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Rivista di Chirurgia Cardiaca, Vascolare e Toracica

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The Journal of Cardiovascular Surgery 1999 February;40(1):147-51


lingua: Inglese

Is 30 min­utes the gold­en peri­od to per­form emer­gen­cy ­room tho­rat­o­my (ERT) in pen­e­trat­ing ­chest inju­ries?

Frez­za E. E., Mez­ghebe H.

From the Howard University Hospital Department of Surgery Washington, DC, USA


Background. Emergency ­room thor­a­cot­o­my (ERT), a con­tro­ver­sial pro­ce­dure, was intro­duced to ­improve resus­ci­ta­tion of trau­ma ­patients. No ­study has ­been con­duct­ed to eval­u­ate the impor­tance of the ­time in the ­field (­down ­time) in the ­initial sur­vi­val of pen­e­trat­ing ­chest trau­ma requir­ing ERT. In addi­tion to ­this, ­many fac­tors ­have ­been con­sid­ered to pre­dict the suc­cess of ERT, but ­they are mul­ti­ple and are not ­easy to ­assess in the ­brief peri­od of deci­sion mak­ing to per­form an ERT. We decid­ed, there­fore, to see if the pre hos­pi­tal ­time ­could be ­used as the prin­ci­pal param­e­ter to pre­dict wheth­er TERT in emer­gen­cy Department (ED) ­with the arri­val of pen­e­trat­ing ­chest trau­ma is use­ful.
Methods. Records of the Howard University Hospital Emergency Department (ED) ­were ­reviewed for all trau­ma ­patients ­between June 1992 and January 1995. The pre­-ad­mis­sion ­data were ­obtained ­from Emergency Medical Service (EMS) ­reports, includ­ing the “­down ­time”. All ­patients who under­went ERT had ­vital ­signs doc­u­ment­ed by EMS in the ­field. Forensic autop­sies ­were per­formed with­in 48 ­hours ­after ­death fol­low­ing prac­tice stan­dards ­already ­described.
Results. Between January 1987 and June 1994, 58 ­adult ­patients pre­sent­ed ­with pen­e­trat­ing ­chest trau­ma at the Howard University Hospital Emergency Department. Pre-admis­sion ­data were avail­able for 49 of 58 ­chest trau­ma ­patients. Sixteen ­patients (33%), ­with no doc­u­ment­ed ­vital ­signs in the ­field, ­were pro­nounced ­dead on arri­val in the ED, and no ERT was per­formed on ­them. The ­remaining thir­ty-­three ­patients (57%) under­went ERT. In all ­patients ­with ­chest inju­ry, the Revised Trauma Score (RTS) was ­below 4 on arri­val to the ED. Considering ­only the ­patients (n=33) ­that under­went ERT 82% (n=27) of ­patients had ­vital ­sings ­upon arri­val in ED, 19% (n=6) had no ­vital ­signs ­until arri­val to the ED. Patients ­with mul­ti­ple ­wound GS or SW (­more ­than ­four) ­died on arri­val (18%; n=6). The ­patients ­with sin­gle gun ­shot ­wounds or ­stab ­wounds (GSW/SW) sur­vived initial­ly and under­went ERT (82%; n=27). Of the ­patients who under­went ERT, (n=6; 18%) had GSW and (12%), (n=4) had SW. Among ­those ­patients ­that ­died in ED, 12% (n=4) had a ­drop of SBP of ­more ­than 50 mmHg and ­only 24% (n=8) pre­sent­ed ­with a SBP ­less ­than 70 mmHg. Average ­scene ­time was 11.2±8.1 min, the tran­sit ­time was 7.9±5.6 ­min and the aver­age ED resus­ci­ta­tion ­time was 10±3.2 min. Of the ­patients ­that ­arrived in ED with­in 30 min­utes 63% (n=20) sur­vived the ­first 24 ­hours, and of ­these ­only 9% (n=3) had no ­vital ­signs ­upon arri­val. The remain­ing 28% (n=6), who ­arrived in ED ­after ­half ­hour, ­either ­died dur­ing the trans­por­ta­tion or ­upon arri­val to the ED; ­none of ­them had ­vital ­signs ­upon arri­val. All the ­patients trans­ferred to the ICU ­died with­in 24 to 78 hr, sec­on­dary to ­severe ­arrhythmia or cere­bral hypox­ia. Autopsy was per­formed in all the ­patients. Among the ­patients ­that ­died ­upon arri­val in the ED, the ­most com­mon inju­ry respon­sible for ­death was ven­tric­u­lar inju­ry ­with exan­gui­na­tion in the ­first 24 ­hours. Of the 9% of ­patients ­that ­died in the ED ­after ERT, the inju­ry was ­caused by a 9 mm cal­i­ber gun, ­which creat­ed a ­major lac­er­a­tion to the ven­tri­cle ­which was not pos­sible to ­repair dur­ing the ERT. In the ­patients ­that ­died ­after ­stab ­wound (12%; n=4), the ­patients ­were ­stabbed at ­least 3 ­times in the ­chest and ­they ­died of ­arrhythmia. Among the sur­vi­vors of ERT ­that ­were trans­port­ed in ICU, uncon­trol­la­ble arrhyth­mia and ­acute ­lung inju­ry was the ­cause of ­death with­in 24-72 ­hours in 45% (n=15) of ­patients ­while cere­bral hypox­ia com­pli­cat­ed irrep­a­ra­bly the ­life expec­tan­cy ­with ­death at 72 ­hours in 60% (n=20) of ­patients.
Conclusions. The ­only ­role of ERT in our opin­ion is in ­patients who ­arrive with­in 30 min­utes of pre hos­pi­tal ­time, ­with a wit­nessed ­vital ­signed in the ­field. Multiple ­wounds, low SBP and high­er cal­i­ber bul­let inju­ries are ­also neg­a­tive prog­nos­tic fac­tors.

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