Outcomes and guideline adherence for emergency department thoracotomy: a single-center experience in Saudi Arabia.

Abstract

Background: Emergency department thoracotomy (EDT) is a high-risk, salvage procedure performed during the resuscitation of critically injured patients who are in extremis or experience cardiac arrest immediately before or after arrival at the emergency department (ED) following trauma. Despite its potential to improve outcomes in selected patients, its indications and ideal clinical applications remain controversial due to significant risks of morbidity and mortality. In Saudi Arabia, trauma is responsible for approximately 20% of fatalities and is the leading cause of disability-adjusted life-years lost among males. However, there is limited research on EDT outcomes in this region.

Methods: This retrospective cohort study was conducted at a tertiary academic trauma center in Riyadh with dedicated trauma and surgical services. Medical records from 2015 to 2023 were reviewed to identify adult patients who underwent EDT, using trauma team activations as a screening criterion. Data collected included demographics, mechanisms of injury, procedure indications, and timing.

Results: During the study period, the center averaged 151 trauma activations per year, identifying 11 patients who underwent EDT. All were male, with a mean age of 35.64 ± 8.89 years. Blunt trauma was the cause in 64.6% of cases. Of these, 45.4% met the Eastern Association for the Surgery of Trauma (EAST) guideline recommendations for EDT, while 18.2% had contraindications. Traumatic arrest in the ED or prehospital settings was the most common indication 72.7%. Mean time between ED arrival to procedure initiation was 25.45 ± 15.85 min. One patient survived to discharge. Among 45 traumatic arrests screened, 4.44% lacked documentation for withholding EDT despite conditional guideline recommendations.

Conclusions: Given the limited data available on EDT in the MENA region, our study offers important perspectives from a high-volume trauma center in KSA, where the rate of EDT was found to be very low. This low rate is likely due to the predominant injury patterns observed, presenting few candidates who might benefit from the procedure. At the same time, most patients who may have benefited based on guideline recommendations did undergo the procedure. These findings emphasize the need for heightened clinician awareness and systematic decision-making regarding EDT in trauma care. To enhance the generalizability of our findings and assess EDT's utility in regional settings, further research involving larger multicenter registries is necessary in the country and the region.