1
|
Krammel M, Frimmel N, Hamp T, Grassmann D, Widhalm H, Verdonck P, Reisinger C, Sulzgruber P, Schnaubelt S. Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 - 2017. Injury 2024; 55:110971. [PMID: 37544864 DOI: 10.1016/j.injury.2023.110971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/08/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Trauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe - with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on. METHODS For this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician. RESULTS We included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients. CONCLUSIONS Severe cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented. TRIAL REGISTRATION Retrospective analysis without intervention.
Collapse
Affiliation(s)
| | - Nikolaus Frimmel
- Dept. of Anaesthesia, General Intensive Care Medicine, and Pain Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Hamp
- Emergency Medical Service Vienna, Vienna, Austria; Dept. of Anaesthesia, General Intensive Care Medicine, and Pain Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Harald Widhalm
- Dept. of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Philip Verdonck
- Dept. of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium
| | | | - Patrick Sulzgruber
- Division of Cardiology, Dept. of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Sebastian Schnaubelt
- Dept. of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium; Dept. of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
2
|
Stretch B, Gomez D. Resuscitative thoracotomy in blunt traumatic cardiac arrest. Scand J Trauma Resusc Emerg Med 2022; 30:30. [PMID: 35468804 PMCID: PMC9036700 DOI: 10.1186/s13049-022-01010-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Denise Gomez
- Barts And The London school of Anaesthesia, London, UK
| |
Collapse
|
3
|
Almond P, Morton S, OMeara M, Durge N. A 6-year case series of resuscitative thoracotomies performed by a helicopter emergency medical service in a mixed urban and rural area with a comparison of blunt versus penetrating trauma. Scand J Trauma Resusc Emerg Med 2022; 30:8. [PMID: 35081989 PMCID: PMC8793242 DOI: 10.1186/s13049-022-00997-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background Resuscitative thoracotomy (RT) is an intervention that can be performed in the prehospital setting for relieving cardiac tamponade and/or obtaining vascular control of suspected sub-diaphragmatic haemorrhage in patients in traumatic cardiac arrest. The aim of this retrospective case study is to compare the rates of return of spontaneous circulation (ROSC) in RTs performed for both penetrating and blunt trauma over 6 years in a mixed urban and rural environment. Methods The electronic records of a single helicopter emergency medical service were reviewed between 1st June 2015 and 31st May 2021 for RTs. Anonymised data including demographics were extracted for relevant cases. Data were analysed with independent t-tests and Χ2 tests. A p value < 0.05 was considered statistically significant. Results Forty-four RTs were preformed within the 6 years (26 for blunt trauma). Eleven ROSCs were achieved (nine blunt, two penetrating) but no patient survived to discharge. In contrast to RTs for penetrating trauma, twelve of the RTs for blunt trauma had a cardiac output present on arrival of the prehospital team (p = 0.01). Two patients had an RT performed in a helicopter (one ROSC) and two on a helipad (both achieving ROSC), likely due to the longer transfer times seen in a more rural setting. Four of the RTs for blunt trauma (15%) were found to have a cardiac tamponade versus seven (39%) of the penetrating trauma RTs. Conclusion Prehospital RT remains a procedure with low rates of survival but may facilitate a ROSC to allow patients to reach hospital and surgery, particularly when distances to hospitals are greater. A higher-than-expected rate of cardiac tamponade was seen in RTs for blunt trauma, although not caused by a right ventricular wound but instead due to underlying vessel damage. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-00997-4.
Collapse
Affiliation(s)
- Phillip Almond
- Essex and Herts Air Ambulance, Earls Colne, Colchester, Essex, CO6 2NS, UK
| | - Sarah Morton
- Essex and Herts Air Ambulance, Earls Colne, Colchester, Essex, CO6 2NS, UK.
| | - Matthew OMeara
- Essex and Herts Air Ambulance, Earls Colne, Colchester, Essex, CO6 2NS, UK
| | - Neal Durge
- Essex and Herts Air Ambulance, Earls Colne, Colchester, Essex, CO6 2NS, UK
| |
Collapse
|
4
|
Plodr M, Safr M, Novak I. Thoracic aortic rupture due to airbag deployment. World J Emerg Med 2021; 12:327-329. [PMID: 34512833 DOI: 10.5847/wjem.j.1920-8642.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 05/26/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Michal Plodr
- Department of Emergency Medicine and Military General Medicine, Faculty of Military Health Sciences, University of Defence, Hradec Kralove 50001, Czech Republic.,Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove 50002, Czech Republic
| | - Miroslav Safr
- Department of Forensic Medicine, University Hospital Hradec Kralove, Hradec Kralove 50005, Czech Republic
| | - Ivo Novak
- Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove 50002, Czech Republic
| |
Collapse
|
5
|
Skarupa DJ. The Evolution of Thoracotomy. J Am Coll Surg 2021; 231:719-720. [PMID: 33243400 DOI: 10.1016/j.jamcollsurg.2020.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 10/22/2022]
|
6
|
Schimrigk J, Baulig C, Buschmann C, Ehlers J, Kleber C, Knippschild S, Leidel BA, Malysch T, Steinhausen E, Dahmen J. [Indications, procedure and outcome of prehospital emergency resuscitative thoracotomy-a systematic literature search]. Unfallchirurg 2020; 123:711-723. [PMID: 32140814 DOI: 10.1007/s00113-020-00777-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital resuscitative thoracotomy (PHRT) is a controversially discussed measure for the acute treatment of traumatic cardiac arrest (TCA) recommended by the current guidelines of the European Resuscitation Council (ERC). The aim of this work is the comprehensive presentation and summary of the available literature with the underlying hypothesis that the available publications show the feasibility and survival following PHRT in patients with TCA with a good neurological outcome. METHOD A systematic literature search was performed in the databases PubMed, EMBASE, Google Scholar, Springer LINK and Cochrane. The study selection, data extraction and evaluation of bias potential were performed independently by two authors. The outcome of patients with TCA after PHRT was selected as the primary endpoint. RESULTS A total of 4616 publications were found of which 21 publications with a total of 287 patients could be included in the analyses. For a detailed descriptive analysis, 15 publications with a total of 205 patients were suitable. The TCA of these patients was most commonly caused by pericardial tamponade, thoracic vascular injuries and severe extrathoracic multiple injuries. In 24% of the cases TCA occurred in the presence of the emergency physician. Clamshell thoracotomy (53%) was used preclinically more often than anterolateral thoracotomy (47%). Of the PHRT patients after TCA 12% (25/205) left the hospital alive, 9% (n = 19/205) with good neurological outcome and 1% (n = 3/205) with poor neurological outcome (according to the Glasgow outcome scale, GOS). CONCLUSION The prognosis of TCA seems to be much better than has long been assumed. Decisive for the success of resuscitation efforts in TCA seems to be the immediate, partly invasive treatment of all reversible causes. The measures for TCA recommended by the ERC resuscitation guidelines, seem to be poorly implemented, especially in the preclinical setting. A controversy regarding the recommendations of the guidelines is the question of whether a PHRT can be successfully implemented and if the comprehensive introduction in Germany seems to be meaningful. Despite the recommendation of the guidelines, this systematic review and meta-analysis underlines the lack of high-quality evidence on PHRT, whereby a survival probability to hospital discharge of 12% was reported, of which 75% had a good neurological outcome. The risk of bias of the results in individual publications as well as in this review is high. Further systematic research in the field of preclinical trauma resuscitation is particularly necessary also for acceptance of the guidelines.
Collapse
Affiliation(s)
- J Schimrigk
- Lehrstuhl für Didaktik und Bildungsforschung im Gesundheitswesen, Department Humanmedizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - C Baulig
- Institut für Medizinische Biometrie und Epidemiologie (IMBE), Department Humanmedizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - C Buschmann
- Institut für Rechtsmedizin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
- AG Trauma, Deutscher Rat für Wiederbelebung - German Resuscitation Council (GRC), Ulm, Deutschland
| | - J Ehlers
- Lehrstuhl für Didaktik und Bildungsforschung im Gesundheitswesen, Department Humanmedizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - C Kleber
- AG Trauma, Deutscher Rat für Wiederbelebung - German Resuscitation Council (GRC), Ulm, Deutschland
- Chirurgische Notaufnahme, Universitätszentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum TU Dresden, Dresden, Deutschland
| | - S Knippschild
- Institut für Medizinische Biometrie und Epidemiologie (IMBE), Department Humanmedizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - B A Leidel
- Zentrale Notaufnahme, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - T Malysch
- Klinik für Anästhesiologie und Intensivtherapie, Klinikum Brandenburg, Medizinische Hochschule Brandenburg, Brandenburg, Deutschland
| | - E Steinhausen
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Duisburg, Deutschland
- Ärztliche Leitung Rettungsdienst Berlin, Fakultät für Gesundheit, Department Humanmedizin, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58455, Witten, Deutschland
| | - J Dahmen
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Duisburg, Deutschland.
- Ärztliche Leitung Rettungsdienst Berlin, Fakultät für Gesundheit, Department Humanmedizin, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58455, Witten, Deutschland.
- Ärztliche Leitung Rettungsdienst, Berliner Feuerwehr, Voltairestraße 2, 10179, Berlin, Deutschland.
| |
Collapse
|
7
|
Thorsen K, Vetrhus M, Narvestad JK, Reite A, Larsen JW, Vennesland J, Tjosevik KE, Søreide K. Performance and outcome evaluation of emergency resuscitative thoracotomy in a Norwegian trauma centre: a population-based consecutive series with survival benefits. Injury 2020; 51:1956-1960. [PMID: 32522355 DOI: 10.1016/j.injury.2020.05.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/08/2020] [Accepted: 05/23/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Emergency resuscitative thoracotomy (ERT) is a lifesaving procedure for select indications in severely injured patients. The main body of the literature stem from regions with a high prevalence of penetrating injuries, while data from European institutions remain scarce. We aimed to evaluate a decade of ERT in a Norwegian trauma centre. METHODS A prospectively collected series from the institutional trauma registry of all consecutive trauma patients who had an ERT at Stavanger University Hospital (SUH) from 2006 to 2018. Data were extracted using both registry and electronic patient record (EPR) data, including injury profile, demographics and outcomes. Comparison of groups were done by descriptive statistics. RESULTS A total of 26 ERTs were performed during the study period, of which 20 were men (75%) and 6 women (25%). Five patients (19%) survived to hospital discharge, of which 3 men and 2 women with a median age of 46 years (range 24-68). All survivors had thoracic injury as location of major injury (LOMI.). Of the five survivors, four suffered blunt injury and one patient penetrating injury. At one-year of follow-up of the survivors, three patients scored 8/8 on Glasgow outcome scale-extended, 1 patient scored 7/8 and one patient 5/8. CONCLUSION In this study, ERT conferred good outcome with survival in one of every five procedures. Performing ERT in severely injured patients presenting in extremis appears to be justified even in low-volume centres and in blunt trauma.
Collapse
Affiliation(s)
- K Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
| | - M Vetrhus
- Department of Vascular Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J K Narvestad
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - A Reite
- Department of Vascular Surgery, Stavanger University Hospital, Stavanger, Norway
| | - J Wiik Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - J Vennesland
- Department of Vascular Surgery, Stavanger University Hospital, Stavanger, Norway
| | - K E Tjosevik
- Department of Emergency Medicine, Stavanger University Hospital, Stavanger, Norway
| | - K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
8
|
Leenen LPH. Penetrating trauma and invasive management of thorax trauma. Eur J Trauma Emerg Surg 2018; 44:803-804. [PMID: 30456417 DOI: 10.1007/s00068-018-1052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- L P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands.
| |
Collapse
|
9
|
Nevins EJ, Bird NTE, Malik HZ, Mercer SJ, Shahzad K, Lunevicius R, Taylor JV, Misra N. A systematic review of 3251 emergency department thoracotomies: is it time for a national database? Eur J Trauma Emerg Surg 2018; 45:231-243. [PMID: 30008075 DOI: 10.1007/s00068-018-0982-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/10/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world. METHODS Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications. RESULTS Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012). CONCLUSIONS Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.
Collapse
Affiliation(s)
- Edward John Nevins
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.
| | - Nicholas Thomas Edward Bird
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Hassan Zakria Malik
- Liverpool Medical School, University of Liverpool, Liverpool, UK.,North West Hepatobiliary Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Simon Jude Mercer
- Liverpool Medical School, University of Liverpool, Liverpool, UK.,Department of Anaesthesia, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Khalid Shahzad
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - Raimundas Lunevicius
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - John Vincent Taylor
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - Nikhil Misra
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| |
Collapse
|