Related Experiment Videos
Emergency Department thoracotomy in children--a critical analysis
S S Rothenberg1, E E Moore, F A Moore
1Department of Surgery, Denver General Hospital, CO 80204-4507.
Insights
Emergency Department (E.D.) thoracotomy in pediatric patients shows low survival, especially with blunt trauma. Selective use is recommended, favoring penetrating injuries over blunt trauma in critically injured children.
Area of Science:
- Pediatric Trauma Surgery
- Emergency Medicine
- Thoracic Surgery
Background:
- Clinical reviews have clarified the role of Emergency Department (E.D.) thoracotomy in critically injured adults.
- Guidelines for pediatric E.D. thoracotomy remain ill-defined.
Purpose of the Study:
- To examine the yield of E.D. thoracotomy in patients 18 years or younger.
- To inform a more cost-effective application of this critical intervention in children.
Main Methods:
- Retrospective review of 689 consecutive E.D. thoracotomies over 11 years.
- Analysis of 83 pediatric patients (≤18 years) including injury mechanism, age, sex, and vital signs on presentation.
- Survival rates were analyzed by injury mechanism and initial physiologic status.
Main Results:
- Pediatric patients represented 12% (83/689) of E.D. thoracotomies, with a mean age of 15 years.
- Overall survival was low, with higher rates for stab wounds (9%) and gunshot wounds (4%) compared to blunt trauma (2%).
- Patients presenting with vital signs had a 14% survival rate, contrasting sharply with those without vital signs (1 survival out of 69).
Conclusions:
- E.D. thoracotomy outcomes in children are comparable to adults.
- Blunt trauma, the leading cause of pediatric trauma deaths, has a poor prognosis with E.D. thoracotomy.
- A selective approach is supported: liberal use for penetrating injuries, but limited use for blunt trauma in patients without vital signs.
Abstract:
Recent clinical reviews have helped to clarify the role of Emergency Department (E.D.) thoracotomy in critically injured adults. However, guidelines in the pediatric population remain ill defined. The purpose of this report is to examine the yield of E.D. thoracotomy in patients less than or equal to 18 years of age to allow for a more cost-effective application of this heroic measure. From an 11-year experience of 689 consecutive E.D. thoracotomies, 83 patients (12%) were less than or equal to 18 years old. Mechanism of injury was blunt trauma in 57%, gunshot wound in 30%, and stab wound in 13%. Mean age was 15 years and 71% were male. Survival by injury mechanism was 9% (1/11) for stab wound, 4% (1/25) for gunshot wound, and 2% (1/47) for blunt trauma. Sixty-nine patients presented to the E.D. without vital signs and only one, a 16-year-old with stab wounds to the chest and abdomen, survived. In contrast, two (14%) among 14 patients presenting with vital signs were salvaged. As in adults, outcome was largely determined by injury mechanism and physiologic status on E.D. presentation. Blunt trauma, the predominant mechanism of lethal injuries in children, had a dismal outcome, with only 2% salvage and no survivors when vital signs were absent. This study demonstrates a similar outcome for E.D. thoracotomy in children compared to adults, and supports a selective policy of liberal use in penetrating injury irrespective of physiologic status but limited in those arriving lifeless following blunt trauma.