Pediatric emergency department thoracotomy: A 40-year review

Emergency department thoracotomy (EDT) has been proposed to be futile in the pediatric patient population. This extreme procedure has survival rates of 0 to 26% in the nonadult population. When taking into consideration that the mechanism of injury is one of the strongest predictors of survival, we hypothesize that the low survival rate in pediatric patients is attributable to a higher rate of blunt trauma compared to their adolescent counterparts.

Prospective data collected from our level 1 trauma center from 1974 to 2014 on all patients undergoing EDT at our institution were evaluated for age 18years or younger. Patient predictor variables included injury mechanism, injury pattern, and detected cardiac activity in the field. Outcomes included successful resuscitation (reestablish of blood pressure and taken to operating room) and overall survival. Patients were dichotomized by age into pediatric (age≤15years) and adolescent (16-18years) categories.

1691 patients who underwent EDT were evaluated for age of 18years or less, which included 179 patents (11%). Overall survival in the adult population was 6.1%, compared to 3.4% in the nonadult population (p=0.157). Pediatric patients were more likely to sustain blunt injury than adolescents (72% vs 32%, p<0.001). This also corresponded to differences in anatomic injury patterns and more multisystem trauma (52% vs 44%, p=0.001). Adolescents had significantly higher survival rates than pediatric patients (5% vs 0%, p=0.036).

In nonadult patients undergoing EDT, adolescents have a higher survival rate than pediatric patients. The pediatric population had a significantly lower incidence of penetrating trauma and higher incidence of head injury. The discrepancy in survival between adolescent and pediatric patients appears to be attributable to differences in mechanism. Therefore, those pediatric patients with penetrating thoracic injuries may still benefit from EDT.