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de Malleray H, de Lesquen H, Boddaert G, Raux M, Lefrançois V, Delhaye N, Ponsin P, Cordorniu A, Floch T, Bounes F, Gaertner E, Hardy A, Bordes J, Meaudre É, Cardinale M. French practice of emergency resuscitative thoracotomy. A study based on the Traumabase Registry. J Visc Surg 2024:S1878-7886(24)00095-X. [PMID: 39097430 DOI: 10.1016/j.jviscsurg.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
AIM OF THE STUDY Emergency resuscitative thoracotomy (ERT) has been described as a potentially life-saving procedure for trauma patients who have been admitted in refractory shock or with recent loss of sign of life (SOL). This nationwide registry analysis aimed to describe the French practice of ERT. PATIENTS AND METHODS From 2015 to 2021, all severe trauma patients who underwent ERT were extracted from the TraumaBase→ registry. Demographic data, prehospital management and in-hospital outcomes were recorded to evaluate predictors of success-to rescue after ERT at 24-hour and 28-day. RESULTS Only 10/26 Trauma centers have an effective practice of ERT, three of them perform more than 1 ERT/year. Sixty-six patients (74% male, 49/66) with a median age of 37 y/o [26-51], mostly with blunt trauma (52%, 35/66) were managed with ERT. The median pre-hospital time was 64mins [45-89]. At admission, the median injury severity score was 35 [25-48], and 51% (16/30) of patients have lost SOL. ERT was associated with a massive transfusion protocol including 8 RBCs [6-13], 6 FFPs [4-10], and 0 PCs [0-1] in the first 6h. The overall success-to-rescue after ERT at 24-h and 28-d were 27% and 15%, respectively. In case of refractory shock after penetrating trauma, survival was 64% at 24-hours and 47% at 28-days. CONCLUSIONS ERT integrated into the trauma protocol remains a life-saving procedure that appears to be underutilized in France, despite significant success-to-rescue observed by trained teams for selected patients.
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Affiliation(s)
- Hilaire de Malleray
- Department of Anesthesiology and Critical Care Medicine, Sainte Anne Military Teaching Hospital, Toulon, France.
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
| | - Guillaume Boddaert
- Department of Thoracic and Vascular Surgery, Percy Military Teaching Hospital, Clamart, France.
| | - Mathieu Raux
- Department of Anesthesiology and Critical Care Medicine, AP-HP-Sorbonne University, Pitié-Salpêtrière University Hospital, Paris, France.
| | - Valentin Lefrançois
- Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Caen, France.
| | - Nathalie Delhaye
- Department of Anesthesiology and Critical Care Medicine, European Hospital Georges Pompidou, AP-HP, Paris, France.
| | - Pauline Ponsin
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France.
| | - Anaïs Cordorniu
- Department of Anesthesiology and Critical Care, Beaujon Hospital, Beaujon, France.
| | - Thierry Floch
- Department of Anesthesiology and Critical Care Medicine, Reims University Hospital, Reims, France.
| | - Fanny Bounes
- Department of Anesthesiology and Critical Care Toulouse University Hospital, Toulouse, France.
| | - Elisabeth Gaertner
- Department of Anesthesiology and Critical Care, Louis Pasteur Hospital, Colmar, France.
| | - Alexia Hardy
- Department of Anesthesiology and Critical Care, Valenciennes Hospital, Beaujon, France.
| | - Julien Bordes
- Department of Anesthesiology and Critical Care Medicine, Sainte Anne Military Teaching Hospital, Toulon, France.
| | - Éric Meaudre
- Department of Anesthesiology and Critical Care Medicine, Sainte Anne Military Teaching Hospital, Toulon, France.
| | - Michael Cardinale
- Department of Anesthesiology and Critical Care Medicine, Sainte Anne Military Teaching Hospital, Toulon, France.
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Wolf J, Buckley GJ, Rozanski EA, Fletcher DJ, Boller M, Burkitt-Creedon JM, Weigand KA, Crews M, Fausak ED. 2024 RECOVER Guidelines: Advanced Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR. J Vet Emerg Crit Care (San Antonio) 2024; 34 Suppl 1:44-75. [PMID: 38924633 DOI: 10.1111/vec.13389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps. DESIGN Standardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization. SETTING Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS Seventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats. CONCLUSIONS These updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.
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Affiliation(s)
- Jacob Wolf
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Tufts University School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Manuel Boller
- VCA Canada Central Victoria Veterinary Hospital, Victoria, British Columbia, Canada
- Faculty of Veterinary Medicine, Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jamie M Burkitt-Creedon
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Kelly A Weigand
- Cary Veterinary Medical Library, Auburn University, Auburn, Alabama, USA
- Flower-Sprecher Veterinary Library, Cornell University, Ithaca, New York, USA
| | - Molly Crews
- Department of Small Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine & Biomedical Sciences, College Station, Texas, USA
| | - Erik D Fausak
- University Library, University of California, Davis, Davis, California, USA
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Schreyer C, Schulz-Drost S, Markewitz A, Breuing J, Prediger B, Becker L, Spering C, Neudecker J, Thiel B, Bieler D. Surgical management of chest injuries in patients with multiple and/or severe trauma- a systematic review and clinical practice guideline update. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02556-1. [PMID: 38888790 DOI: 10.1007/s00068-024-02556-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/14/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Our aim was to update evidence-based and consensus-based recommendations for the surgical and interventional management of blunt or penetrating injuries to the chest in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS MEDLINE and Embase were systematically searched to May and June 2021 respectively for the update and new questions. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared interventions for the surgical management of injuries to the chest in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS One study was identified. This study compared wedge resection, lobectomy and pneumonectomy in the management of patients with severe chest trauma that required some form of lung resection. Based on the updated evidence and expert consensus, one recommendation was modified and two additional good practice points were developed. All achieved strong consensus. The recommendation on the amount of blood loss that is used as an indication for surgical intervention in patients with chest injuries was modified to reflect new findings in trauma care and patient stabilisation. The new good clinical practice points (GPPs) on the use of video-assisted thoracoscopic surgery (VATS) in patients with initial circulatory stability are also in line with current practice in patient care. CONCLUSION As has been shown in recent decades, the treatment of chest trauma has become less and less invasive for the patient as diagnostic and technical possibilities have expanded. Examples include interventional stenting of aortic injuries, video-assisted thoracoscopy and parenchyma-sparing treatment of lung injuries. These less invasive treatment concepts reduce morbidity and mortality in the primary surgical phase following a chest trauma.
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Affiliation(s)
- C Schreyer
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital, Koblenz, Germany
| | - S Schulz-Drost
- Department of Trauma Surgery, Schwerin Helios Hospital, Schwerin and Department of Trauma and Orthopaedic Surgery, Schwerin, Germany
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - A Markewitz
- German Society for Thoracic and Cardiovascular Surgery, Berlin, Germany
| | - J Breuing
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - B Prediger
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - L Becker
- Department of Trauma Surgery, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany
| | - C Spering
- Department of Trauma Surgery, Orthopaedics, and Plastic Surgery, Göttingen University Medical Centre, Göttingen, Germany
| | - J Neudecker
- Department of Surgery, Berlin Charité Hospital, Campus Charité Mitte and Campus Virchow, Berlin, Germany
| | - B Thiel
- Department of Thoracic Surgery, Klinikum Westfalen Knappschaft, Lünen, Germany
| | - D Bieler
- Department for Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery, Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany.
- Department for Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University, Duesseldorf, Germany.
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Saar S, Lipping E, Bahhir A, Talviste M, Lepp J, Väli M, Talving P. Outcomes of resuscitative and emergent thoracotomies following injury at the largest trauma center in Estonia. Eur J Trauma Emerg Surg 2024; 50:243-248. [PMID: 37225875 DOI: 10.1007/s00068-023-02284-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/14/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND An emergency department thoracotomy (EDT) is performed in critically injured patients after a recent or in an imminent cardiac arrest following trauma. Emergent thoracotomy (ET) or operation room thoracotomy is reserved for more stable patients. However, the number of these interventions performed in an European settings is limited. Thus, we initiated the current study to investigate outcomes and risk factors for mortality of patients required EDT or ET at the largest trauma center in Estonia. METHODS All patients admitted after trauma to the North Estonia Medical Centre between 1/1/2017 and 31/12/2021 subjected to EDT or ET were included. Primary outcome was 30-day mortality. RESULTS Overall, 39 patients were included. EDT and ET were performed in 16 and 23 patients, respectively. Median age was 45 (33-53) years and 89.7% were males. The crude 30-day mortality was 56.4% being 87.5% and 34.8% in the EDT and ET group, respectively. None of the patients with pre-hospital CPR requirement, severe head injury (AIS head ≥ 3) or severe abdominal injury (AIS abdomen ≥ 3) survived. All the patients in the survival group had signs of life in the emergency department. The rate of stab wounds was significantly higher in the survival group (p = 0.007). Patients with CGS < 9 had significantly lower possibility for survival (p < 0.001). CONCLUSIONS EDT and ET outcomes in Estonian trauma system are comparable to similar advanced trauma systems in Europe. Patients with GCS > 8, signs of life in the ED and with isolated penetrating chest injury had the most favorable outcomes.
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Affiliation(s)
- Sten Saar
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia.
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Edgar Lipping
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Artjom Bahhir
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Maarja Talviste
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Jaak Lepp
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Marika Väli
- Department of Pathological Anatomy and Forensic Medicine, University of Tartu, Tartu, Estonia
| | - Peep Talving
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Okano H, Terayama T, Okamoto H, Yamazaki T. Emergency resuscitative thoracotomy in severe trauma: Analysis of the nation-wide registry data in Japan. Acute Med Surg 2024; 11:e958. [PMID: 38660025 PMCID: PMC11041373 DOI: 10.1002/ams2.958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024] Open
Abstract
Aim Emergency resuscitative thoracotomy is a potentially lifesaving procedure for patients with cardiac pulmonary arrest and profound circulatory failure resulting from a severe injury. However, survival rate post-emergency resuscitative thoracotomy shows considerable variation, with many studies constrained by limited sample sizes and ambiguous criteria for inclusion. Herein, we assessed the outcomes of emergency resuscitative thoracotomy and identified predictors of futility using Japan Trauma Data Bank data. Methods Data of patients aged ≥18 years between 2004 and 2019 were analyzed. The primary outcome measure was survival at discharge. Descriptive statistics were used to compare the survivor and nonsurvivor groups. A multivariable logistic regression analysis was conducted to identify predictors of survival in patients undergoing emergency resuscitative thoracotomy while adjusting for confounding factors. Results Among patients who underwent emergency resuscitative thoracotomy, 684/5062 (13.5%) survived. Age <65 years (adjusted odds ratio, 1.351; 95% confidence interval, 1.130-1.615; p < 0.001), absence of cardiac pulmonary arrest on emergency department arrival (adjusted odds ratio, 1.694; 95% confidence interval, 1.280-2.243; p < 0.01), Injury Severity Score <16 (adjusted odds ratio, 2.195; 95% confidence interval, 1.611-2.992; p < 0.01), and penetrating injury (adjusted odds ratio, 1.834; 95% confidence interval, 1.384-2.431; p < 0.01) were identified as factors associated with survival at discharge. Conclusion The survival rate for emergency resuscitative thoracotomy in Japan stands at approximately 13.5%. Factors contributing to survival include younger age, absence of cardiopulmonary arrest at emergency department arrival, lack of severe trauma, and sustaining penetrating injuries.
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Affiliation(s)
- Hiromu Okano
- Department of Critical Care MedicineSt. Luke's International HospitalTokyoJapan
- Department of Social Medical Sciences, Graduate School of MedicineInternational University of Health and WelfareTokyoJapan
| | - Takero Terayama
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
- Department of Traumatology and Critical Care MedicineNational Defense Medical College HospitalTokorozawaSaitamaJapan
| | - Hiroshi Okamoto
- Department of Critical Care MedicineSt. Luke's International HospitalTokyoJapan
| | - Tsutomu Yamazaki
- Department of Social Medical Sciences, Graduate School of MedicineInternational University of Health and WelfareTokyoJapan
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Chang YR, Kuo LW, Hsu TA, Tee YS, Fu CY, Bajani F, Mis J, Poulakidas S, Bokhari F. The Role of Open Cardiopulmonary Resuscitation in Chest Trauma Patients with No Sign of Life: A National Trauma Data Bank Study. World J Surg 2023; 47:3107-3113. [PMID: 37740005 DOI: 10.1007/s00268-023-07180-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 09/24/2023]
Abstract
PURPOSE The effectiveness of open cardiopulmonary resuscitation (OCPR) remains controversial for trauma patients. In this current study, the role of OCPR in managing chest trauma patients is evaluated using nationwide real-world data. METHODS From 2014 to 2015, the National Trauma Data Bank was retrospectively queried for chest trauma patients with out-of-hospital cardiac arrest status. The emergency department (ED) and overall survival of patients without signs of life were analyzed. Multivariate logistic regression (MLR) analysis was performed to evaluate independent factors of mortality for the target group. Furthermore, a subset group of patients who survived after the ED were studied, focusing on the duration of survival after leaving the ED. RESULTS A total of 911 patients were enrolled in this study (OCPR vs. non-OCPR: 161 patients vs. 750 patients). The average overall mortality rate was 98.6% (N = 898). Among penetrating chest trauma patients, non-survivors in the ED had significantly higher proportions of gunshot injuries (83.9% vs. 69.7%, p = 0.001) and lower proportions of OCPR (20.7% vs. 44.4%, p < 0.001). MLR analysis showed that gunshot injuries and non-OCPR were significantly related to ED mortality in penetrating trauma patients without signs of life (odds ratio = 2.039, p = 0.006 and odds ratio = 2.900, p < 0.001, respectively). However, the overall survival rate of patients after ED survival (n = 99) was 9.9%, and only 21.2% (n = 21) of them survived more than 1 day after leaving the ED. CONCLUSION OCPR could be considered in situations where appropriate indications exist. The survival benefit was observed in critically ill patients with penetrating chest trauma who show no signs of life. By enhancing ED survival, OCPR may also contribute to overall survival improvement.
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Affiliation(s)
- Yau-Ren Chang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
| | - Yu-San Tee
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan.
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA.
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Justin Mis
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
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Rösch RM. From diagnosis to therapy: the acute traumatic hemothorax - an orientation for young surgeons. Innov Surg Sci 2023; 8:221-226. [PMID: 38510367 PMCID: PMC10949117 DOI: 10.1515/iss-2023-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/17/2024] [Indexed: 03/22/2024] Open
Abstract
Introduction This review aims to provide an overview of diagnosing and managing traumatic haemothorax for young surgeons. Content Of 27,333 polytrauma patients in Germany in 2021, 35 % were admitted with thoracic trauma. In polytrauma patients, chest injuries are an independent negative predictor of 30-day mortality. These patients should be treated in an evidence-based and standardized manner to reduce mortality and morbidity. There are several methods of immediate diagnosis that should be used depending on hemodynamic stability. In addition to physical examination and chest X-ray, more specific techniques such as the eFAST protocol and Computed tomography (CT) of the chest are available. Once the source of bleeding has been identified, acute treatment is given depending on hemodynamic stability. Thoracic drainage remains the gold standard in the initial management of hemothorax. If surgery is required because of an active source of bleeding, a hemothorax that has not been completely relieved, or associated injuries, either a minimally invasive or open approach can be used. The main focus is to stabilize the patient and avoid early and late complications. Summary and Outlook Rapid and prompt diagnosis and management of traumatic hemothorax is essential for patient outcome and should be taught to all young surgeons who are in direct contact with these patients.
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Affiliation(s)
- Romina M. Rösch
- Department of Thoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Niemann M, Graef F, Hahn F, Schilling EC, Maleitzke T, Tsitsilonis S, Stöckle U, Märdian S. Emergency thoracotomies in traumatic cardiac arrests following blunt trauma - experiences from a German level I trauma center. Eur J Trauma Emerg Surg 2023; 49:2177-2185. [PMID: 37270467 PMCID: PMC10519862 DOI: 10.1007/s00068-023-02289-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 05/23/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Resuscitative thoracotomies (RT) are the last resort to reduce mortality in patients suffering severe trauma. In recent years, indications for RT have been extended from penetrating to blunt trauma. However, discussions on efficacy are still ongoing, as data on this rarely performed procedure are often scarce. Therefore, this study analyzed RT approaches, intraoperative findings, and clinical outcome measures following RT in patients with cardiac arrest following blunt trauma. METHODS All patients admitted to our level I trauma center's emergency room (ER) who underwent RT between 2010 and 2021 were retrospectively analyzed. Retrospective chart reviews were performed for clinical data, laboratory values, injuries observed during RT, and surgical procedures. Additionally, autopsy protocols were assessed to describe injury patterns accurately. RESULTS Fifteen patients were included in this study with a median ISS of 57 (IQR 41-75). The 24-h survival rate was 20%, and the total survival rate was 7%. Three approaches were used to expose the thorax: Anterolateral thoracotomy, clamshell thoracotomy, and sternotomy. A wide variety of injuries were detected, which required complex surgical interventions. These included aortic cross-clamping, myocardial suture repairs, and pulmonary lobe resections. CONCLUSION Blunt trauma often results in severe injuries in various body regions. Therefore, potential injuries and corresponding surgical interventions must be known when performing RT. However, the chances of survival following RT in traumatic cardiac arrest cases following blunt trauma are small.
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Affiliation(s)
- Marcel Niemann
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Frank Graef
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Fabienne Hahn
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Elisa Celine Schilling
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tazio Maleitzke
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany
| | - Serafeim Tsitsilonis
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ulrich Stöckle
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sven Märdian
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Center for Musculoskeletal Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
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Schreyer C, Eckermann C, Neudecker J, Becker L, Schulz-Drost S. [VATS in Thorax Trauma]. Zentralbl Chir 2023; 148:74-84. [PMID: 36470290 DOI: 10.1055/a-1957-5511] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Since the early 1990s, video-assisted thoracoscopy (VATS) has been increasingly established for a variety of indications in the treatment of patients with thoracic trauma. During this time, one premise for the use of thoracoscopy has not changed. Its use is consistently recommended only for trauma patients with stable circulation and respiration. To define the indications of VATS for use in thoracic trauma, the Pulmonary Injury Group - as part of the Working Committee for Thoracic Trauma of the German Society for Thoracic Surgery (DGT) and the German Society for Trauma Surgery (DGU) - has developed treatment recommendations based on a current literature review (based on the PRISMA Checklist/here: MEDLINE via PubMed from 1993 to 2022). In the present study, after reviewing the available literature, the indications for VATS in the care of thoracic trauma were identified, in order to formulate clinical recommendations for the use of VATS in thoracic trauma. The analysis of 1679 references identified a total of 4 randomised controlled trials (RCTs), 4 clinical trials, and 5 meta-analyses or systematic reviews and 39 reviews, which do not allow a higher level of recommendation than consensual recommendations, due to the low evidence of the available literature. Over the past 30 years, stabilisation options in the care of trauma patients have improved significantly, allowing expansion of indications for the use of VATS. Moreover, the recommendation for more than 50 years to thoracotomise trauma patients in case of an initial blood loss ≥ 1500 ml via the inserted chest drainage or in case of continuous blood loss ≥ 250 ml/h over 4 h is now only relative with today's better stabilisation measures. For unstable/non-stabilisable patients with a thoracic injury requiring emergency treatment, thoracotomy remains the method of choice, while VATS is recommended for a wide range of indications in the diagnosis and treatment of stable patients with a penetrating or blunt thoracic trauma. The indications for VATS are persistent haemothorax, treatment of injuries and haemorrhages to the lung, diaphragm, thoracic wall and other organ injuries, and in the secondary phase, treatment of thoracic sequelae of injury (empyema, persistent pulmonary fistula, infected atelectasis, etc.).
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Affiliation(s)
- Christof Schreyer
- Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Koblenz, Deutschland
| | - Christoph Eckermann
- Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Koblenz, Deutschland
| | - Jens Neudecker
- Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Universitätsmedizin Berlin - Charité Campus Mitte, Berlin, Deutschland
| | - Lars Becker
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Stefan Schulz-Drost
- Klinik für Unfallchirurgie und Traumatologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
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Neudecker J, Schulz-Drost S, Walles T. [Treatment of Persistent Parenchymal Lung Injuries in Thoracic Trauma: Lung Laceration, Pleural Fistula and Pneumothorax]. Zentralbl Chir 2023; 148:93-104. [PMID: 36822185 DOI: 10.1055/a-1898-7611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Thoracic trauma is a frequent injury pattern with high patient morbidity and mortality. Preclinical and clinical emergency treatment is consented in a national S3-guideline. Following emergency therapy one third of patients may develop lung lacerations, pleural fistulation and persisting pneumothorax. An interdisciplinary working group of the German Society for Thoracic Surgery and the German Society for Traumatology reviewed the published medical literature on treatment of those injuries and assessed the existing evidence according to consensus recommendations. An inconsistent classification of those subsequent lung injuries was found. Evidence for diagnostic and therapeutic recommendations is small.
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Affiliation(s)
- Jens Neudecker
- Chirurgische Klinik - Zentrum für Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Stefan Schulz-Drost
- Klinik für Unfallchirurgie und Traumatologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Thorsten Walles
- Klinik für Herz- und Thoraxchirurgie, Abteilung Thoraxchirurgie, Otto-von-Guericke-Universität Magdeburg Medizinische Fakultät, Magdeburg, Deutschland
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11
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de Malleray H, Cardinale M, Avaro JP, Meaudre E, Monchal T, Bourgouin S, Vasse M, Balandraud P, de Lesquen H. Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center. Eur J Trauma Emerg Surg 2022; 48:4631-4638. [PMID: 35633378 DOI: 10.1007/s00068-022-01995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate survival after emergency department thoracotomy (EDT) in a physician-staffed emergency medicine system. METHODS This single-center retrospective study included all in extremis trauma patients who underwent EDT between 2013 and 2021 in a military level 1 trauma center. CPR time exceeding 15 minutes for penetrating trauma of 10 minutes for blunt trauma, and identified head injury were the exclusion criteria. RESULTS Thirty patients (73% male, 22/30) with a median age of 42 y/o [27-64], who presented mostly with polytrauma (60%, 18/30), blunt trauma (60%, 18/30), and severe chest trauma with a median AIS of 4 3-5 underwent EDT. Mean prehospital time was 58 min (4-73). On admission, the mean ISS was 41 29-50, and 53% (16/30) of patients had lost all signs of life (SOL) before EDT. On initial work-up, Hb was 9.6 g/dL [7.0-11.1], INR was 2.5 [1.7-3.2], pH was 7.0 [6.8-7.1], and lactate level was 11.1 [7.0-13.1] mmol/L. Survival rates at 24 h and 90 days after penetrating versus blunt trauma were 58 and 41% versus 16 and 6%, respectively. If SOL were present initially, these values were 100 and 80% versus 22 and 11%. CONCLUSION Among in extremis patients supported in a physician-staffed emergency medicine system, implementation of a trauma protocol with EDT resulted in overall survival rates of 33% at 24 h and 20% at 90 days. Best survival was observed for penetrating trauma or in the presence of SOL on admission.
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Affiliation(s)
| | | | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Meaudre
- ICU, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Tristan Monchal
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Stéphane Bourgouin
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Mathieu Vasse
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Paul Balandraud
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
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Meshkinfamfard M, Narvestad JK, Wiik Larsen J, Kanani A, Vennesland J, Reite A, Vetrhus M, Thorsen K, Søreide K. Structured and Systematic Team and Procedure Training in Severe Trauma: Going from 'Zero to Hero' for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods. World J Surg 2021; 45:1340-1348. [PMID: 33566121 PMCID: PMC8026408 DOI: 10.1007/s00268-021-05980-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 11/26/2022]
Abstract
Background Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. Methods An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. Results Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. Conclusion The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care. Supplementary Information The online version contains supplementary material available at (doi:10.1007/s00268-021-05980-1).
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Affiliation(s)
- Maryam Meshkinfamfard
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
| | - Jon Kristian Narvestad
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
- Section for Traumatology, Surgical Clinic, Stavanger University Hospital, Stavanger, Norway
| | - Johannes Wiik Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
| | - Arezo Kanani
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
| | - Jørgen Vennesland
- Department of Surgery, Vascular & Thoracic Surgery Unit, Stavanger University Hospital, Stavanger, Norway
| | - Andreas Reite
- Section for Traumatology, Surgical Clinic, Stavanger University Hospital, Stavanger, Norway
- Department of Surgery, Vascular & Thoracic Surgery Unit, Stavanger University Hospital, Stavanger, Norway
| | - Morten Vetrhus
- Department of Surgery, Vascular & Thoracic Surgery Unit, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
- Section for Traumatology, Surgical Clinic, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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13
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Lustenberger T, Lefering R. Focus on "The German TraumaRegister DGU ® (TR-DGU)". Eur J Trauma Emerg Surg 2020; 46:447-448. [PMID: 32514734 PMCID: PMC7280174 DOI: 10.1007/s00068-020-01394-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
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Affiliation(s)
- S Paulich
- North Bristol NHS Trust, Bristol, UK
| | - D Lockey
- North Bristol NHS Trust, Bristol, UK
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