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 July 2015, Eastern Association for the Surgery of Trauma issued guidelines on the Evidence-Based Approach to Patient Selection for Emergency Department Thoracotomy. The major recommendations of the guidelines are as follows:-

 

Population, Intervention, Comparator, and Outcome (PICO) Question 1

In patients presenting pulseless to the emergency department with signs of life after penetrating thoracic injury (P), does emergency department thoracotomy (EDT) versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Recommendation

Despite moderate overall quality of evidence (see Fig. 1 in the original guideline document) for both critical outcomes, subcommittee panelists believed that patients would strongly favor undergoing EDT in this clinical scenario because of the substantial improvements in both survival and neurologically intact survival over patients resuscitated without EDT. For these reasons, a strong recommendation was made, implying that most patients would want the recommended course of action and only a small proportion would not.

In patients presenting pulseless to the emergency department with signs of life after penetrating thoracic injury, the panel strongly recommends that patients undergo EDT. This recommendation is based on moderate quality of evidence and places emphasis on patient preference for improved survival and neurologically intact survival after EDT.

PICO Question 2

In patients presenting pulseless to the emergency department without signs of life after penetrating thoracic injury (P), does EDT versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Recommendation

Despite moderate overall quality of evidence for both critical outcomes (see Fig. 2 in the original guideline document) subcommittee panelists believed that a majority of patients would favor undergoing EDT in this clinical scenario because of the improvements in both survival and neurologically intact survival over patients resuscitated without EDT. The panel recognizes that the duration of time without signs of life is a vital component to the decision-making process, but an evidentiary basis for exact length of arrest times is extremely limited. For these reasons, a conditional recommendation is made, implying that, although most patients would want the recommended course of action, others would not.

In patients presenting pulseless to the emergency department without signs of life after penetrating thoracic injury, the panel conditionally recommends that patients undergo EDT. This recommendation is based on moderate quality of evidence and places emphasis on patient preference for improved survival and neurologically intact survival after EDT but also acknowledges that elapsed time without signs of life is an important component.

PICO Question 3

In patients presenting pulseless to the emergency department with signs of life after penetrating extrathoracic injury (P), does EDT versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Recommendation

Despite moderate overall quality of evidence for both critical outcomes (see Fig. 3 in original guideline document), subcommittee panelists believed that a majority of patients would favor undergoing EDT in this clinical scenario because of the improvements in both survival and neurologically intact survival over patients resuscitated without EDT. The panel recognizes that all extrathoracic injury locations such as the neck, abdomen, and extremities may not have equivalent salvage rates after EDT. For these reasons, a conditional recommendation is made.

In patients presenting pulseless to the emergency department with signs of life after penetrating extrathoracic injury, the panel conditionally recommends that patients undergo EDT. This recommendation does not pertain to patients with isolated cranial injuries. This recommendation is based on moderate quality of evidence and places emphasis on patient preference for improved survival and neurologically intact survival after EDT but also acknowledges that penetrating injuries to all extrathoracic anatomic areas will not have equivalent salvage rates after EDT.

PICO Question 4

In patients presenting pulseless to the emergency department without signs of life after penetrating extrathoracic injury (P), does EDT versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Recommendation

Although all voting members of the subcommittee sought a conditional recommendation, 11 members voted in favor of EDT and 4 voted against the procedure based on the PICO No. 4 Evidence Profile. Group disagreement and low quality of evidence for both critical outcomes (see Fig. 4 in original guideline document) led to a conditional recommendation.

In patients presenting pulseless to the emergency department without signs of life after penetrating extrathoracic injury, the panel conditionally recommends that patients undergo EDT. This recommendation does not pertain to patients with isolated cranial injuries and is based on low quality of evidence. The majority of subcommittee members believed that most patients would prefer undergoing EDT in hopes of improved survival and neurologically intact survival.

PICO Question 5

In patients presenting pulseless to the emergency department with signs of life after blunt injury (P), does EDT versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Recommendation

With a moderate overall quality of evidence for both critical outcomes (see Fig. 5 in the original guideline document), subcommittee panelists believed that most patients would favor undergoing EDT in this clinical scenario because of the improvements in both survival and neurologically intact survival over patients resuscitated without EDT. However, the subcommittee recognizes that many patients would not want to undergo EDT after blunt injury because of the possibility of concomitant severe traumatic brain injury and poor neurologic outcome in survivors.

In patients presenting pulseless to the emergency department with signs of life after blunt injury, the panel conditionally recommends that patients undergo EDT. This recommendation is based on moderate quality of evidence and places emphasis on patient preference for improved survival and neurologically intact survival after EDT.

PICO Question 6

In patients presenting pulseless to the emergency department without signs of life after blunt injury (P), does EDT versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Recommendation

Although subcommittee members unanimously voted against the performance of EDT based on the PICO No. 6 Evidence Profile, 10 members voted for a "strong" recommendation and 5 voted for a "conditional" recommendation. Group disagreement regarding the recommendation strength and low quality of evidence for both critical outcomes (see Fig. 6 in original guideline document) led to a conditional recommendation. Subcommittee panelists believed that a majority of patients would not favor undergoing EDT in this clinical scenario because of the dismal survival and likelihood of poor neurologic outcome.

In patients presenting pulseless to the emergency department without signs of life after blunt injury, the panel conditionally recommends against the performance of EDT. This recommendation is based on low quality of evidence and reflects subcommittee group disagreement regarding the strength of the unanimous recommendation against EDT.

 

For full guidelines click on the following link:

An Evidence-Based Approach to Patient Selection for Emergency Department Thoracotomy

 

Artical Source: Seamon MJ, Haut ER, 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. 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 Jul;79(1):159-73. [93 references] PubMed