Urgent and emergent thoracotomy for penetrating chest trauma

Riyad Karmy-Jones, Avery Nathens, Gregory J Jurkovich, David V Shatz, Susan Brundage, Mathew J Wall, Sandra Engelhardt, David B Hoyt, John Holcroft, M Margaret Knudson, Andrew Michaels, William Long
Journal of Trauma 2004, 56 (3): 664-8; discussion 668-9

BACKGROUND: Resuscitative thoracotomy (TCY) after trauma has an overall dismal survival rate, yet patients with isolated penetrating chest wounds have the best chance of meaningful recovery. Although the major factor in outcome is presenting physiology, the site of the TCY may influence survival, with the operating room offering a superior environment to the emergency room.

PURPOSE: The purpose of this study was to evaluate the impact of location of TCY on outcome after penetrating chest injury.

METHODS: This was a multicenter study of patients admitted with either stab (SW) or gunshot wound (GSW) to the chest, with systolic blood pressure < or = 90 mm Hg, and who underwent TCY within 60 minutes of arrival. Time to TCY, Injury Severity Score, location of TCY (emergency room, operating room, or resuscitation room), and detectable systolic pressure at admission were among the factors studied.

RESULTS: Over a 4-year period, 78 SW and 140 GSW victims underwent TCY. GSW victims had greater Injury Severity Scores (39.4 +/- 23.1 for GSW vs. 27.2 +/- 15.7 for SW, p < 0.001) and mortality (69% for GSW vs. 37% for SW, p < 0.001). No parameter studied was found to be significantly associated with survival after SW. After GSW, survival was 13.5 times more likely if TCY was performed in the resuscitation room (confidence interval, 3.3-54.6) and 22 times more likely if it was performed in the operating room (confidence interval, 6.7-73.7).

CONCLUSION: Although patient selection is the primary factor determining outcome, there may be an independent benefit for performing TCY after GSW in a specialized resuscitation room or the operating room.

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