Clinical Outcome of Urgent Thoracotomy in Patients with Penetrating and Blunt Chest Trauma: A Retrospective Survey

Abstract

Introduction In contrast to an emergency department of thoracotomy (EDT), an urgent thoracotomy (UT) is defined as a surgical thoracic intervention performed in the operating room within the first 48 hours of the patient's intensive care unit (ICU) stay. The factors affecting survival after UT are not fully understood. In this study, we retrospectively analyzed the clinical data and outcome of patients with blunt and penetrating chest injuries who underwent UT.

Methods All adult patients who had blunt or penetrating chest trauma and who underwent UT, were included in the study. All data were collected from the patients' hospital and ICU records. Forty-five patients with thoracic injuries who underwent UT during the first 48 hours of ICU stay were analyzed. Of these, 25 had penetrating chest injuries, and 20 had blunt thoracic injuries. Of the penetrating injuries, 16 were stab wounds, and 9 were gunshot wounds.

Results Overall ICU mortality was 29% (n = 13) and was significantly higher in the blunt chest trauma group than in the penetrating trauma group (45% vs 16%; p = 0.04). Lung parenchyma injuries (lacerations and contusions) were the most common intraoperative findings in both groups. The following independent predictors of in-hospital mortality were found: an Injury Severity Score (ISS) of >40; an Acute Physiology and Chronic Evaluation II (APACHE II) score of >30; prolonged duration of UT; low body temperature on admission to the ED; abnormal arterial blood lactate, bicarbonate, and pH at the end of UT; and use of vasopressors during the first 24 hours of ICU stay.

Conclusion Mortality after UT was higher in patients with blunt chest trauma. The UT should be performed in both penetrating and blunt chest trauma as quickly as possible and should be limited to damage control. It also emerges that acidosis and hypothermia in chest trauma patients need to be treated extremely aggressively before, during, and after UT.

Keywords

urgent thoracotomy - blunt chest trauma - penetrating chest trauma emergency thoracoscopy

Ethics

The Human Research and Ethics Committee at Soroka Medical Center in Beer-Sheva, Israel, approved this study (RN-0124–15-SOR).

Authors' Contributions

Dr. Yael Refaely participated in the study design, data collection, data analysis, data interpretation, and writing. Dr. Leonid Koyfman participated in the literature search, study design, data collection, data analysis, and data interpretation. Prof. Michael Friger participated in data collection and performed the statistical analysis and data interpretation. Dr. Leonid Ruderman participated in the design of the study, performed the statistical analysis, and helped in revising the manuscript. Dr. Mahmud Abu Saleh participated in the design of the study, performed the statistical analysis, and helped in revising the manuscript. Dr. Gidon Sahar participated in the design of the study, performed the statistical analysis, and helped in revising the manuscript. Dr. Gad Shaked participated in the design of the study, performed the statistical analysis, and helped in revising the manuscript. Dr. Moti Klein conceived the study, participated in its design and coordination, and helped to draft the manuscript. Dr. Evgeni Brotfain participated in the design of the study and coordination and helped to draft the manuscript.

All authors read and approved the manuscript. It is important to clarify that all authors listed agreed that both Dr. Refaely and Dr. Koyfman contributed equal work regarding the paper. They both participated in design, data collection, analysis, interpretation, and writing of the paper.

^* Both authors contributed equally to this work.

• References

• 1 Karmy-Jones R, Nathens A, Jurkovich GJ. , et al. Urgent and emergent thoracotomy for penetrating chest trauma. J Trauma 2004; 56 (03) 664-668 , discussion 668–669
• 2 Grove CA, Lemmon G, Anderson G, McCarthy M. Emergency thoracotomy: appropriate use in the resuscitation of trauma patients. Am Surg 2002; 68 (04) 313-316 , discussion 316–317
• 3 Hines MH, Meredith JW. Special problems of thoracic trauma. In: Ritchie WP, Steele Jr G, Dean RH. , eds. General Surgery. Philadelphia: JB Lippincott; 1995: 859-872
• 4 Onat S, Ulku R, Avci A, Ates G, Ozcelik C. Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center. Injury 2011; 42 (09) 900-904
• 5 Karmy-Jones R, Jurkovich GJ, Nathens AB. , et al. Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study. Arch Surg 2001; 136 (05) 513-518
• 6 Thompson DA, Rowlands BJ, Walker WE, Kuykendall RC, Miller PW, Fischer RP. Urgent thoracotomy for pulmonary or tracheobronchial injury. J Trauma 1988; 28 (03) 276-280
• 7 Zieren HU, Müller JM, Pichlmaier H. [Thoracotomies in thoracic injuries--indications and results]. Langenbecks Arch Chir 1991; 376 (06) 330-334
• 8 Seamon MJ, Haut ER, Van Arendonk K. , et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015; 79 (01) 159-173
• 9 Meredith JW, Hoth JJ. Thoracic trauma: when and how to intervene. Surg Clin North Am 2007; 87 (01) 95-118 , vii
• 10 Simmons JW, Pittet JF, Pierce B. Trauma-Induced Coagulopathy. Curr Anesthesiol Rep 2014; 4 (03) 189-199