Survey of trauma surgeon practice of emergency department thoracotomy

•National survey of trauma surgeons was performed to examine ED thoracotomy (EDT) practice.•Many consider other factors beyond mechanism and timing when deciding to perform EDT.•Twenty percent of surgeons would never perform EDT in the setting of blunt traumatic arrest.•Despite published guidelines, there is little agreement on the best timing of EDT.

BackgroundThere continues to be significant debate in the trauma community regarding the indications for emergency department thoracotomy (EDT). Numerous studies have focused on the duration of arrest in EDT, whereas few have examined other factors that influence surgeon decision-making. We hypothesize that there is continued variability among surgeons in the use of EDT.MethodsA 13-question web-based survey was distributed to the membership of a large, national trauma association, examining demographics, trauma fellowship completion, trauma center designation, professional organization membership, and annual EDTs performed. Consideration of patient's age, comorbidities, total injury burden, and the use of technological adjuncts—such as ultrasound—was assessed. Respondents were asked when they would perform the procedure after loss of vital signs for blunt and penetrating trauma. Logistic regression determined factors influencing consideration of EDT.ResultsOverall 540 of 1,485 surveys were completed (36.4%). Patient age, total injury burden, and comorbidities are considered by 38.5%, 29.1%, and 55.7% of respondents, respectively. Technological adjuncts are used always or most of the time by 64% of respondents. A majority of respondents (51.9%) would perform an EDT for penetrating trauma with loss of vital signs 5 to 10 minutes before arrival. For blunt trauma, the largest group of respondents (47.0%) would perform an EDT only when loss of vital signs occurred in the ED. In addition, 20.6% would never perform EDT for blunt traumatic arrest.ConclusionsEDT decision-making is more nuanced than previously described. Variation continues in the use of thoracotomy after loss of vital signs, in both blunt and penetrating trauma. For both mechanisms, there remains little consensus on the appropriate duration of arrest before performing EDT after arrest despite published guidelines. A large proportion of surgeons consider other factors such as patient age, total injury burden, and comorbidities in addition to vital signs when deciding to perform an EDT. Technological adjuncts are frequently used by surgeons to determine the need for EDT.