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eComment: Emergency department thoracotomy and middle income countries

University Hospital Sestre Milosrdnice, Department for Cardiovascular Surgery, Zagreb, Croatia

Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective

For several decades after its introduction to surgical practice in the early 1900s, emergency department thoracotomy (EDT) yielded poor statistical outcome because it was indiscriminately applied to all moribund trauma patients.

Reports from high-income countries, as well as the article by Molina et al. [1], have documented improvement over the past three decades after implementation of strict management protocols with well-defined selection criteria [2–3].

In order to improve our management protocols of comprehensive assessment of the acute and long-term treatment of patients with penetrating cardiac injuries, last year we retrospectively examined records from our University Clinic Cardiovascular Department (UCCD) over a period of 11 years, from January 1995 to January 2006.

Factors that were found to be predictive of early mortality included gunshot wounds, extra-thoracic injuries, prolonged transportation times [transport duration (survivors, n=10), median (range), min- 150 (15–180); (no survivors, n=11) min- 220 (30–210)] and absence of signs of life on presentation. Victims of cardiac trauma for EDT were not stable enough to withstand the delay for transfer to the operating room.

Report by the Philadelphia's group has documented improved outcomes, but these results are not easily reproducible in middle and low-income countries where support services and facilities are not readily available [4]. Moreover, the authors did not analyze pre-hospital transportation times and our data suggested that without adequate pre-hospital resuscitation, longer transport times will herald worse outcomes.

Despite these limitations, the early survival at the UCCD is comparable to that in larger reports from high-income countries.

Several reports have identified the absence of signs of life on arrival at the hospital as a herald of mortality [5]. Similarly, this was noted to be predictive of early mortality in our series.

The fact that EDT is one of the last maneuvers that may preserve life cannot justify its indiscriminate use because there are several complications. The cardiovascular and trauma team is at high risk for percutaneous injuries, blood exposure and disease transmission. Additionally, the financial demands cannot be underscored, especially in middle-income countries where resources are scarce with the health care systems being under-funded. The quality of life in survivors is also of valid concern. The survivors in our series required constant home supervision due to neurologic impairment, much to the distress of his caregivers.

It is time to implement strict protocols to exclude futile operations in unsalvageable patients and we must tailor the indications to suit our local health care environment.

Several limitations of the health care system have been uncovered in Croatia that are likely reflective of most middle-income countries. They must be addressed if we are to expect improved outcomes. Importantly, our data suggested that the UCCD should stock a special EDT kit that contains the basic equipment necessary for this procedure.

Moreover, quantified data represented by Molina et al. could assist young cardiovascular surgeons in the middle-income countries, in the management of penetrating cardiac wounds in a scope of properly EDT indications.

	References

Top References

 

1. Molina EJ, Gaughan JP, Kulp H, McClurken JB, Goldberg AJ, Seamon MJ. Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective. Interact CardioVasc Thorac Surg 2008;7:845–849.[Abstract/Free Full Text]
2. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons. Committee on Trauma. Practice management guidelines for emergency department thoracotomy. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. J Am Coll Surg 2001;193:303–309.[CrossRef][Medline]
3. Aihara R, Millham F, Blansfield J, Hirsch E. Emergency room thoracotomy for penetrating chest injury: effect of institutional protocols. J Trauma 2001;50:1027–1030.[Medline]
4. Biocina B, Sutlic Z, Husedzinovic I, Rudez I, Ugljen R, Letica D, Slobodnjak Z, Karadza J, Brida V, Vladovic-Relja T, Jelic I. Penetrating cardiothoracic war wounds. Eur J Cardiothorac Surg, 197, 11:399–405.
5. Tyburski JG, Astra L, Wilson RF, Dente C, Steffes C. Factors affecting prognosis with penetrating wounds of the heart. J Trauma 2000;48:587–590.[Medline]

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