J. R. Oliver1, C. J. DiMaggio3,4, M. L. Duenes1, A. M. Velez5, S. G. Frangos3, C. D. Berry5, M. Bukur3 1New York University School Of Medicine,New York, NY, USA 3New York University School Of Medicine,Department Of Surgery, Division Of Trauma And Acute Care Surgery,New York, NY, USA 4New York University School Of Medicine,Department Of Population Health,New York, NY, USA 5New York University School Of Medicine,Department Of Surgery,New York, NY, USA
Introduction: Previous studies have demonstrated a survival benefit for severely injured patients treated at Level 1 Trauma Centers (TCs). Emergency thoracotomy (ET) is a rare procedure performed on patients presenting in extremis. The objective of this study was to assess whether ET performed at Level 1 TCs is associated with improved survival.
Methods: This was a retrospective study utilizing the National Trauma Databank 2014-2015. Patients were stratified according to TC ACS verification level. Patient demographics, outcomes, and center characteristics were compared. Multivariate regression was conducted with mortality as the outcome adjusting for differences in patient characteristics.
Results: 1559 ETs were included in this study. 43.3% of ETs were performed at Level 1 TCs, while 14.1% were performed at Level 2 and 43.6% at other TCs. 1079 ETs were performed in the emergency department (ED) while 480 were performed in the operating room (OR). Over the two year study period, Level 1 TCs performed significantly more ETs (12.6 ± 16.4) than non-Level 1 TCs (6.3 ± 11.1, p = 0.0003). Mean patient age (34.6 years) and gender (85.8% male) were similar; more Hispanics and Caucasians were treated at Level 1 TCs (p < 0.0001). Patients treated at Level 1 TCs had higher median Injury Severity Score (ISS) (26.0 ± 20.0 vs. 25.0 ± 20.7, p = 0.007), were less likely to have signs of life on arrival (29.8% vs. 35.4%, p = 0.02), and were more likely to have severe (Abbreviated Injury Score ≥ 3) brain injuries (15.1% vs. 9.8%, p = 0.002) and abdominal injuries (36.4% vs. 27.0%, p = 0.004). Patients treated at level 1 TCs had significantly higher survival (24.3 vs. 19.5%, Adjusted Odds Ratio (AOR) = 1.44, 95% CI = 1.04 – 1.99, p = 0.03). ETs performed in the OR had 45.0% survival vs. 11.1% for ED (AOR = 2.30, 95% CI = 1.70 – 3.18, p < 0.0001), despite patients having a similar injury burden (ED median ISS 25.0 ± 21.5 vs. OR ISS 25.0 ± 17.5, p = 0.56). Penetrating injuries had 25.4% survival following ET vs. 13.7% for blunt injuries (AOR = 3.08, 95% CI = 2.18 – 4.39, p < 0.0001).
Conclusion: ETs performed at Level 1 TCs were associated with higher survival rates as compared with non-Level 1 TCs suggesting that survival after severe injury is to some degree procedurally related. Outcomes were also improved when ETs were performed in the controlled environment of the OR and on patients with penetrating mechanisms of injury.