title: Indication for resuscitative thoracotomy in thoracic injuries-Adherence to the ATLS guidelines. A forensic autopsy based evaluation.
abstract: BACKGROUND
  The appropriate indications for Resuscitative Thoracotomy (RT) are still debated in the literature and various guidelines have been proposed. This study aimed to evaluate whether Advanced Trauma Life Support (ATLS) guidelines for RT were applied correctly and to evaluate the proportion of deceased patients with potentially reversible thoracic lesions (PRTL).
  
  
  METHODS
  The database at the Department of Forensic Medicine at Copenhagen University was queried for autopsy cases with thoracic lesions indicated by the SNOMED autopsy coding system. Patients were included if thoracic lesions were caused by a traumatic event with trauma team activation. Patient cases were blinded for any surgical intervention and evaluated independently by two reviewers for indications or contraindications for RT as determined by the ATLS guidelines. Second, autopsy reports were evaluated for the presence of PRTL.
  
  
  RESULTS
  Sixty-seven patients met the inclusion criteria. Two were excluded due to insufficient data. The overall agreement with guidelines was 86% and 77% for blunt and penetrating trauma, respectively. For patients submitted to RT the overall agreement with guidelines was 63% being 45% and 74% for blunt and penetrating trauma, respectively. For patients who did not undergo RT the agreement with guidelines was 100%. In all cases where RT was performed in agreement between guidelines and the clinical decision the autopsy reports showed PRTL in 16 (84%) patients. In cases of non-agreement PRTL were found in 9 (82%) patients.
  
  
  CONCLUSIONS
  Agreement with ATLS guidelines for RT was 63% for intervention and 100% for non-intervention in deceased patients with thoracic trauma. Agreement was higher for penetrating trauma than for blunt trauma. The adherence to guidelines did not improve the ability to predict autopsy findings of PRTL. Although the study has methodical limitations it represents a novel approach to the evaluation of the clinical use of RT guidelines.
authors.affiliation: Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark. Electronic address: ohrtnissen@gmail.com.
authors.forename: S
authors.initials: S
authors.lastname: Ohrt-Nissen
authors.affiliation: Department of Forensic Medicine, Copenhagen University, Copenhagen, Denmark. Electronic address: bonnie.colville-ebeling@sund.ku.dk.
authors.forename: B
authors.initials: B
authors.lastname: Colville-Ebeling
authors.affiliation: Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark. Electronic address: kristiankandler@gmail.com.
authors.forename: K
authors.initials: K
authors.lastname: Kandler
authors.affiliation: Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark. Electronic address: khornbech@hotmail.com.
authors.forename: K
authors.initials: K
authors.lastname: Hornbech
authors.affiliation: Department of Anesthesiology and Trauma Centre, HOC, Rigshospitalet, Copenhagen, Denmark. Electronic address: jacob.steinmetz@regionh.dk.
authors.forename: J
authors.initials: J
authors.lastname: Steinmetz
authors.affiliation: Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark. Electronic address: jesper.ravn@regionh.dk.
authors.forename: J
authors.initials: J
authors.lastname: Ravn
authors.affiliation: Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark. Electronic address: per.lehnert@regionh.dk.
authors.forename: P
authors.initials: P
authors.lastname: Lehnert
mesh_terms: D000293:Adolescent; D000328:Adult; D061906:Advanced Trauma Life Support Care / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D001344:Autopsy; D002648:Child; D003661:Decision Support Techniques; D003718:Denmark; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013898:Thoracic Injuries / Q000401:mortality / Q000628:therapy*; D013908:Thoracotomy / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000401:mortality / Q000628:therapy*; D014950:Wounds, Penetrating / Q000401:mortality / Q000628:therapy*; D055815:Young Adult
keywords: ATLS; Adherence to guidelines; Resuscitative thoracotomy; Thoracic trauma