Longterm Outcomes after Combat Casualty Emergency Department Thoracotomy

Background

The incidence, survival, and blood product use after emergency department thoracotomy (EDT) in combat casualties is unknown.

Study Design

We performed a prospective and retrospective observational study of EDT at a combat support hospital in Iraq, evaluating the impact of injury mechanisms, blood product use, mortality, and longterm neurologic outcomes of survivors.

Results

From November 2003 to December 2007, 12,536 trauma admissions resulted in 101 EDTs (0.01%). In patients undergoing EDT, penetrating trauma from explosions and firearms accounted for the majority of injuries (93%). There were no survivors after EDT for blunt trauma (n=7). The areas of primary penetrating injury were the abdomen (30%), thorax (40%), and extremities (22%). Twelve percent (12 of 101) of all patients survived until evacuation, with the overall survival rate (8 to 26 months) of US casualties at 11% (6 of 53). There was no difference in survival seen in either injury mechanism or primary injury location. Signs of life were present in all overall survivors. Cardiopulmonary resuscitation (CPR) was performed in 92% (93 of 101) of all patients, and in 75% (9 of 12) of those evacuated. Mean (±SD) transfusion requirements for all patients were 15.0±12.7 U of RBC and 7.3±8.7 U of fresh frozen plasma during the initial resuscitation. Survivors demonstrated higher fresh frozen plasma:RBC ratios. All survivors were neurologically intact.

Conclusions

In the combat casualty with penetrating injury, arriving with signs of life, receiving CPR, and undergoing EDT, longterm survival with normal neurologic outcomes is possible. CPR is not a contraindication to performance of EDT in penetrating injuries if signs of life are present. A large amount of blood products are used in the resuscitation of EDT patients.

Abbreviations and Acronyms: CSH, combat support hospital, ED, emergency department, EDT, emergency department thoracotomy, FFP, fresh frozen plasma, GCS, Glasgow Coma Scale, ISS, Injury Severity Score