title: Appropriate use of emergency department thoracotomy: implications for the thoracic surgeon.
abstract: 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 blood-borne 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.
authors.affiliation: Department of Surgery, Division of Trauma, Mount Sinai Hospital and the University of Illinois at Chicago, Chicago, Illinois 60608, USA. nathan.mollberg@gmail.com
authors.forename: Nathan M
authors.initials: NM
authors.lastname: Mollberg
authors.forename: Cavin
authors.initials: C
authors.lastname: Glenn
authors.forename: Jobin
authors.initials: J
authors.lastname: John
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Wise
authors.forename: Ryan
authors.initials: R
authors.lastname: Sullivan
authors.forename: Amir
authors.initials: A
authors.lastname: Vafa
authors.forename: Norman J
authors.initials: NJ
authors.lastname: Snow
authors.forename: Malek G
authors.initials: MG
authors.lastname: Massad
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D016887:Cardiopulmonary Resuscitation / Q000401:mortality; D002641:Chicago; D000075202:Contraindications; D004636:Emergency Service, Hospital / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D009104:Multiple Trauma / Q000401:mortality / Q000601:surgery; D009460:Neurologic Examination; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate; D013898:Thoracic Injuries / Q000401:mortality / Q000601:surgery*; D013903:Thoracic Surgery / Q000706:statistics & numerical data*; D013908:Thoracotomy / Q000401:mortality / Q000706:statistics & numerical data*; D014193:Trauma Centers / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000401:mortality / Q000706:statistics & numerical data*; D014950:Wounds, Penetrating / Q000401:mortality / Q000601:surgery*; D055815:Young Adult