[Clamshell thoracotomy after thoracic knife wounds]

Erfolgreiche innerklinische Clamshell-Thorakotomie bei einem jungen polytraumatisierten (ISS 57) Patienten

Life-threatened injured patients who suffer a cardiovascular arrest after a trauma are still enormously challenging for both the paramedics and the trauma team in the clinic. This case illustrates the treatment of a 16-year-old boy who suffered a blunt abdominal trauma with a traumatic cardiac arrest followed by an open resuscitation after clamshell thoracotomy. Subsequently, the treatment after damage control is discussed regarding the current literature and recommendations for treatment.

[Emergency thoracotomy in a severely injured patient after hemorrhagic shock in traumatic pelvic bleeding : Case report]

A case of in-hospital thoracotomy with subsequent open chest cardiopulmonary resuscitation of a polytraumatized patient is reported. Emergency thoracotomies are rare interventions in challenging situations. Up to now there are only few standards or uniform education and training concepts. The indications are often a borderline decision. The aim of thoracotomy and open resuscitation in combination with a reduction in circulation, for example by cross-clamping the aorta, is to save time to address reversible causes of the hemorrhage, redirect the blood volume into the vital cerebral and coronary circulation and minimize bleeding from subdiaphragmatic bleeding sources. Ultimately, in case of doubt, the thoracotomy can be performed for the patient's benefit with the appropriate indications.

[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.

Clamshell-Thorakotomie nach singulärem Messerstich in die „cardiac box“

Fallberichte zur präklinischen Durchführung einer Clamshell-Thorakotomie in Deutschland sind bisher rar, wenngleich diese Notfallprozedur in internationalen Leitlinien zur Behandlung des traumatischen Kreislaufstillstands enthalten ist. Im vorliegenden Beitrag wird die Versorgung eines erwachsenen Patienten nach einem Messerstich in den als „cardiac box“ bezeichneten Bereich des Thorax dargestellt. Konventionelle Maßnahmen der kardiopulmonalen Reanimation wie Atemwegssicherung, Beatmung und Thoraxkompression führten nicht zur Wiederherstellung des Kreislaufs („return of spontaneous circulation“, ROSC). Nachdem auch nach Ausschluss eines Spannungspneumothorax mithilfe einer Minithorakotomie kein dauerhafter ROSC erzeugt werden konnte, wurde entsprechend der Leitlinienempfehlung eine Thorakotomie erwogen und vor Ort durchgeführt. Nach dem Ausräumen einer Perikardtamponade und anschließendem ROSC wurde eine stark blutende Myokardverletzung übernäht und der Patient in den Schockraum des Universitätsklinikum Heidelberg gebracht. Dort erfolgten eine Notfalltransfusion und konsekutiv die definitive Versorgung der Verletzung im kardiochirurgischen OP. Der Patient verstarb am Folgetag an den Folgen eines hypoxischen Hirnödems im Beisein seiner Angehörigen.

[Successful prehospital emergency thoracotomy after blunt thoracic trauma : Case report and lessons learned]

BACKGROUND

The European Resuscitation Council guidelines for resuscitation in patients with traumatic cardiac arrest recommend the immediate treatment of all reversible causes, if necessary even prior to continuous chest compression. In the case of cardiac tamponade immediate emergency thoracotomy should also be considered.

OBJECTIVE

The authors report the case of a 23-year-old male patient with multiple injuries including blunt thoracic trauma, which caused a witnessed cardiac arrest. He successfully underwent prehospital emergency resuscitative thoracotomy. The lessons learned from this case on internal and external quality measures are discussed in detail.

RESULTS

After 60 min of technical rescue, extensive trauma life support including intubation, chest decompression and bleeding control was carried out. The cardiovascular insufficiency progressively deteriorated and under the suspicion of a cardiac tamponade a prehospital emergency thoracotomy was carried out. After successful resuscitative thoracotomy and return of spontaneous circulation (ROSC) the patient was airlifted to the next level 1 trauma center for damage control surgery (DCS). The patient could be discharged 59 days after the accident and now 2 years later is living a normal life without neurological or cardiopulmonary limitations. Airway management, chest decompression including resuscitative thoracotomy, fluid resuscitation and blood products were the key components to ensure that the patient achieved ROSC. Advanced Trauma Life Support® as well as structural prerequisites made these measures and good results for the patient possible.

Emergency clamshell thoracotomy in blunt trauma resuscitation: Shelling the paradigm-2 cases and review of the literature

Clamshell thoracotomy (CST) may be indicated and life-saving in carefully selected cases of blunt trauma. As such, the current clinical stance of general contraindication of CST in blunt trauma should be reviewed and criteria developed to accommodate select cases, considering the diversity of injuries resulting from blunt trauma.

[Additional emergency medical measures in trauma-associated cardiac arrest]

INTRODUCTION

More than half of all traumatic deaths happen in prehospital settings. Until now, there have been no long-term studies examining the actual additive treatment during trauma-associated cardiopulmonary resuscitation (tCPR), including pleural decompression, pericardiocentesis, tourniquets and external stabilization of the pelvis. The present cohort study evaluated forensic autopsy reports of trauma deaths occurring at the scene with respect to additive actions in preclinical tCPR as well as the potentially preventable nature of the individual death cases.

MATERIAL AND METHODS

All autopsy protocols from the Institutes of Legal Medicine in Leipzig and Chemnitz, Germany within the years 2011-2017 were retrospectively examined and all trauma deaths with professional prehospital tCPR at the scene, during transport or shortly after arriving at the emergency room were analyzed. In addition to epidemiological parameters all forms of medical procedure performed by emergency physicians and the injury patterns were recorded. Thus, the questions whether any of the trauma deaths were preventable and if failures in work-flow management were evident could be retrospectively answered through a structured Delphi method.

RESULTS

Overall, 3795 autopsy protocols were listed containing 154 trauma cases (4.1%) with various preclinical tCPR attempts (male patients 70.1%; mean age 48 ± 21 years). Most of them died at the accident site (84.4%), some during transport (2.6%) or directly after admission to a hospital (13.0%). Only 23 patients (14.9%) received 25 additional interventions exceeding the normal scope (pleural decompression 80.0%, pericardiocentesis 8.0% and external stabilization of the pelvis 12.0%). A relevant number of potentially reversible causes for trauma-associated cardiac arrest was determined. There were deficits in the performance of pleural decompression in cases of tension pneumothorax. Even if isolated traumatic hemopericardium was a rare occurrence in the examined cases, the rate of pericardiocentesis was still too low. Also, more focus needs to be placed on provisional external pelvic stabilization of trauma patients which was performed too rarely even though an instable pelvic ring was apparent during the postmortem external examination. None of the cases received a rescue thoracotomy even if a few patients might have derived benefit from this and none of the cases showed injury patterns with tourniquet indications. Furthermore, no single case of death due to incorrect or missing airway management was determined. Errors in work-flow management were found in 37.0% and potentially preventable deaths occurred cumulatively in 12.3% of the cases. The potentially preventable deaths were particularly related to penetrating chest injuries caused by a sharp force.

DISCUSSION

The percentage of patients who might benefit from additive treatment implemented in tCPR efforts was shown to be equal between the local situations in Leipzig and Chemnitz compared to previous reports in Berlin. A need for optimizing the professional resuscitation process still remains as not all reversible causes were appropriately addressed. Further training and education should intensively address the mentioned deficits and continuous awareness of necessary additional medical procedures in the preclinical setting in cases of traumatic cardiac arrest is inevitable. Cooperation with forensic institutes can help to impart particular issues and treatment options of emergency medicine in cases of potentially reversible causes of traumatic cardiac arrest.