D. C. Patel1, N. K. Dhillon1, A. Ko1, C. Colovos1, N. Melo1, D. R. Margulies1, E. J. Ley1, G. Barmparas1 1Cedars-Sinai Medical Center,Los Angeles, CA, USA
Introduction: More than 50 years after its introduction, Emergency Department Thoracotomy (EDT) remains a heavily debated procedure due to the absence of high level evidence in its support. We have previously shown that there is significant variation among trauma centers in performing EDT for trauma patients in extremis, with liberal such centers performing additional, unnecessary procedures. We sought to explore the correlation between trauma center practices in regards to the performance of EDT and survival of patients admitted to these centers. We hypothesized that centers that are liberal in performing EDT would not necessarily have increased survival.
Methods: Level I and II trauma centers contributing data to the National Trauma Data Bank between 2007 to 2011 were included. Centers with < 200 subjects reported and ≤ 25 ED deaths (EDD) during the study period were excluded. The data was aggregated and the counts for EDT and EDD were calculated for each center. All centers were then divided into quartiles based on the ratio of EDT:EDD. A multivariate logistic regression model was then utilized to calculate the adjusted odds ratio (AOR) for mortality for patients admitted to each quartile. Patients admitted to centers with the lowest quartile (Q1) were used as the reference group. The primary outcome was overall mortality and mortality among subgroup of patients, including those with penetrating trauma and those with critical injuries (ISS≥25).
Results: A total of 174 trauma centers admitting 1,432,811 subjects were included. The median EDT:EDD ratio ranged from 0 for Q1 to 17.6% for centers in the highest quartile (Q4). Q4 centers were more likely to be Level I (Q4: 53% vs. Q1: 44%, p=0.03) and an academic center (Q4: 67% vs. Q1: 42%, p=0.05). Compared to patients admitted to Q1 centers, those admitted to Q4 centers had a significantly higher adjusted mortality (AOR: 1.06, p<0.01). This difference applied also to the subgroup of patients with a penetrating injury (AOR: 1.21, p<0.01). There was no difference in mortality for patients with critical injuries (AOR: 1.02, p=0.52).
Conclusion: Trauma centers where emergency department thoracotomy is liberally performed for trauma patients in extremis had higher adjusted mortality compared to less liberal centers. This paradoxical finding might be explained in part by triaging patients at extremely high risk for mortality to these centers that are liberal in performing those procedures. Further investigation of this phenomenon is required to identify areas for potential improvement and standardization of the management of the trauma patient in extremis, avoiding unnecessary interventions.