Emergency department thoracotomy

AMERICAN JOURNAL OF EMERGENCY MEDICINE. Volume 4, Number 6. November 1986

and Disability, the Neglected Disease of Modern Society. Washington, DC, 1966. 2. Copass MK, Oreskovich MR, Bladorgreen MR, et at Prehospital cardiopulmonary resuscitation of the critically injured patient. Am J Surg 1984;148:20-28. 3. Jacobs LM, Sinclair A, Beiser A. Prehospital advanced life support: benefits in trauma. J Trauma 1984;24:8-13. 4. Trunkey DD. Is ALS necessary for prehospital trauma care? J Trauma 1984;24:86-87. 5. Mackensie RC, Christensen JM, Lewis FR. The prehospital use of external counterpressure: Does MAST make a difference? J Trauma 1984;24:882-887. 6. Mattox KL, Pepe PE, Bickell W. A prospective randomized evaluation for the "MAST" garment in hemorrhagic shock. Abstract presented AAST Boston, September 12, 1985. 7. Cutler BS, Daggett W. Application of the G-suit to the control of hemorrhage in massive trauma. Arch Surg 1971 ;173:511-514. 8. Gaffney FA, Thai ER, Taylor WF. Hemodynamic effects of the medical antishock trousers. J Trauma 1981 ;21:931937. 9. Flint LM, Brown A, Richardson JD, et at Definitive control of bleeding from severe pelvic fractures. Ann Surg 1979; 189:709-716. 10. Pillegra R, Sandberg EC. Control of intractable abdominal bleeding by external counter pressure. JAM A 1979; 241 :708-712. 11. Abraham E, Cobo JC, Bland RD, et at Cardiorespiratory effects of pneumatic trousers in critically ill patients. Arch Surg 1984;119:912-915. 12. Bivins HG, Knapp R, Tiernan C, et at Blood volume displacement with inflation of antishock trousers. Ann Emerg Med 1982:409-412. 13. Niemann JT, Stapczynski JS, Rosborough JP, et at Hemodynamic effects of penumatic external counterpressure . in canine hemorrhagic shock. Ann Emerg Med 1983; 12:661-667. 14. Gallagher SS, Guyer B, Kotelchuck M, et at A strategy for the reduction of childhood injuries in Massachusetts: SCIPP. N Engl J Med 1982;307:1015-1018. 15. Anonymous. Accident prevention and injury control projects directed at children. Pub Health Rep 1980;95:499-500. 16. Gallagher SS, Finison K, Guyer B, et at The incidence of injuries among 87,000 Massachusetts children and adolescents: Results of the 1980-1981 statewide childhood injury prevention program surveillance system. Am J Pub Health 1984;74:1340-1347. 17. Gladiator antishock pants: Instructions for application, operation, and repair. Toledo, Ohio: Jobst Corporation, 1982. 18. Committee on Trauma, American College of Surgeons. Bull Am Call Surg 1983;68:11-18. 19. Holmes MJ, Reyes HM. A critical review of urban pediatric trauma. J Trauma 1984;24:253-255. 20. Mayer T, Walker ML, Johnson D, et at Causes of morbidity and mortality in severe pediatric trauma. JAMA 1981 ;245: 719-721.

EMERGENCY DEPARTMENT THORACOTOMY To tire Editor:- The article by Roberge et til on emergency department thoracotomy (AJEM 1986;4: 129-135) provides 574

some useful information, and is well presented. Two of the comments of the authors, however, require further discussion. The authors' recommendation that thoracotomy not be carried out on "unsalvageable" group IV (dead at the scene) patients may ultimately prove to be justified, as outcome has been relatively dismal in similar patients in a variety of series. Nevertheless, making such a drastic decision on the basis of the very few cases reported in the literature, not to mention the even smaller group of nine patients in the current series, is potentially dangerous. It would seem prudent to continue efforts to salvage all the victims of penetrating trauma (unless available personnel would by doing so have to choose against resuscitating some potentially more salvageable patients) until there is much greater combined experience that confirms this small initial set of data suggesting a dismal outcome in this group of patients. I find the authors' comments in their section entitled "Transportation Analysis" even more disconcerting. There is a great controversy over the question of "scoop and run" versus "field stabilization" for trauma victims, but definitive studies have not yet been performed. Although the small number of patients involved in this series would not allow firm conclusions regardless of the results (and could not be generalized to any patients other than those suffering penetrating trauma with cardiac arrest in the field), it is important to note that the authors have misstated the significance of their findings in an attempt to validate what seems to be their preconceived bias. They tell us that five of seven survivors in their series were brought to the hospital by private vehicle or police car, and thus represent a "scoop and run" situation, as opposed to only two survivors in the ambulance group. On this basis they suggest a superiority of the "scoop and run" approach. This is not so. Five survivors of 22 total patients in the private vehicle group (23%) is statistically extremely far from significant when compared with two survivors of 13 group VII/III patients (15%) in the ambulance group. In fact, since all the survivors in the series (except for one patient with a gunshot wound to the lung) sustained right ventricular injuries, the survival of two of three group VII/III patients with right ventricular injuries brought by ambulance is certainly equivalent to four survivors of eight group 1/lI/III patients with right ventricular injuries brought in with a "scoop and run" approach. No comparisons regarding one variable (such as mode of transportation) are valid unless the different groups are otherwise matched; speculation about survival based on method of transportation to hospital without any attempt to evaluate similarity of patients on the basis of other critical factors, such as weapon use, site of injury, and condition in the field (all of which the authors indicate elsewhere are important determinants of outcome), is invalid. It is unfortunate that the authors thus chose to make assertions about the importance of mode of transportation in the absence of attempts to match other critical variables, and even more so considering the fact that the proposed effect of mode of transportation is not significant statistically even when such (necessary) 'compensation for these other variables is not done. I believe this point is worth making for two reasons. First, it is important that conclusions based on research data be truly supported by those data; one of the most important reasons why many of the articles We all read do not allow us

CORRESPONDENCE

to make useful conclusions is because authors far too often fail to separate the effects of confounding variables. Second, our understanding of the specific issue of optimal prehospital care for trauma victims is not furthered by biased and unsupported speculation such as is found in this otherwise very useful article. Whether or not these authors' bias will be ultimately validated is not the issue; the fair and accurate reporting and interpretation of data is.

future studies of EDT in trauma victims to help resolve the overall impact, if any, of rapid transportation Upon ultimate survival. We continue this advocacy. RAYMOND J. RODERGE. !\IO RAO R. IVATURY,

xm

Lincoln Medical and Mental Health Center and the Nell' York Medical College Nell' York

JERmlE R. HOFFMAN, !\to

Department of Emergency Medicine UCLA Medical Center Los Angeles

The authors reply:-Dr. Hoffman states that our recommendation not to implement emergency department thoracotomy (EDT) in our Group IV ("dead on the scene")' patients is a measure not supported by the trauma literature. A brief review of the recent trauma literature would seem to support our contention, not refute it as Dr. Hoffman implies. Mattox and Feliciano? reported 100% mortality in 63 victims of penetrating thoracic trauma undergoing EDT after requiring greater than three minutes of CPR prior to arrival at a hospital. Cogbill et aP reported that, of 177 patients with blunt or penetrating trauma who had no vital signs at the scene of injury and then underwent EDT, the lone survivor was a patient who had sustained a severed brachial artery. These authors state that in their study the ratio of penetrating to blunt injuries was 2: I to 3: I. Thus, in that study, even at the more conservative 2: I ratio, over one-hundred patients with penetrating trauma and no vital signs at the scene were not successfully resuscitated with EDT. Flynn et at' reported on seven patients with penetrating trauma who presented without signs of life on arrival and had received CPR during air transport; again. none in this group survived. Rohman et afS reported no survivors among 18 victims of penetrating thoracic injuries who showed no signs of life in the field and subsequently underwent EDT. We have reported nine such cases in our study.' Thus, the trauma literature documents over 200 such cases since 1980. One can only wonder at how many more such cases would be reported if all articles on EDT utilized a patient classification system similar to ours to enable identification of those patients devoid of signs of life in the field. That application of EDT in trauma victims should be selective is a view shared by many authors with considerable experience in the field of trauma resuscitation.l-" Dr. Hoffman further states that our transportation analysis with respect to survival is faulty because of no "attempt to evaluate similarity of patients on the basis of other critical factors, such as weapon used, site of injury, and condition in the field." On the contrary, patients in our study were evaluated with regard to type of weapon used, site of injury, and status of vital signs at the scene, in transit, and upon arrival at the emergency department as outlined in Table 5 of our study. I The data from Table 5 demonstrate remarkable clinical similarity between the ambulance-transported patients and the "scoop and run" group in all parameters except numbers of survivors. We have never stated categorically that "scoop and run" is the definitive answer to field management of penetrating thoracic injuries. Rather, we have advocated the inclusion of pertinent transportation data in

References 1. Roberge RJ, Ivatury Rr, Stahl W, et al. Emergency department thoracotomy for penetrating injuries: Predictive value of patient classification. Am J Emerg Med 1986;4: 129-135. 2. Mattox KL, Feliciano DV. Role of external cardiac compression in truncal trauma. J Trauma 1982;22:934-936. 3. Cogbill TH, Moore EE. Millikan JS, et al. Rationale for selective application of emergency department thoracotomy in trauma. J Trauma 1983;23:453-460. 4. Flynn TC, Ward RE, Miller PW. Emergency department thoracotomy. Ann Emerg Med 1982;11:413-416. 5. Rohman M, Ivatury RR, Steichen FM, et al. Emergency room thoracotomy for penetrating cardiac injuries. J Trauma 1983;23:570-576. 6. Moore EE. Moore JB, Galloway AC, et al. Postinjury thoracotomy in the emergency department: A critical evaluation. Surgery 1979;86:590-598.

OPEN-CHEST CPR To the Editor:- The May 1986 article by Rosenthal and Turbiak (AJEM 1986;4:248-258) was a fascinating review of "Open-Chest Cardiopulmonary Resusitation." My comment is directed toward their opening statement: "The history of cardiac resusitation begins with the work of Professor Schiff in the latter half of the nineteenth century.'>" In this article, and other reviews, I have not seen any credit given to Dr. William Harvey, a great name in English medicine and experimental science. In 1628, his treatise "De Motu Cordis et San Guinis (on the-Motion of the Heart and Blood), states: "Experimenting with a pigeon upon on occasion, after the heart had wholly ceased to pulsate, and the auricles too had become motionless, I kept my finger wetted with saliva and warm for a short time upon the heart, and observed, that under the influence of this fomentation it recovered new strength and life, so that both ventricles and auricles pulsated, contracting and relaxing alternately, recalled as it were from death to life ... " I am not a medical historian. I respectfully submit this view-point for consideration to give Dr. William Harvey recognition as not just "father of cardiology and embryology" but also as a founding father of cardiac resusitation. RANDALL WILLIS, Ml)

Emergency Department Claiborne County Hospital Tazewell, Tennessee

ACADEMIC ASPIRATIONS OF RESIDENTS To the Editor:- The academic evolution of the specialty of emergency medicine includes the training of future faculty to 575