do with patients in whom signs of life may have been present but are subsequently lost (or vice versa). Hopson and colleagues added further clarification as to which patients should have resuscitation withheld or terminated, stating that patients should be assessed for signs of life, If any of these signs are present, the patient should have resuscitation performed

458 MOLLBERG ET AL Ann Thorac Surg EMERGENCY DEPARTMENT THORACOTOMY GUIDELINES 2011;92:455 61 Table 3. Guideline Adherence Comparison Variable Group 1 (Adherence) Group 2 (Nonadherence) p Value n (%) 70 (58.3) 50 (41.7) Demographics Age, mean SD 28.6 10.1 27.5 10.1 0.558 Gender (male) 66 (94.3) 46 (92.0) 0.718 Injury mechanism and anatomy Gunshot wound 56 (80.0) 43 (86.0) 0.470 Cardiac injury 37 (52.9) 39 (78.0) 0.007 a Left ventricle 24 (34.3) 21 (42.0) 0.446 Right ventricle 17 (24.3) 14 (28.0) 0.677 Right atrium 12 (17.1) 8 (16.0) 1.000 Left atrium 1 (1.4) 3 (6.0) 0.307 Great vessel injury 18 (25.7) 8 (16.0) 0.263 Superior vena cava 4 (5.7) 3 (6.0) 1.000 Subclavian artery 8 (11.4) 1 (2.0) 0.078 Aorta 6 (8.6) 4 (8.0) 1.000 Pulmonary hilar injury 24 (34.3) 7 (14.0) 0.019 a Prehospital physiologic status Signs of life in field 70 (100) 19 (38.0) 0.001 a Obtainable vital signs in field 52 (74.3) 6 (12.0) 0.001 a Prehospital CPR 34 (48.6) 44 (88.0) 0.001 a Prehospital CPR time, c mean SD 13.3 10.9 20.7 6.9 0.001 b Glasgow Coma Score in field, mean SD 5.3 4.3 3.0 0.3 0.001 b Time at scene of injury, mean SD 11.1 5.2 13.3 7.3 0.056 Transport time, mean SD 8.2 4.1 9.7 7.9 0.178 Prehospital care Intubation overall 50 (71.4) 42 (84.0) 0.129 Intubation of those receiving prehospital CPR 30 (90.9) 37 (84.1) 0.747 Epinephrine given to those receiving prehospital CPR 28 (82.4) 44 (100) 0.005 a ED physiologic status Signs of life in ED 59 (84.3) 20 (40.0) 0.001 a Obtainable vital signs in ED 34 (48.6) 3 (6.0) 0.001 a Initial cardiac rhythms in ED Sinus rhythms 23 (32.9) 1 (2.0) 0.001 a Pulseless electrical activity 36 (51.4) 16 (32.0) 0.041 a Asystole 11 (15.7) 33 (66.0) 0.001 a NISS, mean SD 42.7 23.2 55.6 23.1 0.003 a Resuscitation in ED Time from loss of vital signs to EDT 22.0 11.6 23.6 7.7 0.397 Units of packed red blood cells given 3.0 1.9 2.4 1.7 0.078 Liters of crystalloid given 3.4 1.8 3.0 1.7 0.222 Doses of epinephrine given 3.9 2.9 4.9 3.0 0.067 Outcomes Survival until arrival to OR 29 (41.4) 4 (8.0) 0.001 a Survival until hospital discharge 6 (8.6) 1 (2.0) 0.237 Neurologically intact hospital survival 6 (8.6) 0 0.040 a a Fischer s exact test. b Student s t test. c mean times are only for patients who underwent prehospital CPR. All values are given as n (%) or mean SD unless otherwise specified. CPR cardiopulmonary resuscitation; ED emergency department; EDT emergency department thoracotomy; NISS New Injury Severity Score; OR operating room. and be transported to the nearest emergency department or trauma center. If these signs of life are absent, resuscitation efforts may be withheld [24]. They further stated that termination of resuscitation efforts should be considered in trauma patients with EMS-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resus-

Ann Thorac Surg MOLLBERG ET AL 2011;92:455 61 EMERGENCY DEPARTMENT THORACOTOMY GUIDELINES Table 4. Operating Room Comparison With and Without the Presence of a Thoracic Surgeon Variable Overall Thoracic Surgeon Present Thoracic Surgeon Not Present p Value Cases, n (%) 33 16 (48.5) 17 (51.5) Demographics Age 27.6 9.2 28.1 10.3 27.1 8.3 0.761 Gender (male) 30 (90.9) 15 (93.8) 15 (88.2) 1.000 Injury mechanism and anatomy Gunshot wound 22 (66.7) 10 (62.5) 12 (70.6) 0.721 Cardiac injury 16 (48.5) 8 (50.0) 8 (47.1) 1.000 Left ventricle 7 (21.2) 3 (18.8) 4 (23.5) 1.000 Right ventricle 8 (24.2) 6 (37.5) 2 (11.8) 0.118 Right atrium 0 0 0... Left atrium 1 (3.0) 1 (6.3) 0 0.485 Great vessel injury 8 (24.2) 3 (18.8) 5 (29.4) 0.434 Superior vena cava 1 (3.0) 1 (6.3) 0 0.485 Subclavian artery 6 (18.2) 2 (12.5) 4 (23.5) 0.656 Aorta 1 (3.0) 0 1 (5.9) 0.485 Lung hilum injury 12 (30.3) 7 (43.8) 5 (29.4) 0.732 Prehospital physiologic status Signs of life in field 30 (90.9) 15 (93.8) 15 (88.2) 1.000 Obtainable vital signs in field 27 (81.8) 14 (87.5) 13 (76.5) 0.656 Prehospital CPR 16 (48.5) 7 (43.8) 9 (52.9) 0.732 Prehospital CPR time a 13.6 9.5 11.1 8.1 15.8 10.6 0.164 Glasgow Coma Scale score in field 7.1 5.2 7.6 5.5 6.6 5.2 0.595 Time at scene of injury 12.2 4.4 11.8 5.5 12.7 5.3 0.636 Transport time 9.7 7.5 8.3 3.9 11.1 9.7 0.291 Hospital physiologic status Signs of life in ED 31 (93.9) 16 (100) 15 (88.2) 0.485 Obtainable vital signs in ED 25 (75.8) 14 (87.5) 11 (64.7) 0.225 Initial cardiac rhythms in ED Sinus rhythms 17 (51.5) 9 (56.3) 8 (47.1) 0.732 Pulseless electrical activity 12 (36.4) 5 (31.3) 7 (41.2) 0.721 Asystole 4 (12.1) 2 (12.5) 2 (11.8) 1.000 NISS, mean SD 41.5 22.1 39.9 22.0 42.9 22.8 0.703 Resuscitation in ED Time from loss of vital signs to EDT 8.5 11.9 9.4 13.5 7.6 10.4 0.670 Time from loss of vital signs to arrival at OR 26.0 16.0 25.7 17.2 26.3 15.3 0.916 Units of packed red blood cells given 3.9 1.8 3.6 1.5 4.3 2.0 0.266 Liters of crystalloid given 4.3 1.8 4.5 1.9 4.2 1.8 0.645 Doses of epinephrine given 3.7 3.0 3.6 3.0 3.9 3.3 0.787 EDT performed within current guidelines 29 (87.9) 14 (87.5) 15 (88.2) 1.000 Outcomes Survival until hospital discharge 7 (21.2) 6 (37.5) 1 (5.9) 0.039 b Neurologically intact hospital survival 6 (18.2) 5 (31.3) 1 (5.9) 0.085 459 a Mean times are only for patients who underwent prehospital CPR. b Fischer s exact test. All the values are given as n (%) or mean SD unless otherwise specified. CPR cardiopulmonary resuscitation; ED emergency department; EDT emergency department thoracotomy; OR operating room. citation and cardiopulmonary resuscitation (CPR). [24] The group at the University of Colorado and their nearly 33-year history of providing data on EDT then proposed a working algorithm directing the use of EDT for those with penetrating trauma that was compatible with the national guidelines [25, 26]. The findings from this current urban level I trauma center study demonstrate the ability of these guidelines to predict mortality based on prehospital physiologic status. Furthermore during the writing of this article, a prospective multiinstitutional study demonstrated similar results with regard to defining the limits of EDT for penetrating trauma [27]. These findings are important in that they allow health care personnel to avoid the inherent risks involved with the

460 MOLLBERG ET AL Ann Thorac Surg EMERGENCY DEPARTMENT THORACOTOMY GUIDELINES 2011;92:455 61 performance of EDT without excluding any potential survivors. Of the 120 EDTs performed for penetrating thoracic trauma over the study period, 41.7% (50/120) were considered to have been performed outside current resuscitative guidelines. There are a variety of reasons that may explain this result. Many EDT policies are based on institution-specific practice guidelines [1, 3 8, 11 13, 15 19]. At MSH the indications to perform EDT for penetrating trauma for the study period state that EDT is appropriate if there is any history of any signs of life either at the scene of injury or on admission to the ED. Using this institutional policy as a reference, 88.3% (106/ 120) of the EDTs during the study period were indicated. Furthermore because of the retrospective nature of the current study we are not able to account for differences between the written record and what may have been communicated to the trauma team by EMS personnel. Reluctance of institutions to adopt national guidelines might reflect doubt regarding their applicability on the local level or doubt regarding their ability to predict mortality and the fear of excluding a potential survivor by withholding EDT [28]. Further research will be needed to determine the institutional, patient, and emotional factors (among others) that may contribute to the decisionmaking process of performing EDT either within or outside the currently accepted indications. It has been demonstrated that trauma surgeons are capable of rendering definitive surgical care for major thoracic injuries secondary to penetrating trauma [29]. However in a survey of 515 level I/III trauma centers nationwide, only 9.5% (49/515) reported that their trauma surgeons performed the full compliment of vascular, thoracic, and abdominal operations [30]. Furthermore a thoracic surgeon s assistance was reported as being needed by 50% of trauma groups responding for the performance of pulmonary lobectomy, 36% for pulmonotomy, and 38% for cardiac repair. These results indicate a high level of thoracic surgeon involvement when dealing with thoracic trauma. Of the 33 patients who survived to reach the OR in this series, 16 (48.5%) were operated on by thoracic surgeons. Furthermore of the 6 neurologically intact survivors discharged from the hospital, 5 (83.3%) were operated on by thoracic surgeons. This is despite the patients being similar with regard to demographics, mechanism of injury, prehospital physiologic status, ED physiologic status, ED resuscitation, and patient selection (ie, patients who underwent EDT within or outside current guidelines). Although patients operated on by a thoracic surgeon experienced greater survival, it is difficult to make any conclusions based on this result. Although NISS was similar between patients who were and those who were not operated on by thoracic surgeons, this alone does not adequately account for patient selection bias and we are reliant on the operative reports to identify what may have contributed to this finding. Similar approaches to the repair of cardiac lacerations, lung hilum injuries, and great vessel injuries between the thoracic and general trauma surgeons were identified. There were no instances in which a patient was placed on cardiopulmonary bypass. Of the 16 cases in which a thoracic surgeon was present, the operative reports were able to identify 7 cases in which they were the sole surgeon, 5 cases in which both the thoracic and trauma surgeons attended to the patient in the OR from the beginning of the operation, and 4 cases in which the thoracic surgeon arrived after the trauma surgeon has already started the operative procedure. However of the 6 survivors in the subpopulation in which a thoracic surgeon was present, they were the only attending surgeon present in 5 of these cases and were identified as performing the definitive repair in the sixth case. In conclusion, this series demonstrates that current guidelines regarding the use of EDT for penetrating thoracic trauma are able to reliably predict mortality based on prehospital physiologic status. 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