Clinical determinants for survival following emergency thoracotomy in trauma patients: An 8-year experience from a level 1 trauma center.

Purpose: Emergency thoracotomy (ET) is a life-saving procedure performed during emergency resuscitation of patients in extremis. The controversy around such an invasive and resource-consuming procedure still lingers after so many years of its introduction. ET can serve as one of several indicators of trauma center efficiency and with information about the trauma system's overall preparedness, resources, and training. Our goal was to examine the clinical determinants of improved outcomes and review our ET experience over the past 8 years.

Methods: All patients who underwent ET during the study period from January 2014 to December 2021 at our hospital were included in this retrospective study. Patients in whom the time of arrest was not known or who had incomplete data were excluded. Also, patients with fixed, dilated pupil on arrival with a significant blunt trauma were excluded. Patients undergoing urgent thoracotomy (not as a part of primary survey/resuscitation) were also not included in the study. All data were collected from the prospectively maintained hospital registry and patient case files. The primary outcome measure was in-hospital mortality and various parameters affecting it including but not limited to patient demographics, prehospital information, injury characteristics and scores, parameters of primary survey and perioperative data. The secondary outcome measures were the clinical spectrum of injury in patients with torso trauma who underwent ET including complications. The data was analysed using Fisher's exact test, Chi-square test or Wilcoxon rank-sum test based on the category of variables. A Kaplan-Meier survival curve was plotted on relevant factors which determined clinical outcomes.

Results: Sixty-seven patients underwent ET, with the majority (94.0%) being young males with a median age of 27 years. Penetrating injuries (61.2%) were more common than blunt trauma. Overall survival was 46.3%, with the best outcomes seen with penetrating stab (61.1%) injuries and patients with isolated intrathoracic injuries (67.5%). Patients who underwent resuscitative thoracotomy had dismal outcomes (mortality: 100%). On arrival, hemodynamic parameters like airway status, heart rate, systolic blood pressure, signs of life, and shock at presentation are statistically significant predictors of mortality (p < 0.05). The log-rank test for equality of survivor functions revealed the mechanism of injury (p = 0.010), the status of the airway (p = 0.002), shock on presentation (p = 0.001), and initial GCS (p = 0.040) to be significantly associated with mortality.

Conclusion: ET can be a life-saving procedure with good outcomes, provided a careful selection of patients based on the mechanism of injury, location of major injury, and signs of life. It is prudent to have a system with proper protocol and a swiftly acting trauma team performing it to optimize the outcomes.