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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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