Emergency Department Thoracotomy: Survival of the Least Expected

Emergency Resuscitative Thoracotomy for Civilian Thoracic Trauma in the Field and Emergency Department Settings: A Systematic Review and Meta-Analysis

BACKGROUND

Emergency department resuscitative thoracotomy (ED-RT) or prehospital resuscitative thoracotomy (PH-RT) is performed for trauma patients with impending or full cardiovascular collapse. This systematic review and meta-analysis analyze outcomes in patients with thoracic trauma receiving PH-RT and ED-RT.

METHODS

PubMed, JAMA Network, and CINAHL electronic databases were searched to identify studies published on ED-RT or PH-RT between 2000-2020. Patients were grouped by location of procedure and type of thoracic injury (blunt versus penetrating).

RESULTS

A total of 49 studies met the criteria for qualitative analysis, and 43 for quantitative analysis. 43 studies evaluated ED-RT and 5 evaluated PH-RT. Time from arrival on scene to PH-RT >5 min was associated with increased neurological complications and time from the initial encounter to PH-RT or ED-RT >10 min was associated with increased mortality. ISS ≥ 25 and absent signs of life were also associated with increased mortality. There was higher mortality in all PH-RT (93.5%) versus all ED-RT (81.8%) (P = 0.02). Among ED-RTs, a significant difference was found in mortality rate between patients with blunt (92.8%) versus penetrating (78.7%) injuries (P < 0.001). When considering only blunt or penetrating injury types, no significant difference in RT mortality rate was found between ED-RT and PH-RT (P = 0.65 and P = 0.95, respectively).

CONCLUSIONS

ED-RT and PH-RT are potentially life-saving procedures for patients with penetrating thoracic injuries in extremis and with signs of life. The efficacy of this procedure is time sensitive. Moreover, there appears to be a greater mortality risk for patients with thoracic trauma receiving RT in the PH setting compared to the ED setting. More studies are needed to determine the significance of PH-RT mortality.

Prehospital Factors Associated with Refractory Traumatic Arrest

Objective

Identification of the prehospital factors associated with a poor prognosis of immediate traumatic arrest should help reduce unwarranted treatment. We aim to reveal the clinical factors related to death after traumatic arrest on the scene.

Methods

We performed a multicenter (4 tertiary hospitals in urban areas of South Korea) retrospective study on consecutive adult patients with trauma arrest on scene who were transferred by fire ambulance from January 2016 to December 2018. Patients with death on arrival in the emergency room (ER) were excluded. Prehospital data were collected from first aid records, and information on each patient's survival outcome in the ER was collected from an electronic database. Patients were divided into ER death and ER survival groups, and variables associated with prehospital trauma were compared.

Results

A total of 145 (84.3%) and 27 (15.7%) patients were enrolled in the ER death and survival groups, respectively. Logistic regression analysis revealed that asystole (OR 4.033, 95% CI 1.342–12.115, p = 0.013) was related to ER death and that ROSC in the prehospital phase (OR 0.100, 95% CI 0.012–0.839, p = 0.034) was inversely related to ER death. In subgroup analysis of those who suffered fall injuries, greater height of fall was associated with ER death (15.0 (5.5–25.0) vs. 4.0 (2.0–7.5) meters, p = 0.001); the optimal height cutoff for prediction of ER death was 10 meters, with 66.1% sensitivity and 100% specificity.

Conclusions

In cases of traumatic arrest, asystole, no prehospital ROSC, and falls from a greater height were associated with trauma death in the ER. Termination of resuscitation in traumatic arrest cases should be done on the basis of comprehensive clinical factors.

Does Clamshell Thoracotomy Better Facilitate Thoracic Life-Saving Procedures Without Increased Complication Compared with an Anterolateral Approach to Resuscitative Thoracotomy? Results from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry

BACKGROUND

Resuscitative thoracotomy (RT) is life-saving in select patients and can be accomplished through a left anterolateral (AT) or clamshell thoracotomy (CT). CT may provide additional exposure, facilitating certain operative procedures, but the added blood and heat loss and time to perform it may increase complications. No prospective multicenter comparison of techniques has yet been reported.

STUDY DESIGN

The observational AAST Aortic Occlusion for Resuscitation in Trauma and Acute care surgery (AORTA) registry was used to compare AT and CT in RT.

RESULTS

AORTA recorded 1,218 RTs at 46 trauma centers from June 2014 to January 2020. Overall survival after RT was 6.0% (AT 6.6%; [59 of 900]; CT 4.2% [13 of 296], p = 0.132). Among all RTs, 11.1% (142 of 1,278) surviving at least 24 hours were used tocompare AT (112) and CT (30). There was no difference between the 2 groups withregard to age, sex, Injury Severity Score, or mechanism of injury (Table 1). CT was significantly more likely to be used in patients needing resection of the lung or cardiac repair. CT was not associated with increased local thoracic/systemic complications, higher transfusion requirement, or greater ventilator, ICU, or hospital days compared with AT.

CONCLUSIONS

Clamshell thoracotomy facilitates thoracic life-saving procedures withoutincreased systemic or thoracic complications compared with AT in patients undergoing RT.

Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians

STUDY OBJECTIVE

Resuscitative thoracotomy is a time-sensitive, lifesaving procedure that may be performed by emergency physicians. The left anterolateral thoracotomy (LAT) is the standard technique commonly used in the United States to gain rapid access to critical intrathoracic structures. However, the smaller incision and subsequent limited exposure may not be optimal for the nonsurgical specialist to complete time-sensitive interventions. The modified bilateral anterior clamshell thoracotomy (MCT) developed by Barts Health NHS Trust clinicians at London's Air Ambulance overcomes these inherent difficulties, maximizes thoracic cavity visualization, and may be the ideal technique for the nonsurgical specialist. The aim of this study is to identify the optimal technique for the nonsurgical-specialist-performed resuscitative thoracotomy. Secondary aims of the study are to identify technical difficulties, procedural concerns, and physician preferences.

METHODS

Emergency medicine staff and senior resident physicians were recruited from an academic Level I trauma center. Subjects underwent novel standardized didactic and skills-specific training on both the MCT and LAT techniques. Later, subjects were randomized to the order of intervention and performed both techniques on separate fresh, nonfrozen human cadaver specimens. Success was determined by a board-certified surgeon and defined as complete delivery of the heart from the pericardial sac and subsequent 100% occlusion of the descending thoracic aorta with a vascular clamp. The primary outcome was time to successful completion of the resuscitative thoracotomy technique. Secondary outcomes included successful exposure of the heart, successful descending thoracic aortic cross clamping, successful procedural completion, time to exposure of the heart, time to descending thoracic aortic cross-clamp placement, number and type of iatrogenic injuries, correct anatomic structure identification, and poststudy participant questionnaire.

RESULTS

Sixteen emergency physicians were recruited; 15 met inclusion criteria. All participants were either emergency medicine resident (47%) or emergency medicine staff (53%). The median number of previously performed training LATs was 12 (interquartile range 6 to 15) and the median number of previously performed MCTs was 1 (interquartile range 1 to 1). The success rates of our study population for the MCT and LAT techniques were not statistically different (67% versus 40%; difference 27%; 95% confidence interval -61% to 8%). However, staff emergency physicians were significantly more successful with the MCT compared with the LAT (88% versus 25%; difference 63%; 95% CI 9% to 92%). Overall, the MCT also had a significantly higher proportion of injury-free trials compared with the LAT technique (33% versus 0%; difference 33%; 95% CI 57% to 9%). Physician procedure preference favored the MCT over the LAT (87% versus 13%; difference 74%; 95% CI 23% to 97%).

CONCLUSION

Resuscitative thoracotomy success rates were lower than expected in this capable subject population. Success rates and procedural time for the MCT and LAT were similar. However, the MCT had a higher success rate when performed by staff emergency physicians, resulted in less periprocedural iatrogenic injuries, and was the preferred technique by most subjects. The MCT is a potentially feasible alternative resuscitative thoracotomy technique that requires further investigation.

[Current treatment concepts for trauma-related cardiac arrest : Focal points, differences and similarities]

Trauma-related deaths are not only a relevant medical problem but also a socioeconomic one. The care of a polytraumatized patient is one of the less commonly occurring missions in the rescue and emergency medical services. The aim of this article is to compare the similarities and differences between different course concepts and guidelines in the treatment of trauma-related cardiac arrests (TCA) and to filter out the main focus of each concept. Because of the various approaches in the treatment of polytraumatized patients, there are decisive differences between trauma-related cardiac arrests and cardiac arrests from other causes.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Contemporary Utilization of Resuscitative Thoracotomy: Results From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Multicenter Registry

INTRODUCTION

Several reviews of resuscitative thoracotomy (RT) use over the last five decades have been conducted, most recently the evidence-based practice management guideline (PMG) of the Eastern Association for the Surgery of Trauma (EAST). The present study was designed to examine contemporary RT utilization and outcomes compared with historical data (n = 10,238) from the EAST PMG review from published series 1974 to 2013.

METHODS

The American Association for the Surgery of Trauma Aortic Occlusion for Trauma and Acute Care Surgery (AORTA) registry was utilized to identify patients undergoing RT in the emergency department (ED) from November 2013 to December 2016. Demographics, injury data, physiologic presentation, and outcomes were reviewed and compared with those of the EAST PMG review.

RESULTS

Three-hundred ten RT patients from 16 contributing AORTA centers were identified. The majority were injured by penetrating mechanisms (197/310, 64% [gunshot (163/197, 83%)]). Signs of life (SOL) (organized electrical activity, pupillary response, spontaneous movement, or appreciable pulse/blood pressure) were present on arrival in 47% (147/310). When compared with the EAST PMG results, there was no difference in either hospital survival (5% vs. 8%) or neurologically intact survival between historical controls or AORTA registry patients in any category combination of mechanism/anatomic location/presenting signs of life. Blunt injuries W/O SOL on admission continue to constitute 14% (45/310) of RTs in the ED, without documented survivors.

CONCLUSION

Comparison of historical RT controls to more contemporary patients from the AORTA registry suggests that practices and outcomes following RT have not changed. Despite a wealth of accumulated data over several decades, RT continues to be performed for patients after blunt mechanisms of injury who present W/O SOL despite lack of demonstrated hope for survival benefit.

Are We Out of the Woods Yet? The Aftermath of Resuscitative Thoracotomy

BACKGROUND

After traumatic arrest, resuscitative thoracotomy is lifesaving in appropriately selected patients, yet data are limited regarding hospital course after intensive care unit (ICU) admission. The objective of this study was to describe the natural history of resuscitative thoracotomy survivors admitted to the ICU.

MATERIALS AND METHODS

We conducted a retrospective review (January 1, 2012-June 30, 2017) of all adult trauma patients who underwent resuscitative thoracotomy after traumatic arrest at two adult level 1 trauma centers. Data evaluated include demographics, injury characteristics, hospital course, and outcome.

RESULTS

Over 66 mo, there were 52,624 trauma activations. Two hundred ninety-eight patients underwent resuscitative thoracotomy and 96 (32%) survived to ICU admission. At ICU admission, mean age was 35.8 ± 14.5 y, 79 (82%) were male, 36 (38%) sustained blunt trauma, and the mean injury severity score was 32.3 ± 13.7. Eight blunt and 20 penetrating patients (22% and 34% of ICU admissions, respectively) survived to discharge. 67% of deaths in the ICU occurred within the first 24 h, whereas 90% of those alive at day 21 survived to discharge. For the 28 survivors, mean ICU length of stay was 24.1 ± 17.9 d and mean hospital length of stay was 43.9 ± 32.1 d. Survivors averaged 1.9 ± 1.5 complications. Twenty-four patients (86% of hospital survivors) went home or to a rehabilitation center.

CONCLUSIONS

After resuscitative thoracotomy and subsequent ICU admission, 29% of patients survived to hospital discharge. Complications and a long hospital stay should be expected, but the functional outcome for survivors is not as bleak as previously reported.

Emergency Resuscitative Thoracotomy in the Combat or Operational Environment

Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock

This clinical practice guideline (CPG) reviews the range of accepted management approaches to profound shock and post-traumatic cardiac arrest and establishes indications for considering Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a hemorrhage control adjunct. The specific management approach - within the parameters of mission, resources, and tactical situation - will depend on the casualty's physical location, mechanism and pattern of injury, and the experience level of the surgeon. The optimal management strategy is best determined by the surgeon at the bedside.

The epidemiology of emergency department thoracotomy in a statewide trauma system: Does center volume matter?

BACKGROUND

The relationship between high volume and improved outcomes has been described for a host of elective high-impact, low-frequency procedures, but there are little data to support such a relationship in high-impact low-frequency procedures in trauma. Using emergency department thoracotomy (EDT) as a model, we hypothesized that patients presenting to centers with higher institutional volumes of EDT would have improved survival referent to those presenting to lower volume institutions.

METHODS

We queried the Pennsylvania Trauma Outcomes Study registry from 2007 to 2015 for all EDTs performed at Level I and II centers identified by ICD-9 procedure codes and a location stamp indicating the emergency department. We examined patient-level risk factors for survival in univariate regression and multivariable regression models. Centers were divided into tertiles of mean annual EDT volume, and the association between mean annual EDT volume and patient survival was examined using logistic regression after controlling for patient factors.

RESULTS

1,399 EDTs were performed at 28 centers. Overall survival was 6.8%. After controlling for patient age, mechanism of injury, signs of life, and injury severity, patients presenting to centers in the highest tertile of volume had significantly higher odds of survival compared with patients presenting to centers in the lowest tertile of volume (OR 4.56, 95% CI 1.43-14.50).

CONCLUSIONS

Patients presenting to centers with higher mean annual volume of EDTs have improved survival compared with those presenting to institutions with lower mean annual EDT volume. Efforts to understand the etiology of this finding may lead to interventions to improve outcomes at lower-volume centers.

LEVEL OF EVIDENCE

Prognostic/Epidemiological, level III; Therapeutic, level IV.

Resuscitative Endovascular Balloon Occlusion of the Aorta: A Review for Emergency Clinicians

BACKGROUND

Non-compressible torso hemorrhage (NCTH) is difficult to control and associated with significant mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes an infra-diaphragmatic approach to control NCTH and is less invasive than resuscitative thoracotomy (RT). This article highlights the evidence for REBOA and provides an overview of the indications, procedural steps, and complications in adults for emergency clinicians.

DISCUSSION

Traumatic hemorrhage can be life threatening. Patients in extremis, whether from NCTH or exsanguination from other sites, may require RT with aortic cross-clamping. REBOA offers another avenue for proximal hemorrhage control and can be completed by emergency clinicians. The American College of Surgeons Committee on Trauma and the American College of Emergency Physicians recently released a joint statement detailing the indications for REBOA in adults. The evidence behind its use remains controversial, with significant heterogeneity among studies. Most studies demonstrate improved blood pressure without a significant improvement in mortality. Procedural steps include arterial access (most commonly the common femoral artery), positioning the initial sheath, balloon preparation and positioning, balloon inflation, securing the balloon/sheath, subsequent hemorrhage control, balloon deflation, and balloon/sheath removal. Several major complications can occur with REBOA placement. Future studies should evaluate training protocols, the role of simulation, and which target populations would benefit most from REBOA.

CONCLUSIONS

REBOA can provide proximal hemorrhage control and can be performed by emergency clinicians. This article evaluates the evidence, indications, procedure, and complications for emergency clinicians.

The National Trauma Data Bank story for emergency department thoracotomy: How old is too old?

BACKGROUND

The fastest growing segment of the American population is the elderly (>65 years). This change in demographics also is being seen in trauma centers. Emergency department thoracotomy is utilized in an attempt to restore circulation for patients arriving in extremis. The purpose of this study was to investigate the relationship between clinical variables, particularly age, and outcomes for injured patients receiving an emergency department thoracotomy.

METHODS

Using the National Trauma Data Bank for years 2008-2012, observations with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for exploratory thoracotomy were identified. Emergency department thoracotomy was defined as any observation that occurred at a time to thoracotomy less than the total time spent in the emergency department thoracotomy, and within 15 minutes of arrival. Mechanisms of injury, demographic data, and injuries were analyzed for predictors of survival and mortality rates. Mortality rates were determined for each decade and year of life.

RESULTS

There were 11,380 observations for thoracotomy identified. Of these, 2,519 were emergency department thoracotomy, with the majority (n= 2,026, 80% observations) performed for penetrating wounds. Mortality rates ranged from 80% to 100% for each decade of life. Mortality was 100% for patients >57 years old with either penetrating or blunt mechanisms of injury.

CONCLUSION

Emergency department thoracotomy offered no survival benefit for patients older than 57 years of age. These data suggest that emergency department thoracotomy performed in elderly patients may be futile.

Thoracotomy in the emergency department for resuscitation of the mortally injured

PURPOSE

Emergency department resuscitative thoracotomy is an intervention of last resort for the acutely dying victim of trauma. In light of improvements in pre-hospital emergency systems, improved operative strategies for survival such as damage control and improvements in critical care medicine, the most extreme of resuscitation efforts should be re-evaluated for the potential survivor, with success properly defined as the return of vital signs which allow transport of the patient to the operating room.

METHODS

A retrospective review of all patients at a suburban level I trauma center who underwent emergency department resuscitative thoracotomy as an adjunct to the resuscitation efforts normally delivered in the trauma receiving area over a 22 year period was performed. Survival of emergency department resuscitative thoracotomy was defined as restoration of vital signs and transport out of the trauma resuscitation area to the operating room.

RESULTS

Sixty-eight patients were identified, of whom 27 survived the emergency department resuscitative thoracotomy and were transported to the operating room. Review of pre-hospital and initial hospital data between these potential long term survivors and those who died in the emergency department failed to demonstrate trends which were predictive of survival of emergency department resuscitative thoracotomy. The only subgroup which failed to respond to emergency department resuscitative thoracotomy was patients without signs of life at the scene who arrived to the treatment facility without signs of life.

CONCLUSION

The patient population of the "potential survivor" has been expanded due to advances in critical care practices, technology, and surgical technique and every opportunity for survival should be provided at the outset. Emergency department resuscitative thoracotomy is warranted for any patient with thoracic or subdiaphragmatic trauma who presents in extremis with a history of signs of life at the scene or organized cardiac activity upon arrival. Patients who have no evidence of signs of life at the scene and have no organized cardiac activity upon arrival should be pronounced.

FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation

OBJECTIVE

The objective of this study was to examine the ability of Focused Assessment Using Sonography for Trauma (FAST) to discriminate between survivors and nonsurvivors undergoing resuscitative thoracotomy (RT).

BACKGROUND

RT is a high-risk, low-salvage procedure performed in arresting trauma patients with poorly defined indications.

METHODS

Patients undergoing RT from 10/2010 to 05/2014 were prospectively enrolled. A FAST examination including parasternal/subxiphoid cardiac views was performed before or concurrent with RT. The result was captured as adequate or inadequate with presence or absence of pericardial fluid and/or cardiac motion. A sensitivity analysis utilizing the primary outcome measure of survival to discharge or organ donation was performed.

RESULTS

Overall, 187 patients arrived in traumatic arrest and underwent FAST. Median age 31 (1-84), 84.5% male, 51.3% penetrating. Loss of vital signs occurred at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. Emergent left thoracotomy was performed in 77.5% and clamshell thoracotomy in 22.5%. Sustained cardiac activity was regained in 48.1%. However, overall survival was only 3.2%. An additional 1.6% progressed to organ donation. FAST was inadequate in 3.7%, 28.9% demonstrated cardiac motion and 8.6% pericardial fluid. Cardiac motion on FAST was 100% sensitive and 73.7% specific for the identification of survivors and organ donors.

CONCLUSIONS

With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.

An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival?

METHODS

All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest.

RESULTS

The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825).

CONCLUSION

We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury.

LEVEL OF EVIDENCE

Systematic review/guideline, level III.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether or not recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care, because the evidence suggests that either death or a poor outcome is inevitable.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the joint NAEMSP-ACSCOT position statements

In the setting of traumatic cardiopulmonary arrest, protocols that direct emergency medical service (EMS) providers to withhold or terminate resuscitation, when clinically indicated, have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Protocols to withhold resuscitation should be based on the determination that there are no obvious signs of life, the injuries are obviously incompatible with life, there is evidence of prolonged arrest, and there is a lack of organized electrocardiographic activity. Termination of resuscitation is indicated when there are no signs of life and no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation. Further research is needed to determine the appropriate duration of cardiopulmonary resuscitation before termination of resuscitation and the proper role of direct medical oversight in termination of resuscitation protocols. This article is the resource document to the position statements, jointly endorsed by the National Association of EMS Physicians and the American College of Surgeons' Committee on Trauma, on withholding and termination of resuscitation in traumatic cardiopulmonary arrest.

Emergency Department Thoracotomy: Too Little, Too Much, or Too Late

Emergency department thoracotomy (EDT) is a dramatic lifesaving procedure demanding timely surgical intervention, technical expertise, and coordinated resuscitation efforts. Inappropriate use is costly and futile. All patients admitted to a Level II trauma center who underwent EDT from January 2003 to July 2012 were studied. The primary end point was appropriateness of EDT. Secondary end points were staff exposure, survival, and return to normal function. Eighty-seven patients including 59 patients with penetrating wounds had a mean loss of vital signs (LOV) 11.6 610.6 minutes and Injury Severity Score (ISS) of 45.8 ± 16.1, whereas 28 blunt injury patients had a mean LOVof 10.4 ± 11.5 minutes and ISS of 50.4 ± 19.4. Mortality was 81 per cent (48 of 59) in penetrating injury and 93 per cent (26 of 28) in blunt injury patients, respectively (odds ratio [OR] 2.99; P 0.21). Fifty-five EDTs were indicated with 10 survivors (18.2%) and 32 not indicated with three survivors (9.4%). Surgeons adhered to guidelines more compared with ED physicians (OR, 4.9; P = 0.03) whose patients were more likely to die (OR, 3.52; P = 0.124). Survivors (11 of 13 [84.6%]) were discharged home without significant long-term neurologic disability. EDT is lifesaving when performed for penetrating injury by experienced surgeons following established guidelines but futile in blunt injury or when performed by nonsurgeons regardless of mechanism.

Life after near death: long-term outcomes of emergency department thoracotomy survivors

BACKGROUND

Predictors of hospital survival after emergency department thoracotomy (EDT) are well established, but little is known of long-term outcomes after hospital survival. Our primary study objective was to analyze the long-term social, cognitive, functional, and psychological outcomes in EDT survivors.

METHODS

Review of our Level I trauma center registry (2000-2010) revealed that 37 of 448 patients survived hospitalization after EDT. Demographics and clinical characteristics were analyzed. After attempts to contact survivors, 21 patients or caretakers were invited to an outpatient study evaluation; 16 were unreachable (none of whom were present in the Social Security Death Index). Study evaluation included demographic and social data and an outpatient multidisciplinary assessment with validated scoring instruments (Mini-Mental Status Exam, Glasgow Outcome Scores, Timed Get-Up and Go Test, Functional Independence Measure Scoring, SF-36 Health Survey, and civilian posttraumatic stress disorder checklist).

RESULTS

After extended hospitalization (43 ± 41 days), disposition varied (home, 62%; rehabilitation, 32%; skilled nursing facility, 6%), but readmission was common (33%) in the 37 EDT hospital survivors. Of the 21 contacted, 16 completed the study evaluation, 2 had died, 1 remained in a comatose state, and 2 were available by telephone only. While unemployment (75%), daily alcohol (50%), and drug use (38%) were common, of the 16 patients who underwent the comprehensive, multidisciplinary outpatient assessment after a median of 59 months following EDT, 75% had normal cognition and returned to normal activities, 81% were freely mobile and functional, and 75% had no evidence of posttraumatic stress disorder upon outpatient screening.

CONCLUSION

Despite the common belief that EDT survivors often live with severe neurologic or functional impairment, we have found that most of our sampled EDT survivors had no evidence of long-term impairment. It is our hope that these results are considered by physicians making life or death decisions regarding the "futility" of EDT in our most severely injured patients.

Immediate thoracotomy for penetrating injuries: ten years' experience at a Dutch level I trauma center

BACKGROUND

An emergency department thoracotomy (EDT) or an emergency thoracotomy (ET) in the operating theater are both beneficial in selected patients following thoracic penetrating injuries. Since outcome-descriptive European studies are lacking, the aim of this retrospective study was to evaluate ten years of experience at a Dutch level I trauma center.

METHOD

Data on patients who underwent an immediate thoracotomy after sustaining a penetrating thoracic injury between October 2000 and January 2011 were collected from the trauma registry and hospital files. Descriptive and univariate analyses were performed.

RESULTS

Among 56 patients, 12 underwent an EDT and 44 an ET. Forty-six patients sustained one or multiple stab wounds, versus ten with one or multiple gunshot wounds. Patients who had undergone an EDT had a lower GCS (p < 0.001), lower pre-hospital RTS and hospital triage RTS (p < 0.001 and p = 0.009, respectively), and a lower SBP (p = 0.038). A witnessed loss of signs of life generally occurred in EDT patients and was accompanied by 100 % mortality. Survival following EDT was 25 %, which was significantly lower than in the ET group (75 %; p = 0.002). Survivors had lower ISS (p = 0.011), lower rates of pre-hospital (p = 0.031) and hospital (p = 0.003) hemodynamic instability, and a lower prevalence of concomitant abdominal injury (p = 0.002).

CONCLUSION

The overall survival rate in our study was 64 %. The outcome of immediate thoracotomy performed in this level I trauma center was similar to those obtained in high-incidence regions like the US and South Africa. This suggests that trauma units where immediate thoracotomies are not part of the daily routine can achieve similar results, if properly trained.

The use of emergency department thoracotomy for traumatic cardiopulmonary arrest

Despite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageability in these situations remain difficult even for experienced physicians. Regardless, survival is limited after traumatic cardiopulmonary arrest. One applicable, well-described resuscitative technique is the emergency department thoracotomy-a procedure that, when applied correctly, is effective in saving small but significant numbers of critically injured patients. By understanding the indications, technical details, and predictors of survival along with the inherent risks and costs of emergency department thoracotomy, the physician is better equipped to make rapid futile versus salvageable decisions for this most severely injured subset of patients.

The Impact of American College of Surgeons Trauma Center Designation and Outcomes after Early Thoracotomy: A National Trauma Databank Analysis

Trauma centers are designated by the American College of Surgeons (ACS) into four different levels based on resources, volume, and scientific and educational commitment. The purpose of this study was to evaluate the relationship between ACS center designation and outcomes after early thoracotomy for trauma. The National Trauma Databank (v. 7.0) was used to identify all patients who required early thoracotomy. Demographics, clinical data, and outcomes were extracted. Patients were categorized according to ACS trauma center designation. Multivariate logistic regression was used to evaluate the impact of ACS trauma center designation on mortality. From 2002 to 2006, 1834 (77.4%) patients were admitted to a Level I ACS verified trauma center, 474 (20.0%) to a Level II, and 59 (3.6%) to a Level III/IV facility. After adjusting for differences between the groups, there were no significant differences in mortality (overall: 53.3% for Level I, 63.1% for Level II, and 52.5% for Level III/IV, adjusted P = 0.417; or for patients arriving in cardiac arrest: 74.9% vs 87.1% vs 85.0%, P = 0.261). Subgroup analysis did not show any significant difference in survival irrespective of mechanism of injury. Glasgow Coma Scale score # 8, Injury Severity Score >16, no admission systolic blood pressure, time from admission to thoracotomy, and nonteaching hospitals were found to be independent predictors of death. For trauma patients who have sustained injuries requiring early thoracotomy, ACS trauma center designation did not significantly impact mortality. Nonteaching institutions however, were independently associated with poorer outcomes after early thoracotomy. These findings may have important implications in educational commitment of institutions. Further prospective evaluation of these findings is warranted.

Resuscitative emergency thoracotomy in a Swiss trauma centre

BACKGROUND

Resuscitative emergency thoracotomy (ET) is performed as a salvage manoeuvre for selected patients with trauma. However, reports from European trauma centres are scarce.

METHODS

A retrospective analysis was undertaken of injured patients who underwent resuscitative ET in the emergency department (ED) or operating room (OR) between January 1996 and September 2008. Survival in the ED and to hospital discharge was analysed using logistic regression.

RESULTS

During the study interval 121 patients required a resuscitative thoracotomy, of which 49 (40·5 per cent) were performed in the ED and 72 (59·5 per cent) in the OR. Patients in the OR had higher blood pressure on arrival (median 110 versus 60 mmHg; P < 0·001), were less often in severe haemorrhagic shock (63 versus 94 per cent; P < 0·001), had fewer serious head injuries (Abbreviated Injury Score of 3 or above in 33 versus 53 per cent; P = 0·031) and more often had a penetrating stab wound as the dominating mechanism (25 versus 10 per cent; P = 0·042) compared with those in the ED. Ten patients (20 per cent) survived to hospital discharge after ED thoracotomy, compared with 53 (74 per cent) of those treated in the OR. Penetrating injury and Glasgow Coma Scale score above 8 were independent predictors of hospital survival following ED thoracotomy. No patient with a blunt injury and no detectable signs of life on admission survived. Three of 26 patients with blunt trauma and signs of life on admission survived to hospital discharge.

CONCLUSION

Resuscitative ET may be life-saving in selected patients. Location of the procedure is dictated by injury severity and vital parameters. Outcome is best when signs of life are present on admission, even for blunt injuries.

Emergency thoracotomies in the largest trauma center in Denmark: 10 years' experience

AIM

The aim of our study was to investigate the outcome in terms of 30-day survival and to determine whether preoperative factors could predict the outcome.

METHODS

All patients who underwent an emergency thoracotomy (ET) during the period 2000 to 2009 were included. The patients were divided into two groups: emergency department thoracotomy and operating room thoracotomy. Data on demographics, mechanism of injury, intraoperative data, Injury Severity Scores (ISS), probability of survival, signs of life, transportation time, indications, and outcome were collected.

RESULTS

Forty-four ETs were performed. The mechanisms of injury were penetrating in 28 (64%) and blunt in 16 (36%) cases. In the emergency department thoracotomy group, the survival was 45 versus 20% for penetrating and blunt trauma, respectively. The total survival was 33%. In the operating room thoracotomy group, the survival was 83%. The survivors had a significantly lower ISS and a higher calculated probability of survival. The calculated mean probability of survival was 44 and 84% in the emergency department thoracotomy and operating room thoracotomy groups, respectively. The actual survival was similar, with 33% in the emergency department thoracotomy group and 83% in the operating room thoracotomy group.

CONCLUSIONS

The probability of survival and ISS are good predictors of survival in these patients and should be included in the future in order to make upcoming studies easier to compare. Patients with very high ISS or low probability of survival survived, justifying the procedure in our center.

Appropriate use of emergency department thoracotomy: implications for the thoracic surgeon

BACKGROUND

Practice guidelines for the appropriate use of emergency department thoracotomy (EDT) according to current national resuscitative guidelines have been developed by the American College of Surgeons Committee on Trauma (ACS-COT) and published. At an urban level I trauma center we analyzed how closely these guidelines were followed and their ability to predict mortality.

METHODS

Between January 2003 and July 2010, 120 patients with penetrating thoracic trauma underwent EDT at Mount Sinai Hospital (MSH). Patients were separated based on adherence (group 1, n=70) and nonadherence (group 2, n=50) to current resuscitative guidelines, and group survival rates were determined. These 2 groups were analyzed based on outcome to determine the effect of a strict policy of adherence on survival.

RESULTS

Of EDTs performed during the study period, 41.7% (50/120) were considered outside current guidelines. Patients in group 2 were less likely to have traditional predictors of survival. There were 6 survivors in group 1 (8.7%), all of whom were neurologically intact; there were no neurologically intact survivors in group 2 (p=0.04). The presence of a thoracic surgeon in the operating room (OR) was associated with increased survival (p=0.039).

CONCLUSIONS

A policy of strict adherence to EDT guidelines based on current national guidelines would have accounted for all potential survivors while avoiding the harmful exposure of health care personnel to blood-borne pathogens and the futile use of resources for trauma victims unable to benefit from them. Cardiothoracic surgeons should be familiar with current EDT guidelines because they are often asked to contribute their operative skills for those patients who survive to reach the OR.

Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective

BACKGROUND

Since the promulgation of emergency department (ED) thoracotomy>40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival.

METHODS

Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively.

RESULTS

During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge.

CONCLUSION

Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

Emergency thoracotomy--the indications, contraindications and evidence

Emergency thoracotomy is a dramatic and controversial intervention which may be life saving after major torso trauma. Success rates are variable and differ widely according to mechanism of injury. This article outlines the current indications and contraindications to emergency thoracotomy and examines the evidence to support it accumulated over 40 years.

Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

A variety of CPR techniques and devices may improve hemodynamics or short-term survival when used by well-trained providers in selected patients. All of these techniques and devices have the potential to delay chest compressions and defibrillation. In order to prevent delays and maximize efficiency, initial training, ongoing monitoring, and retraining programs should be offered to providers on a frequent and ongoing basis. To date, no adjunct has consistently been shown to be superior to standard conventional (manual) CPR for out-of-hospital basic life support, and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.

Thoracotomy in Thoracic Injuries: Results from a Tertiary Referral Hospital

INTRODUCTION

Critically injured patients may require thoracotomy after a thoracic injury. This study is a retrospective analysis of the results of thoracotomy in patients with thoracic injury.

MATERIALS AND METHODS

Injured patients with detectable signs of life on arrival at the hospital and who underwent thoracotomy within 4 h of the injury were investigated. Demographic data and medical records were reviewed for associated injuries, indications, intraoperative findings, and outcomes. The factors affecting the mortality were analyzed.

RESULTS

Between April 2003 and January 2009, 488 patients with thoracic injury (blunt/penetrating = 73.7%/26.3%) were treated, and 20 (4.1%) underwent thoracotomy (male/female = 17/3, mean age = 27 ± 9 years). The injury was penetrating in 15 (11.7%) and blunt in five (1.4%). None of them required an endotracheal intubation at the scene or in transit. The mean transport time was 58 min. Severe and continuous hemothorax (80%), massive air leak, major vessel injury, and trauma causing an open chest wall defect with bleeding were indications of the thoracotomy. Eighty-five percent survived after the surgery (penetrating/ blunt = 86.6%/80%). The mean injury severity score (ISS) of the survivors was lower (21 ± 9 vs. 39 ± 10, p = 0.05). Mortality was associated with a lower Glasgow coma scale (GCS) (p = 0.03), a higher ISS (p = 0.05), and a longer transport time (p = 0.05).

CONCLUSIONS

Thoracotomy after thoracic injury is a life-saving procedure in selected cases. Lower GCS and higher ISS are associated with increased mortality. Early transport and quick attempts to diagnose the indications necessitating thoracotomy play a significant role in improving the outcome.

Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers

BACKGROUND

Historically, patients with penetrating cardiac injuries have enjoyed the best survival after emergency department thoracotomy (EDT), but further examination of these series reveals a preponderance of cardiac stab wound (SW) survivors with only sporadic cardiac gunshot wound (GSW) survivors. Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable.

METHODS

All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival.

RESULTS

The study population (n = 283) comprised young (mean age, 27.1 years +/- 10.1 years) men (96.1%) injured by gunshot (GSW, 88.3%) or SWs (11.7%). Patients were compared by injury mechanism and number of CGV wounds with respect to survival (SW, 24.2%; GSW, 2.8%; p < 0.001; single, 9.5%; multiple, 1.4%; p = 0.003). Three predictors-injury mechanism, ED SOL, and number of CGV wounds-were then analyzed alone and in combination with respect to hospital survival. Only one patient (0.8%) with multiple CGV GSW survived EDT.

CONCLUSION

When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival.