A systematic review of 3251 emergency department thoracotomies: is it time for a national database?

Survival predictor in emergency resuscitative thoracotomy for blunt trauma patients: Insights from a Chinese trauma center

PURPOSE

Emergency resuscitative thoracotomy (ERT) is a final salvage procedure for critically injured trauma patients. Given its low success rate and ambiguous indications, its use in blunt trauma scenarios remains highly debated. Consequently, our study seeks to ascertain the overall survival rate of ERT in blunt trauma patients and determine which patients would benefit most from this procedure.

METHODS

A retrospective case-control study was conducted for this research. Blunt trauma patients who underwent ERT between January 2020 and December 2023 in our trauma center were selected for analysis, with the endpoint outcome being in-hospital survival, divided into survival and non-survival groups. Inter-group comparisons were conducted using Chi-square and Fisher's exact tests, the Kruskal-Wallis test, Student's t-test, or the Mann-Whitney U test. Univariate and multivariate logistic regression analyses were conducted to assess potential predictors of survival. Then, the efficacy of the predictors was assessed through sensitivity and specificity analysis.

RESULTS

A total of 33 patients were included in the study, with 4 survivors (12.12%). Multivariate logistic regression analysis indicated a significant association between cardiac tamponade and survival, with an adjusted odds ratio of 33.4 (95% CI: 1.31 - 850, p = 0.034). Additionally, an analysis of sensitivity and specificity, targeting cardiac tamponade as an indicator for survivor identification, showed a sensitivity rate of 75.0% and a specificity rate of 96.6%.

CONCLUSION

The survival rate among blunt trauma patients undergoing ERT exceeds traditional expectations, suggesting that select individuals with blunt trauma can significantly benefit from the procedure. Notably, those presenting with cardiac tamponade are identified as the subgroup most likely to derive substantial benefits from ERT.

Predictors of long-term survival in 5,680 patients admitted to a UK major trauma centre with thoracic injuries

INTRODUCTION

The long-term outcomes of chest trauma are largely unknown. We sought to determine the predictors of in-hospital and long-term survival in patients admitted to a major trauma centre (MTC) with chest injuries and to evaluate spatial patterns of injury in our network area.

METHODS

Retrospective analysis of data collected on the National Trauma Audit Research Network (TARN) database using multivariate analysis and Cox regression analysis. Spatial analysis was performed using ArcGis 10.7.1.

RESULTS

Some 5,680 patients were admitted with chest trauma between December 1999 and December 2019. Median patient age was 45 years and the median Injury Severity Score (ISS) was 20. The proportion of patients who had an operation was 39.8%. Age, blood transfusion, head injury, shock, emergency thoracotomy and heart disease were predictors of hospital mortality (p < 0.05). However, having an operation on concomitant injuries was protective. ISS and Glasgow Coma Score were discriminators of in-hospital mortality (C-indices 0.76 and 0.80, respectively). The 10-year survival values for patients who survived to discharge from hospital and who were aged <40, 50, 60, 70, 80 and >80 years were 99%, 93%, 95%, 87%, 75% and 43%, respectively. Preadmission lung disease and alcohol/drug misuse were poor predictors of long-term survival (p < 0.05). Hotspot analysis revealed the areas with the highest incidents were all close to the MTC.

CONCLUSIONS

The MTC is geographically central to areas with high numbers of trauma incidents. Although emergency thoracotomy was a predictor of poor in-hospital outcomes, having surgery for concomitant injuries improved outcomes. Patients surviving to discharge have good long-term survivals.

Performance and outcome of ressucitative thoracotomies in a southern Brazil trauma center: a 7-year retrospective analysis

OBJECTIVE

the study aims to analyze the performance and outcome of resuscitation thoracotomy (TR) performed in patients victims of penetrating and blunt trauma in a trauma center in southern Brazil during a 7 years period.

METHODS

retrospective study based on the analysis of medical records of patients undergoing TR, from 2014 to 2020, in the emergency service of the Hospital do Trabalhador, Curitiba - Paraná, Brazil.

RESULTS

a total of 46 TR were performed during the study period, of which 89.1% were male. The mean age of patients undergoing TR was 34.1±12.94 years (range 16 and 69 years). Penetrating trauma corresponded to the majority of indications with 80.4%, of these 86.5% victims of gunshot wounds and 13.5% victims of knife wounds. On the other hand, only 19.6% undergoing TR were victims of blunt trauma. Regarding the outcome variables, 84.78% of the patients had declared deaths during the procedure, considered non-responders. 15.22% of patients survived after the procedure. 4.35% of patients undergoing TR were discharged from the hospital, 50% of which were victims of blunt trauma.

CONCLUSION

the data obtained in our study are in accordance with the world literature, reinforcing the need for a continuous effort to perform TR, respecting its indications and limitations in patients victims of severe penetrating or blunt trauma.

A Life Saving Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with Open Groin Technique

A 53-year-old male pedestrian was hit by a car and arrived at our hospital with a blunt abdominal injury and hemorrhagic shock. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was performed in a timely fashion using the open groin technique in the emergency room. The procedure resulted in rapid improvement of hemodynamic status while the bleeding source was controlled. Recently, REBOA is a proper adjunctive procedure in major non-compressible torso hemorrhage patients. The procedure requires a portable X-ray or fluoroscopic machine in the ER to confirm the balloon’s position. This method has likely limited the use of REBOA in developing countries. The procedure with open groin technique, using anatomical landmarks and physiologic change to confirm the position of the balloon, has been developed to address these concerns. Here we report on the treatment’s success with this technique and believe that it can benefit trauma patient care.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review

BACKGROUND

Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries.

METHODS

Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints.

RESULTS

A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT.

CONCLUSIONS

EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

[Indications, procedure and outcome of prehospital emergency resuscitative thoracotomy-a systematic literature search]

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.

Performance and outcome evaluation of emergency resuscitative thoracotomy in a Norwegian trauma centre: a population-based consecutive series with survival benefits

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.

Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients with signs of life upon hospital arrival: a retrospective multicenter study

Background

The effectiveness and indications of open-chest cardiopulmonary resuscitation (OCCPR) have been still debatable. Although current guidelines state that the presence of signs of life (SOL) is an indication for OCCPR, scientific evidence corroborating this recommendation has been scarce. This study aimed to compare the effectiveness of OCCPR to closed-chest cardiopulmonary resuscitation (CCCPR) in severe trauma patients with SOL upon arrival at the emergency department (ED).

Methods

A retrospective cohort study analyzing data from the Trauma Quality Improvement Program (TQIP) database, a nationwide trauma registry in the USA, between 2010 and 2016 was conducted. Severe trauma patients who had SOL upon arrival at the hospital and received cardiopulmonary resuscitation within the first 6 h of ED admission were identified. Survival to hospital discharge was evaluated using logistic regression analysis, instrumental variable analysis, and propensity score matching analysis adjusting for potential confounders.

Results

A total of 2682 patients (OCCPR 1032; CCCPR 1650) were evaluated; of those 157 patients (15.2%) in the OCCPR group and 193 patients (11.7%) in the CCCPR group survived. OCCPR was significantly associated with higher survival to hospital discharge in both the logistic regression analysis (adjusted odds ratio [95% confidence interval] = 1.99 [1.42–2.79], p <  0.001) and the instrumental variable analysis (adjusted odds ratio [95% confidence interval] = 1.16 [1.02–1.31], p = 0.021). In the propensity score matching analysis, 531 matched pairs were generated, and the OCCPR group still showed significantly higher survival at hospital discharge (89 patients [16.8%] in the OCCPR group vs 58 patients [10.9%] in the CCCPR group; odds ratio [95% confidence interval] = 1.66 [1.13–2.42], p = 0.009).

Conclusions

Compared to CCCPR, OCCPR was associated with significantly higher survival at hospital discharge in severe trauma patients with SOL upon ED arrival. Further studies to confirm these results and to assess long-term neurologic outcomes are needed.

Improving out-of-hospital notification in traumatic cardiac arrests with novel usage of smartphone application

INTRODUCTION

Timely out-of-hospital notifications in patients with traumatic cardiac arrest are associated improvements in mortality. Details surrounding these events are often limited, and decisions to perform advanced resuscitative procedures must be made based on limited data. This study evaluated the ability of a mobile application (app) called Citizen (sp0n Inc., New York, NY) to address these issues by providing a novel, secondary source of out-of-hospital information in traumatic cardiac arrest. Citizen sends notifications to mobile devices in response to nearby detected public safety events, and we sought to evaluate its utility in prenotification for traumatic cardiac arrest.

METHODS

This was a retrospective observational study. Patients ≥ 15 years of age with traumatic cardiac arrest attributed to penetrating trauma were included. The 2 coprimary outcomes observed were the time difference between the app notification and emergency medical services notification, and the app's success rate in generating a notification for each patient in traumatic cardiac arrest.

RESULTS

From February 2, 2019 to October 10, 2019, there were 43 patients who met the criteria for this study. On average, the Citizen app notification arrived 12.9 minutes before emergency medical services radio notification (95% confidence interval, 9.2-16.6; P < 0.001). Citizen generated a notification for 36 of 43 patients (84%).

CONCLUSION

The Citizen app generates earlier notifications in traumatic cardiac arrest compared with standard radio communications. It also provides a previously unavailable secondary source of information for making rapid resuscitative decisions upon the arrival of the arresting patient to the emergency department. Further research is needed to determine how to optimally integrate the app into existing trauma systems.

Outcomes and indications for emergency thoracotomy after adoption of a more liberal policy in a western European level 1 trauma centre: 8-year experience

The role of emergency thoracotomy (ET) in blunt trauma is still a matter of debate and in Europe only a small number of studies have been published. We report our experience about ET both in penetrating and blunt trauma, discussing indications, outcomes and proposing an algorithm for patient selection. We retrospectively analysed patients who underwent ET at Maggiore Hospital Trauma Center over two periods: from January 1st, 2010 to December 31st, 2012, and from January 1st, 2013 to May 31st, 2017. Demographic and clinical data, mechanism of injury, Injury Severity Score, site of injury, time of witnessed cardiac arrest, presence/absence of signs of life, length of stay were considered, as well as survival rate and neurological outcome. 27 ETs were performed: 21 after blunt trauma and 6 after penetrating trauma. Motor vehicle accident was the main mechanism of injury, followed by fall from height. The mean age was 40.5 years and the median Injury Severity Score was of 40. The most frequent injury was cardiac tamponade. The overall survival rate was 10% during the first period and 23.5% during the second period, after the adoption of a more liberal policy. No long-term neurological sequelae were reported. The outcomes of ET in trauma patient, either after penetrating or blunt trauma, are poor but not negligible. To date, only small series of ET from European trauma centres have been published, although larger series are available from USA and South Africa. However, in selected patients, all efforts must be made for the patient’s survival; the possibility of organ donation should be taken into consideration as well.