Emergency department thoracotomy (EDT). A 26-month experience using an "agonal" protocol.
EDT can be successfully performed with the proper system in place. This includes an established thoracotomy protocol, a well-integrated EMS system, and an in-house team. Time seems to be critical, and the time between injury and EDT may be the single most important factor affecting survival other than the mechanism of injury. Cardiac penetrations, especially stab wounds, were found to have a 93 per cent survival while subdiaphragmatic penetrations had only one survivor from a group of 18 patients (5.5%). The high rate of salvage in the heart wound group probably reflects the speed of prehospital transport, though all other major series have found this group to gain the maximum benefit. No patient was successfully resuscitated from blunt injury with EDT. Three additional patients had "signs of life" restored (one pediatric blunt; two subdiaphragmatic gunshot wounds) but died of coagulopathies shortly thereafter. The experience with air ambulance patients was far too small to allow any conclusions or observations. It is felt that as the use and application of helicopters to EMS situations becomes widespread, more patients will be arriving at trauma centers with no vital signs and massive blunt injury but only moments from the accident. This special group of "dying" patients will require intense scrutiny and possibly new and inventive approaches for any hopeful salvage. Emergency thoracotomy will, no doubt, have a place as part of this. The development of a simple working protocol is of extreme importance. The protocol should be one that will allow maximum selection of patients who can benefit and elimination of those patients where EDT would be useless. The primary benefactor for EDT remains the patient sustaining a stab wound to the heart who arrives at the center shortly after injury. In other areas, such as abdominal exsanguination or severe blunt injury, further study is needed to determine what factors, prehospital and resuscitative, will improve outcome.
D000007:Abdominal Injuries / Q000601:surgery*; D000293:Adolescent; D002675:Child, Preschool; D006801:Humans; D008297:Male; D011379:Prognosis; D012151:Resuscitation; D013898:Thoracic Injuries / Q000601:surgery*; D014193:Trauma Centers; D000078329:Workforce; D014948:Wounds, Gunshot / Q000601:surgery; D014949:Wounds, Nonpenetrating / Q000601:surgery; D014950:Wounds, Penetrating / Q000601:surgery