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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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Malysch T, Breuer F, Wolff J, Poloczek S, Dahmen J. Präklinische Notfallthorakotomie in der Berliner Notfallrettung – Darstellung der Umsetzung im Land Berlin und Diskussion erster Erkenntnisse. Notf Rett Med 2022. [DOI: 10.1007/s10049-022-01104-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
ZusammenfassungIm Jahr 2015 fand das Thema „traumatisch bedingter Herz-Kreislauf-Stillstand“ erstmalig Einzug in die aktualisierten Reanimationsleitlinien des European Resuscitation Council. Neben dem speziell anzuwendenden Maßnahmenbündel mit Atemwegsmanagement, Therapie der Hypovolämie, externer Blutungskontrolle und beidseitiger Thoraxentlastung sollte auch eine Notfallthorakotomie bei geeigneten Patienten erwogen werden. Um dieses Vorgehen systematisch in der Berliner Notfallrettung zu etablieren und standardisieren, hat die Ärztliche Leitung Rettungsdienst der Berliner Feuerwehr verschiedene Maßnahmen unternommen, um die optimale Ausnutzung der Schlüsselfaktoren Expertise, „elapsed time“, Equipment und „environment“ sicherzustellen. Dabei konnten im Laufe der ersten 2,5 Jahre auch bereits wichtige Erfahrungen aus der neuen Versorgungsstruktur dieser schwerstverletzten Patienten gewonnen werden.
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Dhillon NK, Patel DC, Huang R, Yang AR, Sekhon HK, Margulies DR, Ley EJ, Barmparas G. Impact of Aggressive Treatments in Trauma: Using the Emergent Department Thoracotomy to Death Ratio. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03392-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Haida VM, Yamashita EM, Franco GS, Amado WBR, Arakaki IK, Dal-Bosco CLB, Zwierzikowski JA, Collaço IA, Cavassin GP. Performance and outcome of ressucitative thoracotomies in a southern Brazil trauma center: a 7-year retrospective analysis. Rev Col Bras Cir 2022; 49:e20223146. [PMID: 35319564 PMCID: PMC10578860 DOI: 10.1590/0100-6991e-20223146] [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: 08/04/2021] [Accepted: 10/06/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE the study aims to analyze the performance and outcome of resuscitation thoracotomy (TR) performed in patients victims of penetrating and blunt trauma in a trauma center in southern Brazil during a 7 years period. METHODS retrospective study based on the analysis of medical records of patients undergoing TR, from 2014 to 2020, in the emergency service of the Hospital do Trabalhador, Curitiba - Paraná, Brazil. RESULTS a total of 46 TR were performed during the study period, of which 89.1% were male. The mean age of patients undergoing TR was 34.1±12.94 years (range 16 and 69 years). Penetrating trauma corresponded to the majority of indications with 80.4%, of these 86.5% victims of gunshot wounds and 13.5% victims of knife wounds. On the other hand, only 19.6% undergoing TR were victims of blunt trauma. Regarding the outcome variables, 84.78% of the patients had declared deaths during the procedure, considered non-responders. 15.22% of patients survived after the procedure. 4.35% of patients undergoing TR were discharged from the hospital, 50% of which were victims of blunt trauma. CONCLUSION the data obtained in our study are in accordance with the world literature, reinforcing the need for a continuous effort to perform TR, respecting its indications and limitations in patients victims of severe penetrating or blunt trauma.
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Affiliation(s)
- Vitor Mamoru Haida
- - Universidade Positivo, Departamento de Medicina - Curitiba - PR - Brasil
- - Hospital do Trabalhador, Departamento de Cirurgia Geral - Curitiba - PR - Brasil
| | | | | | | | | | | | | | - Iwan Augusto Collaço
- - Hospital do Trabalhador, Departamento de Cirurgia Geral - Curitiba - PR - Brasil
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Liu A, Nguyen J, Ehrlich H, Bisbee C, Santiesteban L, Santos R, McKenney M, Elkbuli A. Emergency Resuscitative Thoracotomy for Civilian Thoracic Trauma in the Field and Emergency Department Settings: A Systematic Review and Meta-Analysis. J Surg Res 2022; 273:44-55. [PMID: 35026444 DOI: 10.1016/j.jss.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/20/2021] [Accepted: 11/22/2021] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Amy Liu
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Jackie Nguyen
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Haley Ehrlich
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Charles Bisbee
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Luis Santiesteban
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Radleigh Santos
- Department of Mathematics, NOVA Southeastern University, Fort Lauderdale, Florida
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida.
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Khalifa A, Avraham JB, Kramer KZ, Bajani F, Fu CY, Pires-Menard A, Kaminsky M, Bokhari F. Surviving traumatic cardiac arrest: Identification of factors associated with survival. Am J Emerg Med 2021; 43:83-87. [PMID: 33550103 DOI: 10.1016/j.ajem.2021.01.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/09/2021] [Accepted: 01/10/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary arrest varies across institutions and even among providers. The purpose of this study was to examine survival characteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED). METHODS The National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hospitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed. RESULTS A total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mechanism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99). CONCLUSION Over a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physicians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.
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Affiliation(s)
- Andrew Khalifa
- Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA.
| | - Jacob B Avraham
- Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA; Department of Surgery, Division of General and Gastrointestinal Surgery, NorthShore University HealthSystem, Evanston IL, USA.
| | - Kristina Z Kramer
- Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA; Department of Surgery, Division of Trauma and Acute Care Surgery, Baystate Medical Center, Springfield MA, USA.
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA; Department of Surgery, Carle Foundation Hospital, Urbana IL, USA.
| | - Chih Yuan Fu
- Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA; Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
| | - Alexandra Pires-Menard
- Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA.
| | - Matthew Kaminsky
- Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA.
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA.
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Panossian VS, Nederpelt CJ, El Hechi MW, Chang DC, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA. Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility. J Surg Res 2020; 255:486-494. [PMID: 32622163 DOI: 10.1016/j.jss.2020.05.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/18/2020] [Accepted: 05/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.
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Affiliation(s)
- Vahe S Panossian
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Charlie J Nederpelt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Aseni P, Rizzetto F, Grande AM, Bini R, Sammartano F, Vezzulli F, Vertemati M. Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review. Am J Surg 2020; 221:1082-1092. [PMID: 33032791 DOI: 10.1016/j.amjsurg.2020.09.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/29/2020] [Accepted: 09/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries. METHODS Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints. RESULTS A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT. CONCLUSIONS EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.
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Affiliation(s)
- Paolo Aseni
- Department of Emergency, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, via Giovanni Battista Grassi 74, 20157, Milan, Italy.
| | - Francesco Rizzetto
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, via Giovanni Battista Grassi 74, 20157, Milan, Italy; Department of Radiology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Antonino M Grande
- Department of Cardiac Surgery, IRCCS Fondazione Policlinico San Matteo Pavia, viale Camillo Golgi 19, 27100, Pavia, Italy.
| | - Roberto Bini
- Trauma Center and Metropolitan Trauma Network Department, Niguarda Hospital, Milan, Italy.
| | - Fabrizio Sammartano
- Trauma Center and Metropolitan Trauma Network Department, Niguarda Hospital, Milan, Italy.
| | - Federico Vezzulli
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, via Giovanni Battista Grassi 74, 20157, Milan, Italy.
| | - Maurizio Vertemati
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, via Giovanni Battista Grassi 74, 20157, Milan, Italy; CIMaINa (Interdisciplinary Centre for Nanostructured Materials and Interfaces), Università degli Studi di Milano, Milan, Italy.
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Dumitrescu M, Bobocea A, Cordos I. Muscle sparing lateral thoracotomy: the standard incision for thoracic procedures. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2017. [DOI: 10.25083/2559.5555.21.6065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Lateral thoracotomy is a versatile approach with many variations and is currently the most widely used incision in thoracic surgery. In the current article we are presenting the muscle-sparing lateral thoracotomy in the lateral decubitus position which we consider to be the “standard” for lateral thoracotomies. Indications, surgical technique and pitfalls are described alongside our experience with thoracic drainage. Although there is no consensus regarding the name of this incision, some authors call it “axillary thoracotomy” while others call it a “modified lateral thoracotomy”, they all agree on one aspect – the importance of muscle sparing – which makes it the go-to thoracotomy for both small and large procedures involving the lung. Lateral muscle sparing thoracotomy allows for good exposure of the pulmonary hilum, fissures, apex and diaphragm. The approach is easy and quick to perform while at the same time ensuring faster postoperative recovery by sparing the latissimus dorsi muscle, better cosmetics and lower postoperative pain score when compared to the posterolateral or classical lateral thoracotomies.
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