Pediatric emergency department thoracotomy: A 40-year review

Abstract

Background/purpose 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 non-adult 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. Methods Prospective data collected from our level 1 trauma center from 1974 - 2014 on all patients undergoing EDT at our institution was evaluated for age 18 or younger. Patient predictor variables included injury mechanism, injury pattern, and detected cardiac activity in the field. Outcomes included successful resuscitation (re-establish of blood pressure and taken to operating room) and overall survival. Patients were dichotomized by age into pediatric (age ≤ 15 yrs) and adolescent (16-18yrs) categories. Results 1691 patients who underwent EDT were evaluated for age of 18 or less, which included 179 patents (11%). Overall survival in the adult population was 6.1%, compared to 3.4% in the non-adult 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). Conclusion In non-adult 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 due to differences in mechanism. Therefore, those pediatric patients with penetrating thoracic injuries may still benefit from EDT.

Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis

“…Conversely, chest tube placement and thoracotomy were more likely in patients who suffered early mortality, an expected finding given that these procedures are often performed in the ED for patients who are either pulseless or in extremis. [24,25] Reported complication rates in children suffering late death are relatively low, which suggests that mortality in this group is not commonly related to complications – but these low complication rates must be interpreted cautiously due to known problems with reporting bias related to complications in the NTDB. [23]…”

Patterns of Pediatric Thoracic Penetrating Injuries: a Single Trauma Center Experience – Riyadh, Saudi Arabia

“…In H.B. Moore et al review, adolescents aged 15-18 years had a survival rate of 4.8% while none survived of patients aged less than 15 years [19]. Furthermore, C. J. Allen reported a 10% survival rate after ED thoracotomy performed in 128 penetrating trauma victims [20].…”

“…Despite the fact that penetrating trauma is less frequent than blunt ones, penetrating injuries is associated with higher mortality regardless of age group [3][4][5]. Worldwide incidence of penetrating trauma varies from 10%-22% of all trauma cases [18][19][20].…”

Is emergency department thoracotomy effective in trauma resuscitation? The retrospective study of the emergency department thoracotomy in trauma patients at thammasat university hospital, Thailand

“…[5891112131415] The most successful location was cardiac injuries, especially a single cardiac penetrating wound, and the least successful was multiple injuries, especially blunt mechanisms. Another injury location, in this case severe head injuries, was examined in a study by Lustenberger et al , in which a Glasgow Coma Scale of <8 was related to unsuccessful EDT.…”

“…Furthermore, as with the previous literature, no conclusions can be made about prehospital and in-hospital mortality predictability factors. [5891112131415]…”