title: Comparative Effectiveness of Emergency Resuscitative Thoracotomy versus Closed Chest Compressions among Patients with Critical Blunt Trauma: A Nationwide Cohort Study in Japan.
abstract: BACKGROUND
  Although emergency resuscitative thoracotomy is performed as a salvage maneuver for critical blunt trauma patients, evidence supporting superior effectiveness of emergency resuscitative thoracotomy compared to conventional closed-chest compressions remains insufficient. The objective of this study was to investigate whether emergency resuscitative thoracotomy at the emergency department or in the operating room was associated with favourable outcomes after blunt trauma and to compare its effectiveness with that of closed-chest compressions.
  
  
  METHODS
  This was a retrospective nationwide cohort study. Data were obtained from the Japan Trauma Data Bank for the period between 2004 and 2012. The primary and secondary outcomes were patient survival rates 24 h and 28 d after emergency department arrival. Statistical analyses were performed using multivariable generalized mixed-effects regression analysis. We adjusted for the effects of different hospitals by introducing random intercepts in regression analysis to account for the differential quality of emergency resuscitative thoracotomy at hospitals where patients in cardiac arrest were treated. Sensitivity analyses were performed using propensity score matching.
  
  
  RESULTS
  In total, 1,377 consecutive, critical blunt trauma patients who received cardiopulmonary resuscitation in the emergency department or operating room were included in the study. Of these patients, 484 (35.1%) underwent emergency resuscitative thoracotomy and 893 (64.9%) received closed-chest compressions. Compared to closed-chest compressions, emergency resuscitative thoracotomy was associated with lower survival rate 24 h after emergency department arrival (4.5% vs. 17.5%, respectively, P < 0.001) and 28 d after arrival (1.2% vs. 6.0%, respectively, P < 0.001). Multivariable generalized mixed-effects regression analysis with and without a propensity score-matched dataset revealed that the odds ratio for an unfavorable survival rate after 24 h was lower for emergency resuscitative thoracotomy than for closed-chest compressions (P < 0.001).
  
  
  CONCLUSIONS
  Emergency resuscitative thoracotomy was independently associated with decreased odds of a favorable survival rate compared to closed-chest compressions.
authors.affiliation: Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.
authors.forename: Kodai
authors.initials: K
authors.lastname: Suzuki
authors.affiliation: Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Shigeaki
authors.initials: S
authors.lastname: Inoue
authors.affiliation: Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Seiji
authors.initials: S
authors.lastname: Morita
authors.affiliation: Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Nobuo
authors.initials: N
authors.lastname: Watanabe
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Ayumi
authors.initials: A
authors.lastname: Shintani
authors.affiliation: Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Sadaki
authors.initials: S
authors.lastname: Inokuchi
authors.affiliation: Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.
authors.forename: Shinji
authors.initials: S
authors.lastname: Ogura
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007564:Japan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009026:Mortality; D012042:Registries; D012151:Resuscitation / Q000379:methods*; D012189:Retrospective Studies; D013908:Thoracotomy; D013997:Time Factors; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D055815:Young Adult