The last year or two have seen some excellent online discussion and teaching around the enigmatic procedure of ED thoracotomy, including Scott Weingart from EMCrit’s “Crack to Cure” talk (also given at SMACC recently), and Cliff Reid at Resus.me has done some posts on traumatic arrest and thoracotomy as well (here and here).
In the latest Journal of Trauma there’s an interesting article that looks at post discharge functional outcomes from a group of ED thoracotomy survivors. Despite the small sample size, some interesting points are noted, including an impressive 8.3% survival to discharge rate (nearly all were penetrating trauma), the vast majority of which had a reasonable functional status at long term followup. Two-thirds were discharged home, and only 6% were discharged to nursing homes.
75% of survivors had normal cognition, had returned to “normal activities”, and had no evidence of post-traumatic stress disorder, and over 80% were freely mobile and functional. The authors note a high incidence of unemployment and drug/alcohol use, however this was not covered in the discussion, so pre-morbid factors may be at play with these results. The discussion section is worth a read as a summary of outcomes for different types of traumatic injury, as these have been studied in detail in other referenced papers. Importantly they note a comment from a study of survivors of traumatic brain injury, that sometimes resuscitation and ICU care leading to survival sentences the patient to “a fate worse than death” (ie long term severe impairment and nursing home care). No clear predictors of who will do well after ED thoractotomy can be gleaned from this study, but younger age appeared to be the main factor associated with better outcome.
So what’s the take home message?
The chance of survival of an ED thoracotomy is low, and you need to know the right patients to try it on, however if the patient survives the procedure, they have a high chance of regaining some semblance of normal function should they make it to hospital discharge. The younger the (adult) patient, the higher the chances of a good outcome.
As Cliff mentioned in his post about Kenji Inaba’s study, even if they don’t survive, the potential for organ donation should also be kept in mind.