Indications for emergency thoracotomy in penetrating thoracic trauma
Background: Violent interpersonal acts account for a large proportion of unnatural deaths in South Africa. A significant proportion is due to penetrating thoracic trauma and the preventable haemorrhage it leads to. Current indications for emergency thoracotomy are unreliable. We propose the use of lactate, shock index (SI) and base deficit (BD) as a triage tool in patients with penetrating thoracic injuries to identify high-risk patients requiring surgical intervention in order to prevent treatment delays. Methods: A review of the trauma registry of the Charlotte Maxeke Johannesburg Academic Hospital was carried out between March 2011 and March 2016. We collected 491 patients consisting of a non-operative group of 245 patients and an operative group of 246 patients. We compared lactate; SI and BD independently and within panels to ascertain which would best predict the need for operative interventionin these patients. Abnormal was defined as lactate ≥ 4 mmol/l, SI ≥ 08 and BD ≤ -4 mmol/l. Results: Of the 491 patients, lactate (p <0.001), SI (p<0.001) and BD (p<0.001) differed significantly between operative and non-operative groups. Statistical significance was lost (p=0.34) once BD was analysed in combination with lactate and SI. Lactate alone was a strong predictor of intervention (AUC=0.814). The strongest predictor was a combined panel of lactate and SI (AUC=0.8308, p<0.001). Conclusion: Lactate and SI in combination are useful as triage tools that could assist in decision making, as well as aid in predicting which patients are more likely to require surgical intervention and thus avoid unnecessary delay.
A research report submitted in fulfilment of the requirements for the degree of Master of Medicine to the Faculty of Health Science, University of the Witwatersrand, Johannesburg, 2019