Crack the Chest

Part of our recurring ’52 Articles’ series exploring landmark articles in Emergency Medicine, inspired by the ALiEM blog’s index project, 

Main Points:

  1. Over 23 years 950 patients underwent post injury thoracotomy at Denver Health Medical Center and overall survival was noted to be 4.4 percent with 3.9 percent surviving functionally intact.
  1. Using various assumptions for cost analysis the authors concluded that “the benefit-charge ratio was strongly in favor of performing EDT [emergency department thoracotomy] at 5.6:1, it was 1.8:1 if adjusted for the cost of maintaining all neurologically injured survivors throughout their lifetime.”

Background:

Emergency department thoracotomy remains a hotly debated procedure within the scope of emergency medicine.  Not only is it a resource intense process that potentially places providers at increased risk for blood borne infections, but it is also one whose utility has been questioned given the limited success rate of meaningful patient outcomes. The authors of this study reviewed a cohort of consecutive trauma patients presenting to a level I hospital in Denver, CO in hopes of clarifying not only the costs as well as the utility of the procedure. The authors in this study reported “neurologically intact survival at time of discharge” as one of the study outcomes; however, it does not appear that any patients had post-hospitalization follow up to evaluate for any future changes. This study helps raise many important questions regarding the clinical practice of emergency department thoracotomy, but it is limited in its retrospective design and relative geographic isolation to apply broadly to the entire field of emergency medicine. The discussion of cost peaks the curiosity of many who evaluate healthcare utilization but it if fraught with limitations secondary to the assumptions made in the calculations.

 

Details:

Overall 950 patients’ records were reviewed for this study and amongst this cohort the injury pattern most prevalent was blunt injury mechanism. This represented 45 percent of total cases followed closely by gunshot wounds at 38 percent and subsequently by stab wounds at 17 percent. Overall 8 out of 385 blunt injury trauma patients survived EDT and were discharged; however, four of these patients had global neurologic injury (three suffered closed head injury, one from anoxic brain injury). This left only one percent of blunt trauma patients neurologically intact at the time of discharge. Survival was higher in the penetrating trauma category and was 7 percent for all comers. If one separates out the stab wounds and gunshot wounds the data reveals 12.6 percent and 3.7 percent neurologically intact survival to discharge respectively.

 

The authors calculated charges for EDT by reviewing the final billing statements for patients who underwent EDT in 1996 and calculating an average charge that year which was then applied to each patient in the entire study population. Though it is important to acknowledge that medical costs are difficult to calculate, especially over wide periods of time, this choice undermines the entire cost analysis. The cohort enrolled in this data was collected from 1974-1997 and therefore this cost fails to represent different insurer reimbursement patterns as well as the evolving financial landscape of medicine. The authors included the cost of caring for patients with head injuries as well as the overall benefit that neurologically intact individuals would offer to the economy in their benefit-cost discussion within table 5, but many questions remain.

 

Level of Evidence:

According to the ACEP grading template for therapeutic questions this study receives a grade 3. This is primarily due to the retrospective design of this cohort review. Some doubts remain as to how generalizable this data set is for other level I trauma centers and the ED community at large.

 

Thoracotomy Kit

Surprises:

Nine of the 160 patients who presented to the ED with vital signs underwent EDT while a measurable pulse or a blood pressure was still detectable. Two of these patients survived stab wounds to the chest. The prehospital care also seemed more comprehensive then anecdotal experience at RIH would suggest with almost 90 percent of the patients receiving definitive airway management and intravenous access. Of note the authors also found that 23 survivors (56%) in their study cohort had CPR in progress at the time of ED arrival, with the duration ranging from 2-13 minutes.

 

Relevant articles:

Slessor, D. Hunter S. “To Be Blunt: Are we Wasting our Time? Emergency Department Thoracotomy Following Blunt Trauma: A Systematic Review and Meta-Analysis.” Ann Emerg Med March, 2015: 65(3): 297-307

 

Source Articles:

Branney, S. Moore, E. Feldhaus, K. et al. “Critical Analysis of Two Decades of Experience with Postinjury Emergency Department Thoracotomy in a Regional Trauma Center.”Journal of Trauma July, 1998: 45(1): 87-94

 

Anatoly Kazakin MD

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