A systematic review of 3251 emergency department thoracotomies: is it time for a national database?

PURPOSE: Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world. METHODS: Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications. RESULTS: Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012). CONCLUSIONS: Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.

Assessing the implementation of guidelines for the management of the potentially injured cervical spine in unconscious trauma patients in England.

BACKGROUND: There are many complications involved in the immobilization of unconscious patients with potential cervical spine injuries. In February 2005, the Intensive Care Society (ICS), United Kingdom, produced consensus guidelines to evaluate spinal injuries in unconscious victims of blunt multiple injuries to address this important clinical problem. METHODS: A postal questionnaire was sent to lead consultants of intensive care units in England enquiring about the management of the cervical spine in unconscious trauma patients. Data were collated, and the responses to open questions were grouped into themes. Responses were compared with published ICS guidelines. RESULTS: The response rate was 46% (91 of 199). Forty-four of 89 units had formal policies. Twenty-two of 44 of these units had adopted national guidelines. Common methods of immobilization were "collar & head blocks" (59 of 83) and collar only (18 of 83). Thirty of the 70 were immobilized in a semirigid collar. Common X-ray combinations were combined lateral/anteroposterior/Odontoid views (18 of 64) and lateral and anteroposterior views (21 of 64). Fifty of 71 would perform computed tomography scans if images were unsatisfactory. Senior radiologist involvement in reporting was mentioned by 65 of 78. Immobilization was discontinued in the presence of normal X-ray studies and computed tomography scans by 44 of 83. CONCLUSION: A unit policy ensures that current recommendations are followed. Despite the ICS guidelines being published 4 years ago, over half of the individual intensive care units have no policy in place. A lack of adequate guidance for junior doctors can lead to steps in the process of clearance being omitted and potential injuries being missed. We recommend that the national organization do more to facilitate a wider dissemination of these guidelines.