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The Role of Emergency Department Thoracotomy in Patients with Cranial Gunshot Wounds.
Journal of Trauma and Acute Care Surgery 2024 Februrary 21
BACKGROUND: Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low.
METHODS: We used Pennsylvania Trauma Outcomes Study (PTOS) data, 2002-2021, and included EDTs for GSWs. We defined EDT by ICD codes for thoracotomy or procedures requiring one, with a location flagged as ED. We defined head injuries as any head abbreviated injury scale (AIS) ≥1 and severe head injuries as head AIS ≥ 4. Head injuries were "isolated" if all other body regions AIS < 2. Descriptive statistics were performed. Discharge functional status was measured in 5 domains.
RESULTS: Over 20 years in Pennsylvania, 3,546 EDTs were performed, 2,771 (78.1%) for penetrating injuries. Most penetrating EDTs (2,003, 72.3%) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head-injured (n = 94/1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound - 0% (0/81) with a severe head injury (p = 0.035 vs no severe head injury), and 4.5% (5/110) with a non-severe head injury. Of the 5 head-injured survivors, 2 were fully dependent for transfer mobility, and 3 were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation.
CONCLUSIONS: Though there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head-injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued.
LEVEL OF EVIDENCE: Level II, retrospective observational cohort study.
METHODS: We used Pennsylvania Trauma Outcomes Study (PTOS) data, 2002-2021, and included EDTs for GSWs. We defined EDT by ICD codes for thoracotomy or procedures requiring one, with a location flagged as ED. We defined head injuries as any head abbreviated injury scale (AIS) ≥1 and severe head injuries as head AIS ≥ 4. Head injuries were "isolated" if all other body regions AIS < 2. Descriptive statistics were performed. Discharge functional status was measured in 5 domains.
RESULTS: Over 20 years in Pennsylvania, 3,546 EDTs were performed, 2,771 (78.1%) for penetrating injuries. Most penetrating EDTs (2,003, 72.3%) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head-injured (n = 94/1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound - 0% (0/81) with a severe head injury (p = 0.035 vs no severe head injury), and 4.5% (5/110) with a non-severe head injury. Of the 5 head-injured survivors, 2 were fully dependent for transfer mobility, and 3 were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation.
CONCLUSIONS: Though there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head-injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued.
LEVEL OF EVIDENCE: Level II, retrospective observational cohort study.
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