Current opinion regarding indications for emergency department thoracotomy

Background. Emergency department thoracotomy (EDT) is a dramatic but rarely lifesaving intervention. Clinical variability regarding indications for ED T has yet to be quantified. Members of the Eastern and American Association s for the Surgery of Trauma were questioned by mail to evaluate which clini cal and demographic factors influence the decision to perform EDT and wheth er physicians perform EDT in accordance with current practice guidelines. Methods. A single mailing of an anonymous survey was sent to 1,124 surgeons to collect institutional and physician demographics as well as indications for EDT on the basis of variable mechanisms of trauma, duration of arrest, and signs of life (SOL). Statistical analysis included the Pearson and lin ear-by-linear association chi (2) tests, independent samples t test, and un ivariate and multivariate analyses of variance; p values of < 0.05 were con sidered significant. Results. Completed surveys were received from 358 respondents. After 54 sur veys were excluded that were incomplete, late, or from noneligible responde nts, 304 surveys were analyzed. There were no significant differences in ED T indications among institutions of differing caseload volume, exposure to penetrating trauma, trauma level designation, American College of Surgeons verification status, or residency program affiliation. In addition, neither the respondent's position nor whether attendings versus residents performe d the majority of EDTs influenced clinical decision-making. Performance cri teria for EDT were liberal in comparison with established guidelines, espec ially for blunt trauma. The presence or recent loss of SOL influenced respo nses, but respondents varied greatly in their definition of SOL. Conclusion. A lack of agreement exists regarding the indications for EDT in multiple clinical scenarios as well as in defining SOL. Indications for ED T were liberal, especially for blunt trauma-related indications, and were d etermined by clinical parameters, not by physician or institutional factors . Our results suggest that clinical practice is at variance with Advanced T rauma Life Support guidelines. We recommend that practice guidelines for ED T be established on the basis of a consensus definition of SOL to allow for a more uniform and selective approach to EDT.