LIMITED UTILITY OF EMERGENCY DEPARTMENT THORACOTOMY

To assess the therapeutic role and cost effectiveness of resuscitative thoracotomy in an urban trauma center, a retrospective review of thor acotomies (n = 273) performed in a trauma unit between 1986 and 1992 w as undertaken. A total of 252 thoracotomies were performed for penetra ting injuries (92%), and 21 (8%) were performed for blunt trauma. Ten neurologically intact survivors (3.7%) were identified. Mechanisms of injury in survivors were stab wound (n = 6) and gunshot wound (n = 4). There were no neurologically intact survivors when resuscitative thor acotomy was done for blunt trauma. All survivors sustained penetrating truncal injuries, isolated thoracic injuries existed in six patients, while four patients presented with both thoracic and abdominal wounds . All survivors had signs of life either in the field or in the trauma unit. Of the 242 nonsurvivors who had sustained penetrating trauma, o nly 49 had signs of life either in the field or upon arrival at the tr auma unit. In this group, survival was 17 per cent. Revised Trauma Sco res, calculated in the trauma unit, failed to differentiate between su rvivors and nonsurvivors. In 1992, the average hospital charge for res uscitative thoracotomy was $3413 per patient. Total charges during the study period for resuscitative thoracotomy were approximately $932,00 0. This represents an expenditure of $93,000 per successful thoracotom y. If thoracotomy was limited to patients sustaining penetrating traum a who demonstrated signs of life, total charges would be approximately $201,367, representing an expenditure of $20,137 per successful thora cotomy. Our series confirms that 1) resuscitative thoracotomy should b e reserved for patients with reasonable potential for salvage (i.e., p enetrating truncal injury with signs of life in the field or in the tr auma unit); 2) thoracotomy should not be performed on patients sustain ing blunt trauma; 3) the Revised Trauma Score was not useful in predic ting survival of individual patients; and 4) a substantial reduction i n costs would result if these guidelines were followed.