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De Matteis C, Maury JM, Passot G. Anterior bi-thoracotomy for resuscitation - The Clamshell incision (with video). J Visc Surg 2024:S1878-7886(24)00102-4. [PMID: 39122623 DOI: 10.1016/j.jviscsurg.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Affiliation(s)
- Charles De Matteis
- Hospices civils de Lyon, Department of Surgical Oncology, centre hospitalier Lyon Sud, 165, chemin du Grand Revoyet, 69310 Pierre-Bénite, France.
| | - Jean Michel Maury
- Department of Thoracic Surgery and Lung Transplantation, hospices civils de Lyon, hôpital Louis-Pradel, Lyon, France.
| | - Guillaume Passot
- Hospices civils de Lyon, Department of Surgical Oncology, centre hospitalier Lyon Sud, 165, chemin du Grand Revoyet, 69310 Pierre-Bénite, France; EMR 3738, Claude-Bernard University, Lyon 1, Lyon, France.
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Liu S, Ling L, Fu Y, Zhang WC, Zhang YH, Li Q, Zeng L, Hu J, Luo Y, Liu WJ. Survival predictor in emergency resuscitative thoracotomy for blunt trauma patients: Insights from a Chinese trauma center. Chin J Traumatol 2024:S1008-1275(24)00082-8. [PMID: 39138046 DOI: 10.1016/j.cjtee.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/30/2024] [Accepted: 06/27/2024] [Indexed: 08/15/2024] Open
Abstract
PURPOSE Emergency resuscitative thoracotomy (ERT) is a final salvage procedure for critically injured trauma patients. Given its low success rate and ambiguous indications, its use in blunt trauma scenarios remains highly debated. Consequently, our study seeks to ascertain the overall survival rate of ERT in blunt trauma patients and determine which patients would benefit most from this procedure. METHODS A retrospective case-control study was conducted for this research. Blunt trauma patients who underwent ERT between January 2020 and December 2023 in our trauma center were selected for analysis, with the endpoint outcome being in-hospital survival, divided into survival and non-survival groups. Inter-group comparisons were conducted using Chi-square and Fisher's exact tests, the Kruskal-Wallis test, Student's t-test, or the Mann-Whitney U test. Univariate and multivariate logistic regression analyses were conducted to assess potential predictors of survival. Then, the efficacy of the predictors was assessed through sensitivity and specificity analysis. RESULTS A total of 33 patients were included in the study, with 4 survivors (12.12%). Multivariate logistic regression analysis indicated a significant association between cardiac tamponade and survival, with an adjusted odds ratio of 33.4 (95% CI: 1.31 - 850, p = 0.034). Additionally, an analysis of sensitivity and specificity, targeting cardiac tamponade as an indicator for survivor identification, showed a sensitivity rate of 75.0% and a specificity rate of 96.6%. CONCLUSION The survival rate among blunt trauma patients undergoing ERT exceeds traditional expectations, suggesting that select individuals with blunt trauma can significantly benefit from the procedure. Notably, those presenting with cardiac tamponade are identified as the subgroup most likely to derive substantial benefits from ERT.
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Affiliation(s)
- Shan Liu
- Department of Emergency, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China
| | - Lin Ling
- The Second Affiliated Hospital, National Regional Key Cities and Sub-central Cities in Hunan Province Hengyang Academician and Expert International Academic Exchange High Tech University, Building A First-class Discipline for Trauma and Critical Care, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China
| | - Yong Fu
- Department of Pediatric Orthopedics and Hand & Foot Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China
| | - Wen-Chao Zhang
- Department of Emergency, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China
| | - Yong-Hu Zhang
- Department of Emergency, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China
| | - Qing Li
- Department of Emergency, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China
| | - Liang Zeng
- Department of Emergency, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China
| | - Jun Hu
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Yong Luo
- Department of Emergency, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China.
| | - Wen-Jie Liu
- The Second Affiliated Hospital, National Regional Key Cities and Sub-central Cities in Hunan Province Hengyang Academician and Expert International Academic Exchange High Tech University, Building A First-class Discipline for Trauma and Critical Care, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China; Department of Anesthesiology, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan province, China.
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Aumaitre A, Delteil C, Tuchtan L, Piercecchi-Marti MD, Gainnier M, Carvelli J, Boussen S, Bruder N, Heireche F, Florant T, Gaillat F, Lagier D, Porto A, Velly L, Simeone P. Resuscitation and Forensic Factors Influencing Outcome in Penetrating Cardiac Injury. Diagnostics (Basel) 2024; 14:1406. [PMID: 39001296 PMCID: PMC11241016 DOI: 10.3390/diagnostics14131406] [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: 06/05/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Cardiac injury caused by a sharp object is a medical and surgical therapeutic challenge. Mortality risk factors have been identified but there are major discrepancies in the literature. The aim of this study was to analyse the management of victims of penetrating cardiac injuries before and after admission to hospital and the anatomical characteristics of these injuries in order to facilitate diagnosis of the most critical patients. METHODS To carry out this study, we conducted a retrospective analytical study with epidemiological data on victims of penetrating cardiac injuries. We included two types of patients, with those who underwent autopsy in our institution after death from sharp injury to the heart or great vessels and those who survived with treatment in the emergency department or intensive care unit between January 2015 and February 2022. RESULTS We included 30 autopsied patients and 12 survivors aged between 18 and 73 years. Higher mortality was associated with prehospital or in-hospital cardiorespiratory arrest (OR = 4, CI [1.71-9.35]), preoperative mechanical ventilation (OR = 10, CI [1.53-65.41]), preoperative catecholamines (OR = 7, CI [1.12-6.29]), preoperative and perioperative adrenaline (OR = 13, CI [1.98-85.46] and [1.98-85.46]), penetrating cardiac injury (OR = 14, CI [2.10-93.22]), multiple cardiac injuries (OR = 1.5, CI [1.05-2.22]) and an Organ Injury Scaling of the American Association for the Surgery of Trauma (AAST-OIS) score of 5 (OR = 2.9, CI [1.04-8.54]; p = 0.0329) with an AUC-ROC curve value of 0.708 (CI [0.543-0.841]). CONCLUSIONS This study identified risk mortality factors in penetrating cardiac injury patients. These findings can help improve the diagnosis and management of these patients. The AAST-OIS score may be a good tool to diagnose critical patients.
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Affiliation(s)
- Astrid Aumaitre
- Service de Médecine Légale, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
- Faculté de Médecine Secteur Nord 51, Boulevard Pierre Dramard, ADES, Aix Marseille University, 13344 Marseille, CEDEX 15, France
| | - Clémence Delteil
- Service de Médecine Légale, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lucile Tuchtan
- Service de Médecine Légale, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
- Faculté de Médecine Secteur Nord 51, Boulevard Pierre Dramard, ADES, Aix Marseille University, 13344 Marseille, CEDEX 15, France
| | - Marie-Dominique Piercecchi-Marti
- Service de Médecine Légale, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
- Faculté de Médecine Secteur Nord 51, Boulevard Pierre Dramard, ADES, Aix Marseille University, 13344 Marseille, CEDEX 15, France
| | - Marc Gainnier
- Réanimation des Urgences, Assistance Publique-Hôpitaux de Marseille, CHU La Timone, 13385 Marseille, France
| | - Julien Carvelli
- Réanimation des Urgences, Assistance Publique-Hôpitaux de Marseille, CHU La Timone, 13385 Marseille, France
| | - Salah Boussen
- Département d'Anesthésie-Réanimation, CHU Timone, Aix Marseille University, 13005 Marseille, France
- Faculté de Médecine Secteur Nord 51, Boulevard Pierre Dramard, IFSTTAR, LBA UMR_T 24, Aix Marseille University, 13344 Marseille, CEDEX 15, France
| | - Nicolas Bruder
- Département d'Anesthésie-Réanimation, CHU Timone, Aix Marseille University, 13005 Marseille, France
| | - Fouzia Heireche
- SAMU13, Pôle RUSH, CHU La Timone, AP-HM, 13005 Marseille, France
| | - Thibault Florant
- Department of Public Health, University Hospital of Marseille, 13015 Marseille, France
| | - Françoise Gaillat
- Département d'Anesthésie et Réanimation (SAR 2), CHU La Timone, Assistance Publique des Hôpitaux de Marseille, 13015 Marseille, France
| | - David Lagier
- Département d'Anesthésie et Réanimation (SAR 2), CHU La Timone, Assistance Publique des Hôpitaux de Marseille, 13015 Marseille, France
| | - Alizée Porto
- Département de Chirurgie Cardiaque, CHU Timone, 13005 Marseille, France
| | - Lionel Velly
- Département d'Anesthésie-Réanimation, CHU Timone, Aix Marseille University, 13005 Marseille, France
- Institut des Neurosciences de la Timone, CNRS, Aix Marseille University, 13005 Marseille, France
| | - Pierre Simeone
- Département d'Anesthésie-Réanimation, CHU Timone, Aix Marseille University, 13005 Marseille, France
- Institut des Neurosciences de la Timone, CNRS, Aix Marseille University, 13005 Marseille, France
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L'Huillier JC, Jalal K, Nohra E, Boccardo JD, Olafuyi O, Jordan MB, Myneni AA, Schwaitzberg SD, Flynn WJ, Brewer JJ, Noyes K, Cooper CA. Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database. J Surg Res 2024; 298:24-35. [PMID: 38552587 DOI: 10.1016/j.jss.2024.02.020] [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: 09/20/2023] [Revised: 02/06/2024] [Accepted: 02/29/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.
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Affiliation(s)
- Joseph C L'Huillier
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Kabir Jalal
- Department of Biostatistics, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Eden Nohra
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Joseph D Boccardo
- Department of Biostatistics, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Olatoyosi Olafuyi
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Marcy Bubar Jordan
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Ajay A Myneni
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Steven D Schwaitzberg
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - William J Flynn
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Jeffrey J Brewer
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Katia Noyes
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Clairice A Cooper
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York.
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Roche AF, Voborsky M, Meighan V, O'Connor G, Eppich WJ, Condron CM. Developing a clamshell thoracotomy training model to support hybrid teaching in simulation-based education. Emerg Med Australas 2024; 36:482-484. [PMID: 38418385 DOI: 10.1111/1742-6723.14398] [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: 11/21/2023] [Revised: 01/18/2024] [Accepted: 02/15/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Thoracotomy is an acute, time-sensitive procedure. Simulation-based education provides a safe-learning platform to learn these techniques under close supervision. METHODS We used the spiral model and concepts of functional fidelity to guide the evolutionary design and fabrication of a hybrid thoracotomy simulator. RESULTS This model simulates a clamshell thoracotomy that physically integrates with bespoke manikins and adds a high-fidelity technical skills element to immersive team-based simulation training. CONCLUSIONS We describe the creation of a thoracotomy simulation model that allows trainees to practice these techniques in a safe-learning environment.
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Affiliation(s)
- Adam F Roche
- RCSI SIM Centre for Simulation Education and Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Miroslav Voborsky
- RCSI SIM Centre for Simulation Education and Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Victoria Meighan
- Emergency Department, Tallaght University Hospital, Dublin, Ireland
| | - Gerard O'Connor
- Emergency Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Walter J Eppich
- School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Claire M Condron
- RCSI SIM Centre for Simulation Education and Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Leeper WR, James N. Trauma Bay Evaluation and Resuscitative Decision-Making. Surg Clin North Am 2024; 104:293-309. [PMID: 38453303 DOI: 10.1016/j.suc.2024.01.002] [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] [Indexed: 03/09/2024]
Abstract
The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.
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Affiliation(s)
- William Robert Leeper
- Department of Surgery, Western University, Victoria Campus, London Health Sciences Center, Room E2-215, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada; Trauma Program at London Health Sciences Center, Division of Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Nicholas James
- London Health Sciences Center, Victoria Campus, Room E2-214, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada; Trauma Program at London Health Sciences Center, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Adami EA, Poillucci G, Di Saverio S, Khan M, Fransvea P, Podda M, Rampini A, Marini P. A critical appraisal of emergency resuscitative thoracotomy in a Western European level 1 trauma centre: a 13-year experience. Updates Surg 2024; 76:677-686. [PMID: 37839047 DOI: 10.1007/s13304-023-01667-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
Emergency Resuscitative Thoracotomy (ERT) is a lifesaving procedure in selected patients. Outcome mostly in blunt trauma is believed to be poor. The primary aim of this study was to determine the predictors of postoperative mortality following ERT. We retrospectively reviewed 34 patients ≥ 18 years who underwent ERT at San Camillo-Forlanini Hospital (Rome, Italy) between January 2009 and December 2022 with traumatic arrest for blunt or penetrating injuries. Of 34 ERT, 28 (82.4%) were for blunt trauma and 6 (17.6%) were for penetrating trauma. Injury Severity Score (p-value 0.014), positive E-FAST (p-value 0.023), Systolic Blood Pressure (p-value 0.001), lactate arterial blood (p-value 0.012), pH arterial blood (p-value 0.007), and bicarbonate arterial blood (p-value < 0.001) were significantly associated with postoperative mortality in a univariate model. After adjustment, the only independent predictor of postoperative mortality was Injury Severity Score (p-value 0.048). Our experience suggests that ERT is a technique that should be utilized for patients with critical penetrating injuries and blunt trauma in patients in extremis. Our study highlights as negative prognostic factors high values of ISS and lactate arterial blood, a positive E-FAST, and low values of Systolic Blood Pressure, pH arterial blood and bicarbonate arterial blood.
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Affiliation(s)
- Ennio Alberto Adami
- General and Emergency Surgery, St. Camillo Forlanini's Hospital, Rome, Italy
| | - Gaetano Poillucci
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, San Matteo Hospital, Spoleto, Italy.
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Mansoor Khan
- University Hospitals Sussex NHSFT, Eastern Rd, Brighton, UK
| | - Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Mauro Podda
- Department of Surgical Science, Policlinico Universitario "Duilio Casula", University of Cagliari, Cagliari, Italy
| | - Alessia Rampini
- General and Emergency Surgery, St. Camillo Forlanini's Hospital, Rome, Italy
| | - Pierluigi Marini
- General and Emergency Surgery, St. Camillo Forlanini's Hospital, Rome, Italy
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Godbole M, Olafson S, Cohen RB, Ward CL, Sailes S, Sharlin M, Parsikia A, Moran BJ, Leung PSP. Eastern Association for the Surgery of Trauma (EAST) vs Western Trauma Association (WTA): How a Level 1 Trauma Center Splits the Difference in Resuscitative Thoracotomy. Cureus 2024; 16:e56521. [PMID: 38646323 PMCID: PMC11026983 DOI: 10.7759/cureus.56521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/23/2024] Open
Abstract
Background Resuscitative thoracotomy (RT) is performed in severe trauma cases as a final lifesaving effort. Prominent, yet differing, practice management guidelines exist from Eastern Association for the Surgery of Trauma (EAST) and Western Trauma Association (WTA). This study evaluates all RTs performed from 2012 to 2019 at an urban Level 1 trauma center for management guideline indication and subsequent outcomes. Methods Our trauma registry was queried to identify RT cases from 2012 to 2019. Data was collected on patient demographics, prehospital presentation, cardiopulmonary resuscitation (CPR) requirements, and resuscitation provided. Survival to the operating room, intensive care unit, and overall were recorded. Information was compared with regard to EAST and WTA criteria. Results Eighty-seven patients who underwent RTs were included. WTA guidelines were met in 78/87 (89.7%) of cases, comparatively EAST guidelines were met in every case. Within the EAST criteria, conditional and strong recommendations were met in 70/87 (80.4%) and 17/87 (19.5%) of cases, respectively. In nine cases (10.3%) indications were discordant, each meeting conditional indication by EAST and no indication by WTA. All patients that survived to the operating room (OR), ICU admission, and overall met EAST criteria. Conclusion All RTs performed at our Level 1 trauma center met indications provided by EAST criteria. WTA guidelines were not applicable in nine salvaging encounters due to the protracted duration of CPR before proceeding to RT. Furthermore, more patients that survived to OR and ICU admission met EAST guidelines suggesting an improved potential for patient survivability. As increased data is derived, management guidelines will likely be re-established for optimized patient outcomes.
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Affiliation(s)
- Moshumi Godbole
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Samantha Olafson
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Ryan B Cohen
- General Surgery, Einstein Healthcare Network, Philadelphia, USA
| | - Candace L Ward
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Stephanie Sailes
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Mia Sharlin
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Afshin Parsikia
- General Surgery, Einstein Healthcare Network, Philadelphia, USA
| | | | - Pak Shan P Leung
- Trauma and Acute Care Surgery, Einstein Healthcare Network, Philadelphia, USA
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Kim E, Song S, Kim SH, Lee NH, Lee S. Role of extracorporeal life support for traumatic hemopericardium: A single level I trauma center review. Injury 2024; 55:111193. [PMID: 37985267 DOI: 10.1016/j.injury.2023.111193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 10/15/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Traumatic hemopericardium may lead to cardiac tamponade, arrhythmia, arrest, or death and requires emergency surgery. We reviewed cases of traumatic hemopericardium in our center and the role of extracorporeal life support in these cases. METHODS From November 2011 to January 2022, 28 patients with significant hemopericardium and suspected cardiac injury were enrolled. In our center, surgery is the primary treatment of choice; however, if the patient is in an unstable condition, extracorporeal life support is administered in the emergency room prior to surgery. RESULTS Preoperative extracorporeal life support was applied to 10 patients (36 %). Two patients (20 %) were converted from extracorporeal life support to cardiopulmonary bypass during operation. After surgery, 2 patients (20 %) needed postoperative extracorporeal membrane oxygenation support. Overall, 21 patients (75 %) survived; of these, 6 (29 %) received extracorporeal life support. Meanwhile, 7 patients (25 %) died; of these, 4 patients (57 %) received extracorporeal life support. CONCLUSION Resuscitation method is the most crucial survival strategy in patients with severe chest trauma. Extracorporeal life support in cases of traumatic hemopericardium may be beneficial and efficient in stabilizing patients prior to surgery.
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Affiliation(s)
- Eunji Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, BioMedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, BioMedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea.
| | - Seon Hee Kim
- Department of Trauma and Surgical Critical Care, Pusan National University School of Medicine, BioMedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea.
| | - Na Hyeon Lee
- Department of Trauma and Surgical Critical Care, Pusan National University School of Medicine, BioMedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Soojin Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
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Alremeithi R, Tran QK, Quintana MT, Shahamatdar S, Pourmand A. Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers. World J Emerg Med 2024; 15:3-9. [PMID: 38188559 PMCID: PMC10765073 DOI: 10.5847/wjem.j.1920-8642.2023.085] [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: 05/08/2023] [Accepted: 07/28/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA. METHODS We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process. RESULTS A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS. CONCLUSION TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.
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Affiliation(s)
- Rashed Alremeithi
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Quincy K. Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore 21201, USA
- Program in Trauma, the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore 21201, USA
| | - Megan T. Quintana
- Center for Trauma and Critical Care, Department of Surgery, the George Washington University School of Medicine & Health Sciences, Washington DC 20037, USA
| | - Soroush Shahamatdar
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
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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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Dongming G, Yuequan J, Qi Z, Huajie X, Zhiqiang W. A novel technique for lymphadenectomy along the left recurrent laryngeal nerve during minimally invasive esophagectomy: a retrospective cohort study. BMC Surg 2023; 23:355. [PMID: 37990240 PMCID: PMC10662753 DOI: 10.1186/s12893-023-02263-5] [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: 08/21/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND In the context of esophageal cancers, lymph nodes located along the left recurrent laryngeal nerve (RLN) exhibit significant involvement, posing significant challenges for lymphadenectomy. The objective of this study is to assess the safety and efficacy of a novel technique for lymphadenectomy called "elastic suspension of left RLN" method, comparing it with the conventional approach. METHODS Between January 2016 and June 2020, a total of 393 patients who underwent minimally invasive esophagectomy with gastroplasty and cervical esophagogastric anastomosis were enrolled in the study. Among them, 291 patients underwent the "elastic suspension of left RLN" method, while 102 patients underwent the conventional method. We compared the number of harvested lymph nodes along the left RLN and assessed postoperative complications between these two groups. Additionally, the overall survival (OS) rate was calculated and analyzed for the entire cohort. RESULTS In comparison to the conventional group, the elastic suspension group exhibited a higher yield of harvested lymph nodes along the left RLN (5.36 vs 3.07, P < 0.001). Moreover, the incidence of postoperative hoarseness was lower in the elastic suspension group (10.65% vs 18.63%, P = 0.038). The average duration of lymphadenectomy along the left RLN was 11.85 min in the elastic suspension group and 11.51 min in the conventional group, although this difference was not statistically significant (P = 0.091). Notably, the overall 5-year OS was markedly higher in the elastic suspension group compared to the conventional group (64.1% vs. 50.1%, P = 0.020). CONCLUSIONS The findings suggest that the novel "elastic suspension of left RLN" method for lymphadenectomy along the left RLN in minimally invasive esophagectomy is both safe and effective. This technique holds promise for widespread adoption in esophagectomy procedures.
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Affiliation(s)
- Guo Dongming
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Jiang Yuequan
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Zhang Qi
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Xing Huajie
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Wang Zhiqiang
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China.
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14
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Atkins K, Schneider A, Gallaher J, Cairns B, Charles A. Who benefits from resuscitative thoracotomies following penetrating trauma: The patient or the learner? Injury 2023; 54:111033. [PMID: 37716863 PMCID: PMC10591838 DOI: 10.1016/j.injury.2023.111033] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/23/2023] [Accepted: 09/08/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Resuscitative thoracotomy (RT) is a salvage procedure following traumatic cardiac arrest. We aim to evaluate RT trends and outcomes in adults with cardiac arrest following penetrating trauma to determine the effect on mortality in this population. Further, we aim to estimate the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality. METHODS We reviewed the National Trauma Data Bank (2017-2021) for adults (≥16 years old) with penetrating trauma and prehospital cardiac arrest, stratified by the performance of a RT. We performed multivariable logistic regressions to estimate the effect of RT on mortality and the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality. RESULTS 13,115 patients met our inclusion criteria. RT occurred in 12.7% (n = 1,664) of patients. Rates of RT trended up over the study period. Crude mortality was similar in RT and Non-RT patients (95.6% vs. 94.5%, p = 0.07). There was no statistically significant difference in the adjusted odds of mortality based on RT status (OR 0.82, 95%CI 0.56-1.21). University-teaching hospitals had an adjusted odds ratio of 1.68 (95% CI 1.31-2.17) for performing a RT than non-teaching hospitals. There was no difference in the adjusted odds of mortality in patients that underwent RT based on hospital teaching status. CONCLUSION Despite up-trending rates, a resuscitative thoracotomy may not improve mortality in adults with penetrating, traumatic cardiac arrest. University teaching hospitals are nearly twice as likely to perform a RT than non-teaching hospitals, with no subsequent improvement in mortality.
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Affiliation(s)
- Kathryn Atkins
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Andrew Schneider
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, USA.
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15
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Yamamoto R, Suzuki M, Sasaki J. Potential harms of emergency department thoracotomy in patients with persistent cardiac arrest following trauma: a nationwide observational study. Sci Rep 2023; 13:16042. [PMID: 37749170 PMCID: PMC10520031 DOI: 10.1038/s41598-023-43318-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023] Open
Abstract
Emergency department thoracotomy (EDT) was incorporated into traumatic out-of-hospital cardiac arrest (t-OHCA) resuscitation. Although current guidelines recommend EDT with survival predictors, futility following EDT has been demonstrated and the potential risks have not been thoroughly investigated. This study aimed to elucidate the benefits and harms of EDT for persistent cardiac arrest following injury until hospital arrival. This retrospective cohort study used a nationwide trauma registry (2019-2021) and included adult patients with t-OHCA both at the scene and on hospital arrival. Survival to discharge, hemostatic procedure frequency, and transfusion amount were compared between patients treated with and without EDT. Inverse probability weighting using a propensity score was conducted to adjust age, sex, comorbidities, mechanism of injury, prehospital resuscitative procedure, prehospital physician presence, presence of signs of life, degree of thoracic injury, transportation time, and institutional characteristics. Among 1289 patients, 374 underwent EDT. The longest transportation time for survivors was 8 and 23 min in patients with and without EDT, respectively. EDT was associated with lower survival to discharge (4/374 [1.1%] vs. 22/915 [2.4%]; adjusted odds ratio [OR], 0.43 [95% CI 0.22-0.84]; p = 0.011), although patients with EDT underwent more frequent hemostatic surgeries (46.0% vs. 5.0%; adjusted OR, 16.39 [95% CI 12.50-21.74]) and received a higher amount of transfusion. Subgroup analyses revealed no association between EDT and lower survival in patients with severe chest injuries (1.0% vs. 1.4%; adjusted OR, 0.72 [95% CI 0.28-1.84]). EDT was associated with lower survival till discharge in trauma patients with persistent cardiac arrests after adjusting for various patient backgrounds, including known indications for EDT. The idea that EDT is the last resort for t-OHCA should be reconsidered and EDT indications need to be deliberately determined.Trial registration This study is retrospectively registered at University Hospital Medical Information Network (UMIN ID: UMIN000050840).
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Affiliation(s)
- Ryo Yamamoto
- Trauma Service, Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Masaru Suzuki
- Department of Emergency Medicine, Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan
| | - Junichi Sasaki
- Trauma Service, Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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16
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Blank JJ, Seamon MJ. Emergency Department Thoracotomy in Trauma. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00347-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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17
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ter Avest E, Carenzo L, Lendrum RA, Christian MD, Lyon RM, Coniglio C, Rehn M, Lockey DJ, Perkins ZB. Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries. Crit Care 2022; 26:184. [PMID: 35725641 PMCID: PMC9210796 DOI: 10.1186/s13054-022-04052-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.
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18
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Ohlén D, Hedberg M, Martinsson P, von Oelreich E, Djärv T, Jonsson Fagerlund M. Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden. Scand J Trauma Resusc Emerg Med 2022; 30:54. [PMID: 36253786 PMCID: PMC9575295 DOI: 10.1186/s13049-022-01039-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/16/2022] [Indexed: 12/05/2022] Open
Abstract
Background Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy. Methods Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors. Results Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min. Conclusion Survival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01039-9.
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Affiliation(s)
- Daniel Ohlén
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Magnus Hedberg
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Paula Martinsson
- Department of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Therese Djärv
- Department of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
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Flanagan M, Ryan J, Bass G, Barry K, Traynor O, McMonagle M. Competency in trauma surgery: a national survey of trainees and consultants. Ir J Med Sci 2022:10.1007/s11845-022-03117-4. [PMID: 35969339 DOI: 10.1007/s11845-022-03117-4] [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: 04/06/2022] [Accepted: 07/23/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The current sparsity of surgical trainees' exposure to training in operative trauma surgery is multifactorial. This concern has been addressed in the revised Intercollegiate Surgical Curriculum Programme (ISCP) for general and vascular surgery (2021). In the lead up to its implementation, we aimed to assess both trainee and consultant confidence levels as a surrogate reflection in the core competency operative skills in general emergency trauma surgery, identify individual experience in commonly performed trauma procedures and gauge interest in a career in trauma surgery. METHOD An online survey was circulated to general surgery and vascular surgery trainees and consultants. Self-reported competencies were assessed using a 1-10 confidence rating scale. Most questions were based on competencies in emergency trauma surgery as set out by the ISCP. RESULTS Out of 251 surgical trainees and consultants, 119 responded to our survey (47.4% response rate). Less than half (44.1%; n = 52) of respondents had experienced a trauma thoracotomy. Respondents scored 'somewhat' or 'not at all' competent in the majority of competencies assessed. CONCLUSION Self-reported competencies in operative trauma skills across all subgroups were sub-standard with incremental levels of perceived competence proportional to years of surgical training. Our data supports the necessity of the new curriculum, in addition to modern training pathways with direct exposure to operative trauma surgery involving dedicated trauma centres and networks, and responsibility of training pathways in the provision of training trauma surgery.
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Affiliation(s)
- Michael Flanagan
- Department of Surgery, University Hospital Waterford, Waterford, Ireland.
| | - Jessica Ryan
- Department of Surgery, University Hospital Waterford, Waterford, Ireland
| | - Gary Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Medicine, Philadelphia, PA, USA
| | - Kevin Barry
- Department of Surgical Affairs, National Surgical Training Programmes, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Oscar Traynor
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin, Ireland
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20
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Sam ASY, Nawijn F, Benders KEM, Houwert RM, Leenen LPH, Hietbrink F. Outcomes of the resuscitative and emergency thoracotomy at a Dutch level-one trauma center: are there predictive factors for survival? Eur J Trauma Emerg Surg 2022; 48:4877-4887. [PMID: 35713680 DOI: 10.1007/s00068-022-02021-x] [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: 04/19/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate the 30-day survival rate of resuscitative and emergency thoracotomies in trauma patients. Moreover, factors that positively influence 30-day survival rates were investigated. METHODS A retrospective study of patients (> 16 years), between 2008 and 2020, who underwent a resuscitative or emergency thoracotomy at a level-one trauma center in the Netherlands was conducted. RESULTS Fifty-six patients underwent a resuscitative (n = 45, 80%) or emergency (n = 11, 20%) thoracotomy. The overall 30-day survival rate was 32% (n = 18), which was 23% after blunt trauma and 72% after penetrating trauma, and which was 18% for the resuscitative thoracotomy and 91% for the emergency thoracotomy. The patients who survived had full neurologic recovery. Factors associated with survival were penetrating trauma (p < 0.001), (any) sign of life (SOL) upon presentation to the hospital (p = 0.005), Glasgow Coma Scale (GCS) of 15 (p < 0.001) and a thoracotomy in the operating room (OR) (p = 0.018). Every resuscitative thoracotomy after blunt trauma and pulseless electrical activity (PEA) or asystole in the pre-hospital phase was futile (0 survivors out of 11 patients), of those patients seven (64%) had concomitant severe neuro-trauma. CONCLUSION This study found a 30-day survival rate of 32% for resuscitative and emergency thoracotomies, all with good neurological recovery. Factors associated with survival were related to the trauma mechanism, the thoracotomy indication and response to resuscitation prior to thoracotomy (for instance, if resuscitation enables enough time for safe transport to the operating room, survival chances increase). Resuscitative thoracotomies after blunt trauma in combination with loss of SOL before arrival at the emergency room were in all cases futile, interestingly in nearly all cases due to concomitant neuro-trauma.
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Affiliation(s)
- A S Y Sam
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - K E M Benders
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R M Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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21
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Penetrating Cardiac Injuries: Outcome of Treatment from a Level 1 Trauma Centre in South Africa. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2020021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Penetrating cardiac injuries are rare in South African and international literature. Penetrating cardiac injuries are regarded as one of the most lethal injuries in trauma patients. The mechanism of injury varies across the world. In developing countries, stab wounds cause the majority of penetrating cardiac injuries. These injuries remain clinically challenging and are associated with high mortalities. Aim: To describe our experience with penetrating cardiac injuries and the outcome of their management at a level 1 trauma unit in Johannesburg, South Africa. Materials and methods: We retrospectively reviewed all patients who presented with penetrating cardiac injuries over a period of four years (1 January 2016 to 31 December 2019). The patients were identified using the hospital database. The patient’s demographics, mechanism of injury, injury severity score, vital signs, investigation findings, final diagnosis, type of operation, length of hospital stay, morbidities, and mortalities were recorded. Results: There was a total of 167 patients with penetrating cardiac injuries identified. There were 151 (90.4%) males, with an overall median age of 29 years (IQR 24–34). Stab wounds accounted for 77.8% of the injuries, while gunshot wounds (GSW) accounted for 22.2%. The median injury severity score (ISS) and revised trauma score (RTS) were 25 and 7.1, respectively. The right ventricle was the most injured chamber (34.7%), followed by the left ventricle (29.3%), right auricle (13.2%), right atrium (10.2%), and combined injuries accounted for 7% of injuries. A commonly used incision was a sternotomy (51.5%), left anterior-lateral thoracotomy (26.9%), emergency room thoracotomy (19.2%), and clamshell thoracotomy (2.4%). The overall mortality rate was 40.7%, with a 29.2% mortality in the stab wounds. Twenty-four (14.4%) patients died in the emergency department, sixteen (9.6%) patients died on the table in theatre, and the remaining twenty-eight (16.7%) died in the intensive care unit or wards. Gunshot wounds, other associated injuries, right ventricle injuries, a high ISS, low RTS, and low Glasgow coma scale were all significantly more likely to result in death (p < 0.001). Conclusions: Penetrating cardiac injuries are often fatal, but the mortality can be improved with appropriate resuscitation and a work-up. The injuries to the heart can be safely managed by trauma/general surgeons in our setting. The physiology in presentation and other associated injuries determines outcomes in patients with penetrating cardiac injury.
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22
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Tanikawa A, Sato T, Fujita M, Tsuchiya C, Katsuta K, Suzuki Y, Kumagai K, Saiki Y, Kushimoto S. Thoracic endovascular aortic repair for avulsion of aortic branches in a trauma patient requiring resuscitative thoracotomy: a case report. Surg Case Rep 2022; 8:71. [PMID: 35438386 PMCID: PMC9018930 DOI: 10.1186/s40792-022-01427-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/09/2022] [Indexed: 11/26/2022] Open
Abstract
Background Resuscitative thoracotomy is a lifesaving procedure for trauma patients that are hemodynamically unstable. Cross-clamping of the descending thoracic aorta is an essential procedure performed during resuscitative thoracotomy in patients with impending cardiac arrest. Although complications related to resuscitative thoracotomy have been reported, there is no report on avulsion of aortic branches related to cross-clamping of the descending aorta and its appropriate management. Case presentation We present the case of a 42-year-old woman who sustained blunt trauma due to an accidental fall. The patient was hemodynamically unstable and required resuscitative thoracotomy with cross-clamping of the thoracic aorta. However, hemorrhage from avulsion of aortic branches related to aortic cross-clamping was identified. Initially, transcatheter arterial embolization was attempted to achieve hemostasis; however, when that proved ineffective, thoracic endovascular aortic repair was performed, which resulted in successful hemorrhage control without any sequelae. Conclusions Thoracic endovascular aortic repair may be a management option for aortic branch avulsion due to cross-clamping of the descending aorta during resuscitative thoracotomy.
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Almond P, Morton S, OMeara M, Durge N. A 6-year case series of resuscitative thoracotomies performed by a helicopter emergency medical service in a mixed urban and rural area with a comparison of blunt versus penetrating trauma. Scand J Trauma Resusc Emerg Med 2022; 30:8. [PMID: 35081989 PMCID: PMC8793242 DOI: 10.1186/s13049-022-00997-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background Resuscitative thoracotomy (RT) is an intervention that can be performed in the prehospital setting for relieving cardiac tamponade and/or obtaining vascular control of suspected sub-diaphragmatic haemorrhage in patients in traumatic cardiac arrest. The aim of this retrospective case study is to compare the rates of return of spontaneous circulation (ROSC) in RTs performed for both penetrating and blunt trauma over 6 years in a mixed urban and rural environment. Methods The electronic records of a single helicopter emergency medical service were reviewed between 1st June 2015 and 31st May 2021 for RTs. Anonymised data including demographics were extracted for relevant cases. Data were analysed with independent t-tests and Χ2 tests. A p value < 0.05 was considered statistically significant. Results Forty-four RTs were preformed within the 6 years (26 for blunt trauma). Eleven ROSCs were achieved (nine blunt, two penetrating) but no patient survived to discharge. In contrast to RTs for penetrating trauma, twelve of the RTs for blunt trauma had a cardiac output present on arrival of the prehospital team (p = 0.01). Two patients had an RT performed in a helicopter (one ROSC) and two on a helipad (both achieving ROSC), likely due to the longer transfer times seen in a more rural setting. Four of the RTs for blunt trauma (15%) were found to have a cardiac tamponade versus seven (39%) of the penetrating trauma RTs. Conclusion Prehospital RT remains a procedure with low rates of survival but may facilitate a ROSC to allow patients to reach hospital and surgery, particularly when distances to hospitals are greater. A higher-than-expected rate of cardiac tamponade was seen in RTs for blunt trauma, although not caused by a right ventricular wound but instead due to underlying vessel damage. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-00997-4.
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Affiliation(s)
- Phillip Almond
- Essex and Herts Air Ambulance, Earls Colne, Colchester, Essex, CO6 2NS, UK
| | - Sarah Morton
- Essex and Herts Air Ambulance, Earls Colne, Colchester, Essex, CO6 2NS, UK.
| | - Matthew OMeara
- Essex and Herts Air Ambulance, Earls Colne, Colchester, Essex, CO6 2NS, UK
| | - Neal Durge
- Essex and Herts Air Ambulance, Earls Colne, Colchester, Essex, CO6 2NS, UK
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Use of a disposable vascular pressure device to guide balloon inflation of resuscitative endovascular balloon occlusion of the aorta: a bench study. Sci Rep 2021; 11:24055. [PMID: 34912008 PMCID: PMC8674295 DOI: 10.1038/s41598-021-03502-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/01/2021] [Indexed: 11/10/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) for rapid hemorrhage control is increasingly being used in trauma management. Its beneficial hemodynamic effects on unstable patients beyond temporal hemostasis has led to growing interest in its use in other patient populations, such as during cardiac arrest from nontraumatic causes. The ability to insert the catheters without fluoroscopic guidance makes the technique available in the prehospital setting. However, in addition to correct positioning, challenges include reliably achieving aortic occlusion while minimizing the risk of balloon rupture. Without fluoroscopic control, inflation of the balloon relies on estimated aortic diameters and on the disappearing pulse in the contralateral femoral artery. In the case of cardiac arrest or absent palpable pulses, balloon inflation is associated with excess risk of overinflation and adverse events (vessel damage, balloon rupture). In this bench study, we examined how the pressure in the balloon is related to the surrounding blood pressure and the balloon's contact with the vessel wall in two sets of experiments, including a pulsatile circulation model. With this data, we developed a rule of thumb to guide balloon inflation of the ER-REBOA catheter with a simple disposable pressure-reading device (COMPASS). We recommend slowly filling the balloon with saline until the measured balloon pressure is 160 mmHg, or 16 mL of saline have been used. If after 16 mL the balloon pressure is still below 160 mmHg, saline should be added in 1-mL increments, which increases the pressure target about 10 mmHg at each step, until the maximum balloon pressure is reached at 240 mmHg (= 24 mL inflation volume). A balloon pressure greater than 250 mmHg indicates overinflation. With this rule and a disposable pressure-reading device (COMPASS), ER-REBOA balloons can be safely filled in austere environments where fluoroscopy is unavailable. Pressure monitoring of the balloon allows for recognition of unintended deflation or rupture of the balloon.
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Mladinov D, Frank SM. Massive transfusion and severe blood shortages: establishing and implementing predictors of futility. Br J Anaesth 2021; 128:e71-e74. [PMID: 34794769 DOI: 10.1016/j.bja.2021.10.013] [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: 08/03/2021] [Revised: 09/16/2021] [Accepted: 10/03/2021] [Indexed: 11/02/2022] Open
Abstract
Massive transfusion protocols were developed to deliver blood for life-threatening haemorrhage; however, there are no guidelines to advise when massive transfusion protocols may be considered futile. Early recognition of clinical futility remains a challenge as studies have not identified variables that can accurately determine early mortality. As blood is a scarce resource, efforts to distribute it equitably to all patients who would benefit are of paramount importance. In this editorial we discuss recent data and various aspects important in developing and implementing tools that assist with determining futility in massive transfusion.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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26
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Abstract
As care of the injured patient continues to evolve, new surgical technologies and new resuscitative therapies can change the algorithms that drive trauma care. In particular, the advent of resuscitative endovascular balloon occlusion of the aorta has changed the way trauma surgeons treat patients in extremis. The science of resuscitation continues to evolve, leading to controversy about the optimal administration of fluid and blood products. Laparoscopy has given additional tools to the trauma surgeon to potentially avoid exploratory laparotomy, and rib fracture fixation can be beneficial in the proper patient.
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Affiliation(s)
- Stephanie Bonne
- Department of Surgery, Division of Trauma and Surgical Critical Care, Rutgers, New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Fariha Sheikh
- Department of Surgery, Division of Trauma and Surgical Critical Care, Rutgers, New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA
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Moore MM, Alejandro EU. Aortic Cross-Clamping to Provide Differential Fixation by Perfusion. Curr Protoc 2021; 1:e81. [PMID: 33740319 DOI: 10.1002/cpz1.81] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
An intricate network of regulation between the brain and the pancreas modulates hormone secretion and organ function. Dysfunction of the brain-pancreas axis occurs in disease states such as diabetes and pancreatitis. Given the delicate nature of the mouse brain, procurement for tissue and cellular analysis is facilitated by fixation by perfusion with paraformaldehyde (PFA). The brain is hardened by PFA during the preservation process, but this hardening also occurs in the pancreas, as well as the remainder of the intra-abdominal organs. This hardening makes the pancreas friable and difficult to dissect without damaging and fragmenting the organ. Additionally, this fixation may preclude the ability to perform analytic techniques such as western blot and quantitative PCR (qPCR) simultaneously. Performing a simple cross-clamping of the thoracic aorta allows for differential perfusion of organs and maximal use of limited samples from a single animal. The brain can be perfused with PFA without compromising tissue collection of the pancreas and other intra-abdominal organs. This simple maneuver allows for greater tissue collection and analysis per mouse in studies evaluating the brain-pancreas or brain-gut axis. © 2021 Wiley Periodicals LLC. Basic Protocol: Differential fixation by perfusion using aortic cross-clamp.
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Affiliation(s)
- Mackenzie M Moore
- Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Emilyn U Alejandro
- Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis, Minnesota
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