CORRESPONDENCE the emergency center. J Thorac Cardiovasc Surg 66:886-895, 1974. 3. Pomerantz M, Hutchison D: Traumatic wounds of the heart. J Trauma 9:135-139, 1969.
Emergency Department Thoracotomy To the Editor: Regarding Dr. MacDonald and Dr. McDowell's article, ~'Emergency D e p a r t m e n t Thoracotomies in a Community Hospital" (7:423-428, 1978), we feel that an equally vital issue deserves comment; specifically, what critically injured patients should undergo this extreme resuscitative measure? In our recent 492 y e a r clinical review 1 of 146 t r a u m a victims undergoing emergency d e p a r t m e n t thoracotemy at the Denver General Hospital, 12 (8%) patients left the hospital alive but four were essentially brain-dead. Only eight (5%) regained functional cerebral activity. The cost of this in the emergency department was $950 (excluding physicians' fees) and exceeded $3500 if further pursued in the operating room. Patients with penetrating injuries of the heart may be salvaged despite minimal signs of life by relief of cardiac tamponade and rapid control of hemorrhage. These suspected injuries w a r r a n t an aggressive approach.2, ~ Indeed, the two long-term survivors in the MacDonald and McDowell s e r i e s had p e n e t r a t i n g heart wounds. We believe emergency d e p a r t m e n t thoracotomy for noncardiac injuries is a low yield, high-cost procedure, and advocate the following policy: 1) Critically injured patients with no signs of life (pulse, pupil reactivity, spontaneous respiration) at the site of the accident should not undergo resuscitation. 2) Patients having signs of life at the scene but none on arrival in the emergency department require selective resuscitation. 3) Multiple system t r a u m a and blunt injuries should be considered unsalvageable and supportive measures not initiated. The occasional young, otherwise h e a l t h y victim of an isolated penetrating injury, who is quickly transported from the scene, may benefit from emergency department thoracotomy. 4) Patients with no signs of life whose systolic blood pressure cannot be maintained above 70 mm Hg despite control of hemorrhage, adequate fluid and blood replacement, and aortic cross-clamping for 30 minutes should be declared dead in the emergency department. These patients should not be taken to the operating room for definitive t r e a t m e n t without a positive response to resuscitation.
Authors' Reply We agree t h a t emergency department thoracotomy for noncritical injury is probably a low yield, high-cost procedure. However, we disagree that critically injured patients "with no signs of life" at the scene of an accident "should not undergo resuscitation." We feel quite strongly this decision should be made in the more stable environment of a hospital by a physician, excepting such conditions as decapitation, incineration, or decomposition of the body. We disagree that the patient with multiple system t r a u m a is unsalvageable. Depending on the resources, the extent of the injury, and the expertise of the emergency measures rendered, some multiply injured patients do survive and deserve resuscitative attempts. We agree t h a t the heart-injured patient is probably t h e most salvageable of these patients but it is often impossible to discern who has the h e a r t injury until the resuscitation is well underway. We feel t h a t cost containment is an i m p o r t a n t issue but we are not sure of its applicability in the emergency setting when in fact there are so many other areas in which to concentrate on cost containment. The majority of victims of t r a u m a are salvageable. The patients can often return to a productive life and deserve vigorous attempts at resuscitation.
Jeffrey R. MacDonald, MD Richard M. McDowell, MD Department of Emergency Medicine St. Mary Medical Center - - B a u e r Hospital Long Beach, California
Impedance Plethysmography in Leg Vein Thrombosis To the Editor: I agree with Dr. Gross and Dr. Burney's point in their informative article, "Therapeutic and Economic Implications of Emergency Department Evaluation for Venous Thrombosis" (8:110-113, 1979), regarding the high cost of ruling out thrombophlebitis in the hospital. However, they are misleading readers on the accuracy of impedance plethysmography. They stated t h a t this procedure has been proven to be 95% accurate when compared with venography. This is not completely true. Impedance plethysmogr a p h y was only this accurate in proximal leg vein thrombosis studies. It showed very poor correlation with venograms in calf deep vein thrombophlebitis. In the references cited in the article, Benedict 1 showed only a 23% correlation between the two evaluation techniques, and Hull's findings 2 of false negative impedance plethysmography were even more misleading when evaluating the leg below the knee. This noninvasive procedure can be an excellent test to rule out
E r n e s t E. Moore, MD John B. Moore, MD Aubrey C. Galloway, MD Ben Eiseman, MD Department of Surgery Denver General Hospital Denver, Colorado 1. Moore EE, Moore JB, Galloway AC, et al: Post injury thoracotomy in the emergency department: a critical evaluation. Surgery (to be published). 2. Mattox KL, Beall AC, Jordan GL, et al: Cardiorrhaphy in
8:9 (September) 1979
JACEP
387/79
Emergency Department Thoracotomy To the Editor: Regarding Dr. MacDonald and Dr. McDowell's article, ~'Emergency D e p a r t m e n t Thoracotomies in a Community Hospital" (7:423-428, 1978), we feel that an equally vital issue deserves comment; specifically, what critically injured patients should undergo this extreme resuscitative measure? In our recent 492 y e a r clinical review 1 of 146 t r a u m a victims undergoing emergency d e p a r t m e n t thoracotemy at the Denver General Hospital, 12 (8%) patients left the hospital alive but four were essentially brain-dead. Only eight (5%) regained functional cerebral activity. The cost of this in the emergency department was $950 (excluding physicians' fees) and exceeded $3500 if further pursued in the operating room. Patients with penetrating injuries of the heart may be salvaged despite minimal signs of life by relief of cardiac tamponade and rapid control of hemorrhage. These suspected injuries w a r r a n t an aggressive approach.2, ~ Indeed, the two long-term survivors in the MacDonald and McDowell s e r i e s had p e n e t r a t i n g heart wounds. We believe emergency d e p a r t m e n t thoracotomy for noncardiac injuries is a low yield, high-cost procedure, and advocate the following policy: 1) Critically injured patients with no signs of life (pulse, pupil reactivity, spontaneous respiration) at the site of the accident should not undergo resuscitation. 2) Patients having signs of life at the scene but none on arrival in the emergency department require selective resuscitation. 3) Multiple system t r a u m a and blunt injuries should be considered unsalvageable and supportive measures not initiated. The occasional young, otherwise h e a l t h y victim of an isolated penetrating injury, who is quickly transported from the scene, may benefit from emergency department thoracotomy. 4) Patients with no signs of life whose systolic blood pressure cannot be maintained above 70 mm Hg despite control of hemorrhage, adequate fluid and blood replacement, and aortic cross-clamping for 30 minutes should be declared dead in the emergency department. These patients should not be taken to the operating room for definitive t r e a t m e n t without a positive response to resuscitation.
Authors' Reply We agree t h a t emergency department thoracotomy for noncritical injury is probably a low yield, high-cost procedure. However, we disagree that critically injured patients "with no signs of life" at the scene of an accident "should not undergo resuscitation." We feel quite strongly this decision should be made in the more stable environment of a hospital by a physician, excepting such conditions as decapitation, incineration, or decomposition of the body. We disagree that the patient with multiple system t r a u m a is unsalvageable. Depending on the resources, the extent of the injury, and the expertise of the emergency measures rendered, some multiply injured patients do survive and deserve resuscitative attempts. We agree t h a t the heart-injured patient is probably t h e most salvageable of these patients but it is often impossible to discern who has the h e a r t injury until the resuscitation is well underway. We feel t h a t cost containment is an i m p o r t a n t issue but we are not sure of its applicability in the emergency setting when in fact there are so many other areas in which to concentrate on cost containment. The majority of victims of t r a u m a are salvageable. The patients can often return to a productive life and deserve vigorous attempts at resuscitation.
Jeffrey R. MacDonald, MD Richard M. McDowell, MD Department of Emergency Medicine St. Mary Medical Center - - B a u e r Hospital Long Beach, California
Impedance Plethysmography in Leg Vein Thrombosis To the Editor: I agree with Dr. Gross and Dr. Burney's point in their informative article, "Therapeutic and Economic Implications of Emergency Department Evaluation for Venous Thrombosis" (8:110-113, 1979), regarding the high cost of ruling out thrombophlebitis in the hospital. However, they are misleading readers on the accuracy of impedance plethysmography. They stated t h a t this procedure has been proven to be 95% accurate when compared with venography. This is not completely true. Impedance plethysmogr a p h y was only this accurate in proximal leg vein thrombosis studies. It showed very poor correlation with venograms in calf deep vein thrombophlebitis. In the references cited in the article, Benedict 1 showed only a 23% correlation between the two evaluation techniques, and Hull's findings 2 of false negative impedance plethysmography were even more misleading when evaluating the leg below the knee. This noninvasive procedure can be an excellent test to rule out
E r n e s t E. Moore, MD John B. Moore, MD Aubrey C. Galloway, MD Ben Eiseman, MD Department of Surgery Denver General Hospital Denver, Colorado 1. Moore EE, Moore JB, Galloway AC, et al: Post injury thoracotomy in the emergency department: a critical evaluation. Surgery (to be published). 2. Mattox KL, Beall AC, Jordan GL, et al: Cardiorrhaphy in
8:9 (September) 1979
JACEP
387/79
