title: An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma.
abstract: BACKGROUND
  Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival?
  
  
  METHODS
  All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest.
  
  
  RESULTS
  The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825).
  
  
  CONCLUSIONS
  We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury.
  
  
  METHODS
  Systematic review/guideline, level III.
authors.affiliation: From the Division of Traumatology (M.J.S.), Surgical Critical Care and Emergency Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Acute Care Surgery (E.R.H.), Department of Surgery (K.V.A.), the Johns Hopkins Hospital, Baltimore, Maryland; Trauma Services (R.R.B.), Legacy Emanuel and Randall Children's Hospitals, Portland, Oregon; R Adams Cowley Shock Trauma Center (W.C.C.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (C.J.D.), Emory University and Grady Memorial Hospital, Atlanta, Georgia; Division of Trauma (N.F.), Department of Surgery, Cooper University Hospital, Camden, New Jersey; Division of Trauma, Emergency Surgery, and Surgical Critical Care (R.S.J.), Stony Brook Medicine, Stony Brook, New York; Division of Trauma and Acute Care Surgery (K.K.), McGIll University Health Centre, Montreal, Quebec, Canada; Division of Trauma Surgery and Surgical Critical Care (J.K.L.), Department of Surgery, Advocate Christ Medical Center, Oak Lawn, Illinois; Department of Surgery (L.J.M.), University of Tennessee Health Science Center, Memphis, Tennessee; Departments of Emergency Medicine and Surgery (J.A.M.), Division of Trauma/Critical Care, Virginia Commonwealth University, Richmond, Virginia; Division of Trauma, Critical Care, Burns, and Acute Care Surgery (A.A.M.), Department of Surgery, Metrohealth Medical Center, Cleveland, Ohio; Division of Trauma, Critical Care and Acute Care Surgery (S.R.), Departments of Surgery and Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Division of Acute Care Surgery (K.B.T.), Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan; Division of Gastroenterology (Y.F.-Y.), Case and VA Medical Center, Case Western Reserve University, Cleveland, Ohio; and Division of Trauma, Critical Care, Burn, and Emergency Surgery (P.R.), Department of Surgery, University of Arizona, Tucson, Arizona.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Seamon
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.forename: Kyle
authors.initials: K
authors.lastname: Van Arendonk
authors.forename: Ronald R
authors.initials: RR
authors.lastname: Barbosa
authors.forename: William C
authors.initials: WC
authors.lastname: Chiu
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Dente
authors.forename: Nicole
authors.initials: N
authors.lastname: Fox
authors.forename: Randeep S
authors.initials: RS
authors.lastname: Jawa
authors.forename: Kosar
authors.initials: K
authors.lastname: Khwaja
authors.forename: J Kayle
authors.initials: JK
authors.lastname: Lee
authors.forename: Louis J
authors.initials: LJ
authors.lastname: Magnotti
authors.forename: Julie A
authors.initials: JA
authors.lastname: Mayglothling
authors.forename: Amy A
authors.initials: AA
authors.lastname: McDonald
authors.forename: Susan
authors.initials: S
authors.lastname: Rowell
authors.forename: Kathleen B
authors.initials: KB
authors.lastname: To
authors.forename: Yngve
authors.initials: Y
authors.lastname: Falck-Ytter
authors.forename: Peter
authors.initials: P
authors.lastname: Rhee
mesh_terms: D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D017408:Guidelines as Topic; D006323:Heart Arrest / Q000628:therapy; D006801:Humans; D018579:Patient Selection; D020399:Practice Management; D016019:Survival Analysis; D013898:Thoracic Injuries / Q000401:mortality / Q000601:surgery*; D013908:Thoracotomy / Q000706:statistics & numerical data; D016896:Treatment Outcome; D019564:Unnecessary Procedures / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000401:mortality / Q000601:surgery*; D014950:Wounds, Penetrating / Q000401:mortality / Q000601:surgery*