An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma

Mark J. Seamon, Elliott Haut, Kyle Van Arendonk, Ronald R. Barbosa, William C. Chiu, Christopher J. Dente, Nicole Fox, Randeep S. Jawa, Kosar Khwaja, J. Kayle Lee, Louis J. Magnotti, Julie A. Mayglothling, Amy A. McDonald, Susan Rowell, Kathleen B. To, Yngve Falck-Ytter, Peter Rhee

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival? METHODS: All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest. RESULTS: The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825). CONCLUSION: We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury. LEVEL OF EVIDENCE: Systematic review/guideline, level III.

Original languageEnglish (US)
Pages (from-to)159-173
Number of pages15
JournalThe journal of trauma and acute care surgery
Volume79
Issue number1
DOIs
StatePublished - Jul 3 2015

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Practice Management
Thoracotomy
Practice Guidelines
Patient Selection
Hospital Emergency Service
Survival
Wounds and Injuries
Thoracic Injuries
Nonpenetrating Wounds
Operating Rooms
Resuscitation
Population

Keywords

  • Emergency department thoracotomy
  • evidence-based medicine
  • practice management guideline
  • resuscitative thoracotomy

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery
  • Medicine(all)

Cite this

An evidence-based approach to patient selection for emergency department thoracotomy : A practice management guideline from the Eastern Association for the Surgery of Trauma. / Seamon, Mark J.; Haut, Elliott; Van Arendonk, Kyle; Barbosa, Ronald R.; Chiu, William C.; Dente, Christopher J.; Fox, Nicole; Jawa, Randeep S.; Khwaja, Kosar; Lee, J. Kayle; Magnotti, Louis J.; Mayglothling, Julie A.; McDonald, Amy A.; Rowell, Susan; To, Kathleen B.; Falck-Ytter, Yngve; Rhee, Peter.

In: The journal of trauma and acute care surgery, Vol. 79, No. 1, 03.07.2015, p. 159-173.

Research output: Contribution to journalArticle

Seamon, MJ, Haut, E, Van Arendonk, K, Barbosa, RR, Chiu, WC, Dente, CJ, Fox, N, Jawa, RS, Khwaja, K, Lee, JK, Magnotti, LJ, Mayglothling, JA, McDonald, AA, Rowell, S, To, KB, Falck-Ytter, Y & Rhee, P 2015, 'An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma', The journal of trauma and acute care surgery, vol. 79, no. 1, pp. 159-173. https://doi.org/10.1097/TA.0000000000000648
Seamon, Mark J. ; Haut, Elliott ; Van Arendonk, Kyle ; Barbosa, Ronald R. ; Chiu, William C. ; Dente, Christopher J. ; Fox, Nicole ; Jawa, Randeep S. ; Khwaja, Kosar ; Lee, J. Kayle ; Magnotti, Louis J. ; Mayglothling, Julie A. ; McDonald, Amy A. ; Rowell, Susan ; To, Kathleen B. ; Falck-Ytter, Yngve ; Rhee, Peter. / An evidence-based approach to patient selection for emergency department thoracotomy : A practice management guideline from the Eastern Association for the Surgery of Trauma. In: The journal of trauma and acute care surgery. 2015 ; Vol. 79, No. 1. pp. 159-173.
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abstract = "BACKGROUND: Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival? METHODS: All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest. RESULTS: The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3{\%}] of 853; neurologically intact survival, 53 [11.7{\%}] of 454) and without (survival, 76 [8.3{\%}] of 920; neurologically intact survival, 25 [3.9{\%}] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6{\%}] of 160; neurologically intact survival, 14 [16.5{\%}] of 85) than without (survival, 4 [2.9{\%}] of 139; neurologically intact survival, 3 [5.0{\%}] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6{\%}] of 454; neurologically intact survival, 7 [2.4{\%}] of 298) and dismal without signs of life (survival, 7 [0.7{\%}] of 995; neurologically intact survival, 1 [0.1{\%}] of 825). CONCLUSION: We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury. LEVEL OF EVIDENCE: Systematic review/guideline, level III.",
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author = "Seamon, {Mark J.} and Elliott Haut and {Van Arendonk}, Kyle and Barbosa, {Ronald R.} and Chiu, {William C.} and Dente, {Christopher J.} and Nicole Fox and Jawa, {Randeep S.} and Kosar Khwaja and Lee, {J. Kayle} and Magnotti, {Louis J.} and Mayglothling, {Julie A.} and McDonald, {Amy A.} and Susan Rowell and To, {Kathleen B.} and Yngve Falck-Ytter and Peter Rhee",
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TY - JOUR

T1 - An evidence-based approach to patient selection for emergency department thoracotomy

T2 - A practice management guideline from the Eastern Association for the Surgery of Trauma

AU - Seamon, Mark J.

AU - Haut, Elliott

AU - Van Arendonk, Kyle

AU - Barbosa, Ronald R.

AU - Chiu, William C.

AU - Dente, Christopher J.

AU - Fox, Nicole

AU - Jawa, Randeep S.

AU - Khwaja, Kosar

AU - Lee, J. Kayle

AU - Magnotti, Louis J.

AU - Mayglothling, Julie A.

AU - McDonald, Amy A.

AU - Rowell, Susan

AU - To, Kathleen B.

AU - Falck-Ytter, Yngve

AU - Rhee, Peter

PY - 2015/7/3

Y1 - 2015/7/3

N2 - BACKGROUND: Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival? METHODS: All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest. RESULTS: The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825). CONCLUSION: We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury. LEVEL OF EVIDENCE: Systematic review/guideline, level III.

AB - BACKGROUND: Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival? METHODS: All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest. RESULTS: The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825). CONCLUSION: We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury. LEVEL OF EVIDENCE: Systematic review/guideline, level III.

KW - Emergency department thoracotomy

KW - evidence-based medicine

KW - practice management guideline

KW - resuscitative thoracotomy

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