Emergency Room Thoracotomy: A Single Surgeon's Thirteen-Year Experience

Abstract

Our objectives were to elucidate the postoperative complications in patients who have had emergency room thoracotomy (ERT), to define anatomic and physiologic parameters that are compatible with survival and to document the evolution of management of these patients. A single surgeon's experience over a 13-year period was reviewed. All patients where he was the primary or supervising surgeon for the ERT were included. Data were analyzed for mechanism (penetrating/blunt), hospital where performed, survival to intensive care unit, survival to discharge, and postoperative complications. Among survivors, data were analyzed for the anatomic injuries and the patients' physiologic condition in the field and on arrival. There were a total of 102 patients; penetrating injury 94 (92 percent); blunt, 8 (8 percent). Ten patients (10 percent) reached the intensive care unit alive. Three of the ten (30 percent) died at 2 hours, 12 hours, and 7 days postoperatively. Seven patients survived to hospital discharge. All seven had penetrating chest injuries and were not in cardiac arrest when first examined by paramedics. Four of the seven survivors (57 percent) had major complications. Survival for the early period was 1.6 percent (1/62) and for the later period 15 percent (6/40); P < 0.05. During the study period, changes in patient management included 1) for penetrating torso injury, withholding ERT when survival was extremely unlikely; 2) increased use of blood- and fluid-warming measures; 3) elimination of aortic cross-clamping, instead judiciously using manual compression; 4) making the main purpose of ERT the relief of cardiac tamponade; and 5) immediately controlling any cardiac injury with a simple running suture on a large needle. We conclude the following: 1) The postoperative course after ERT carried significant mortality and morbidity. 2) Compatibility with survival required both the absence of cardiac arrest when initially evaluated in the field and the presence of penetrating chest injury. 3) Significant changes occurred in patient management during this 13-year period. Survival was higher in the latter part of this period.