By Anthony J. Brown, MD
WESTPORT, CT (Reuters Health) – Except for patients with a cardiac stab wound who deteriorate in the emergency room (ER), penetrating cardiac injuries in suburban hospital settings should not be managed with thoracotomy in the ER.
That conclusion is based on data presented Tuesday at the 67th annual scientific meeting of the American College of Chest Physicians in Philadelphia by Dr. Michael J. Davidson, from Duke University Medical Center in Durham, North Carolina.
Dr. Davidson and colleagues assessed the outcomes of 585 patients with penetrating chest injuries who presented to a suburban, level I trauma center between 1989 and 1998. The study focused on 48 patients who had penetrating cardiac injuries. Gunshot wounds accounted for 63% of injuries and stab wounds for 37%. Thoracotomy was performed in the ER in 28 patients and in the operating room (OR) in 20.
The survival rate in the OR thoracotomy group was significantly higher (p < 0.01) at 95% (19/20) than in the ER thoracotomy at 13% (3/28). All three ER thoracotomy survivors had right ventricular stab-wound injuries with tamponade and all had vital signs present upon arrival to the ER.
"ER thoracotomy has been a contentious issue in the past," Dr. Davidson told Reuters Health. "A number of studies that have suggested that it be applied liberally have come out of specialized urban centers, which typically have very short hospital transit times," he noted. "Also, some of the earlier data came from an era when more of the injuries were due to stab wounds," he said.
"Our trauma center is in a suburban setting with a wider referral base and therefore longer pre-hospital times," Dr. Davidson said. "This setting is probably more representative of the majority of trauma centers around the country."
Dr. Davidson noted "that there are really only a few instances where ER thoracotomy is beneficial." While "other studies have suggested that it be done immediately for patients without any vital signs, we found that this situation was universally fatal and ER thoracotomy did not alter the outcome," he said.
"Because there are costs and risks with ER thoracotomy, we feel it should be limited to patients who are most likely to survive–stab-wound patients who lose their vital signs in the ER," Dr. Davidson concluded.
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