J. C. L’Huillier1,2,3, K. Jalal4, J. D. Boccardo4, O. Olafuyi1, M. B. Jordan1,3, S. D. Schwaitzberg1, K. Noyes1,2, C. A. Cooper1,3 1University at Buffalo, Surgery, Buffalo, NY, USA 2University at Buffalo, Epidemiology And Environmental Health, Buffalo, NY, USA 3Erie County Medical Center, Surgery, Buffalo, NY, USA 4University at Buffalo, Biostatistics, Buffalo, NY, USA
Introduction: The Emergency Department transverse thoracotomy is a last-ditch effort to resuscitate trauma patients in cardiac arrest with signs of life. Median sternotomy also provides access to vital chest structures but is typically performed in more stable patients. Opinions differ on the adequacy of surgical exposure in the chest trauma patient. We sought to examine patterns of utilization of these procedures and corresponding outcomes across trauma centers to inform optimal trauma practices.
Methods: The 2016-2019 TQIP database was queried for patients who underwent thoracotomy or sternotomy for hemorrhage control surgery. Data extracted included patient demographics, comorbidities, admission vital signs, injury severity indices, hospital and ICU LOS, days on mechanical ventilation, and mortality. Univariate analyses, by procedure, were conducted using chi-square or Wilcoxon testing for categorical and continuous data, respectively. Multivariate analyses, propensity score matched comparisons, and survival probability calculations were used to compare outcomes.
Results: The analysis included 5,604 patients who underwent thoracotomy and 320 patients who underwent sternotomy. There were no significant differences in age or gender composition between groups, but sternotomy patients were more likely to be white. The distributions of the use of both procedures were similar by trauma center level and hospital size. Patients who underwent thoracotomy had higher acuity [lower admission systolic blood pressure (53.6 +/- 59.1 vs 96.7 +/- 43.0, p<0.0001), lower admission respiratory rate (12.9 +/- 12.0 vs 20.3 +/- 8.8, p<0.0001), higher ISS (31.3 +/- 19.7 vs 27.5 +/- 15.3, p=0.009), and lower GCS (5.4 +/- 4.4 vs 10.7 +/- 5.1, p<0.0001)] compared to sternotomy patients. However, patients who underwent thoracotomy had lower AIS- Thorax (3.6 +/- 1.7 vs 4.2 +/- 1.2, p<0.0001) and a lower number of comorbidities (0.35 +/- 0.75 vs 0.78 +/- 1.1, p<0.0001). Sternotomy patients had significantly lower 24-hour and overall mortality leading to longer LOS on bivariate (Table 1) and propensity-adjusted analyses [RR=0.60, 95% CI (0.48-0.76), p<0.0001 for 24-hour mortality and RR=0.44, 95% CI (0.36-0.54), p<0.0001 for overall mortality].
Conclusions: Sternotomy could offer significant survival benefit to more stable trauma patients admitted with chest injury when thoracotomy is not mandated by clinical condition. More research is needed to better understand the mechanism behind this benefit and reasons for racial variation in access to the procedure. This could guide the development of new protocols allowing for at-the-door, instantaneous triage to the operating room for sternotomy for select patients.
