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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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Current Management of Hemodynamically Unstable Patients with Pelvic Fracture. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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3
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Haruta K, Endo A, Shiraishi A, Otomo Y. Usefulness of resuscitative endovascular balloon occlusion of the aorta compared to aortic cross-clamping in severely injured trauma patients: Analysis from the Japan Trauma Data Bank. Acute Med Surg 2023; 10:e830. [PMID: 36936741 PMCID: PMC10014424 DOI: 10.1002/ams2.830] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/12/2023] [Indexed: 03/16/2023] Open
Abstract
Aim To compare in-hospital mortality of severely injured trauma patients who underwent resuscitative endovascular balloon occlusion of the aorta (REBOA) or aortic cross-clamping (ACC). Methods In this multicenter, retrospective cohort study using data from a nationwide trauma registry of tertiary emergency medical centers in Japan (n = 280), trauma patients who underwent aortic occlusion at the emergency department from 2004 to 2019 were divided into two groups according to the treatment they received: patients treated with ACC and patients who underwent placement of a REBOA catheter. Multiple imputations were used to handle the missing data. In-hospital mortality of the patients who underwent REBOA or ACC was compared using a mixed-effect logistic regression analysis and a propensity score-matching analysis, in which the confounders, including baseline patient demographics and severity, were adjusted. Results Of 1,670 patients (1,137 with REBOA and 533 with ACC), 66% were male. The median age was 56 years, and the mortality rate was 55.2% in the REBOA group and 81.6% in the ACC group. The mixed-effect model regression analysis showed a significantly lower odds ratio for in-hospital mortality rate in the REBOA group (odds ratio 0.17; 95% confidence interval, 0.12-0.26). A similar odds ratio was observed in the propensity score matching analysis (odds ratio 0.27; 95% confidence interval, 0.18-0.40). Conclusion Compared with ACC, REBOA use was associated with decreased mortality in severely injured trauma patients.
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Affiliation(s)
- Koichi Haruta
- Graduate School of MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Department of Emergency Medicine, Shizuoka Prefectural Hospital OrganizationShizuoka General HospitalShizuokaJapan
| | - Akira Endo
- Department of Acute Critical Care and Disaster MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Department of Acute Critical Care MedicineTsuchiura Kyodo General HospitalIbarakiJapan
| | - Atsushi Shiraishi
- Department of Acute Critical Care and Disaster MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Emergency and Trauma CenterKameda Medical CenterChibaJapan
| | - Yasuhiro Otomo
- Department of Acute Critical Care and Disaster MedicineTokyo Medical and Dental University HospitalTokyoJapan
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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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5
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de Malleray H, Cardinale M, Avaro JP, Meaudre E, Monchal T, Bourgouin S, Vasse M, Balandraud P, de Lesquen H. Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center. Eur J Trauma Emerg Surg 2022; 48:4631-4638. [PMID: 35633378 DOI: 10.1007/s00068-022-01995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate survival after emergency department thoracotomy (EDT) in a physician-staffed emergency medicine system. METHODS This single-center retrospective study included all in extremis trauma patients who underwent EDT between 2013 and 2021 in a military level 1 trauma center. CPR time exceeding 15 minutes for penetrating trauma of 10 minutes for blunt trauma, and identified head injury were the exclusion criteria. RESULTS Thirty patients (73% male, 22/30) with a median age of 42 y/o [27-64], who presented mostly with polytrauma (60%, 18/30), blunt trauma (60%, 18/30), and severe chest trauma with a median AIS of 4 3-5 underwent EDT. Mean prehospital time was 58 min (4-73). On admission, the mean ISS was 41 29-50, and 53% (16/30) of patients had lost all signs of life (SOL) before EDT. On initial work-up, Hb was 9.6 g/dL [7.0-11.1], INR was 2.5 [1.7-3.2], pH was 7.0 [6.8-7.1], and lactate level was 11.1 [7.0-13.1] mmol/L. Survival rates at 24 h and 90 days after penetrating versus blunt trauma were 58 and 41% versus 16 and 6%, respectively. If SOL were present initially, these values were 100 and 80% versus 22 and 11%. CONCLUSION Among in extremis patients supported in a physician-staffed emergency medicine system, implementation of a trauma protocol with EDT resulted in overall survival rates of 33% at 24 h and 20% at 90 days. Best survival was observed for penetrating trauma or in the presence of SOL on admission.
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Affiliation(s)
| | | | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Meaudre
- ICU, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Tristan Monchal
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Stéphane Bourgouin
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Mathieu Vasse
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Paul Balandraud
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
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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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Iida A, Naito H, Nojima T, Yumoto T, Yamada T, Fujisaki N, Nakao A, Mikane T. State-of-the-art methods for the treatment of severe hemorrhagic trauma: selective aortic arch perfusion and emergency preservation and resuscitation-what is next? Acute Med Surg 2021; 8:e641. [PMID: 33791103 PMCID: PMC7995927 DOI: 10.1002/ams2.641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 01/30/2023] Open
Abstract
Trauma is a primary cause of death globally, with non‐compressible torso hemorrhage constituting an important part of “potentially survivable trauma death.” Resuscitative endovascular balloon occlusion of the aorta has become a popular alternative to aortic cross‐clamping under emergent thoracotomy for non‐compressible torso hemorrhage in recent years, however, it alone does not improve the survival rate of patients with severe shock or traumatic cardiac arrest from non‐compressible torso hemorrhage. Development of novel advanced maneuvers is essential to improve these patients’ survival, and research on promising methods such as selective aortic arch perfusion and emergency preservation and resuscitation is ongoing. This review aimed to provide physicians in charge of severe trauma cases with a broad understanding of these novel therapeutic approaches to manage patients with severe hemorrhagic trauma, which may allow them to develop lifesaving strategies for exsanguinating trauma patients. Although there are still hurdles to overcome before their clinical application, promising research on these novel strategies is in progress, and ongoing development of synthetic red blood cells and techniques that reduce ischemia‐reperfusion injury may further maximize their effects. Both continuous proof‐of‐concept studies and translational clinical evaluations are necessary to clinically apply these hemostasis approaches to trauma patients.
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Affiliation(s)
- Atsuyoshi Iida
- Department of Emergency Medicine Japanese Red Cross Okayama Hospital 2-1-1 Aoe, Kita ward Okayama Okayama 7008607 Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Tsuyoshi Nojima
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Taihei Yamada
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Noritomo Fujisaki
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Takeshi Mikane
- Department of Emergency Medicine Japanese Red Cross Okayama Hospital 2-1-1 Aoe, Kita ward Okayama Okayama 7008607 Japan
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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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10
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Emerging hemorrhage control and resuscitation strategies in trauma: Endovascular to extracorporeal. J Trauma Acute Care Surg 2021; 89:S50-S58. [PMID: 32345902 DOI: 10.1097/ta.0000000000002747] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article reviews four emerging endovascular hemorrhage control and extracorporeal perfusion techniques for management of trauma patients with profound hemorrhagic shock including hemorrhage-induced traumatic cardiac arrest: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, extracorporeal life support, and emergency preservation and resuscitation. The preclinical and clinical studies underpinning each of these techniques are summarized. We also present an integrated conceptual framework for how these emerging technologies may be used in the future care of trauma patients in both resource-rich and austere environments.
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11
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Fitzgerald MC, Yong MS, Martin K, Zimmet A, Marasco SF, Mathew J, Smit DV, Yeung M, Tan GA, Marquez M, Cheung Z, Boo E, Mitra B. Emergency department resuscitative thoracotomy at an adult major trauma centre: Outcomes following a training programme with standardised indications. Emerg Med Australas 2020; 32:657-662. [PMID: 32400039 DOI: 10.1111/1742-6723.13530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/16/2019] [Accepted: 10/27/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to report the procedural incidence and patient outcomes after the 2009 introduction of an institutional resuscitative thoracotomy (RT) programme. Emergency physicians, general surgeons and emergency nursing trauma team members were trained to perform RT on thoracic trauma patients with an unresponsive systolic blood pressure (SBP) <70 mmHg within 30 min of arrival, prior to cardiothoracic team back-up. METHODS A retrospective cohort study was conducted on patients who underwent RT from 2009 to 2017. The primary outcome measures were the incidence of the procedure and patients' survival to hospital discharge. Variables associated with survival were assessed using univariable logistic regression analyses. RESULTS There were 12 399 major trauma patients, including 7657 with major thoracic trauma and 315 presenting with SBP <70 mmHg. There were 32 RTs performed (incidence of 0.4%; 95% confidence interval [CI] 0.3-0.6) among patients with major thoracic trauma and 10.2% (99% CI 7.3-13.4) among patients with major thoracic trauma and SBP <70 mmHg. There were eight (25%; 95% CI 13.2-42.1) survivors to hospital discharge and no late mortality (mean follow-up 2.8 years). Survival was significantly associated with the procedure performed within 30 min of arrival (odds ratio 0.09; 95% CI 0.01-0.67) while mortality was associated with the procedure being performed in the setting of traumatic cardiac arrest (odds ratio 18.3; 95% CI 2.4-140.4). CONCLUSIONS A formal training and credentialing programme was associated with a low incidence of the procedure, yet achieved a survival rate of 25%, which is comparable to other reported literature.
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Affiliation(s)
- Mark C Fitzgerald
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Matthew S Yong
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Katherine Martin
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Adam Zimmet
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Silvana F Marasco
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Meei Yeung
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Gim A Tan
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Marc Marquez
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Zoe Cheung
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Ellaine Boo
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Wang M, Lu X, Gong P, Zhong Y, Gong D, Song Y. Open-chest cardiopulmonary resuscitation versus closed-chest cardiopulmonary resuscitation in patients with cardiac arrest: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2019; 27:116. [PMID: 31881900 PMCID: PMC6935193 DOI: 10.1186/s13049-019-0690-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/26/2019] [Indexed: 11/21/2022] Open
Abstract
Background Cardiopulmonary resuscitation is the most urgent and critical step in the rescue of patients with cardiac arrest. However, only about 10% of patients with out-of-hospital cardiac arrest survive to discharge. Surprisingly, there is growing evidence that open-chest cardiopulmonary resuscitation is superior to closed-chest cardiopulmonary resuscitation. Meanwhile, The Western Trauma Association and The European Resuscitation Council encouraged thoracotomy in certain circumstances for trauma patients. But whether open-chest cardiopulmonary resuscitation is superior to closed-chest cardiopulmonary resuscitation remains undetermined. Therefore, the aim of this study was to summarize current studies on open-chest cardiopulmonary resuscitation in a systematic review, comparing it to closed-chest cardiopulmonary resuscitation, in a meta-analysis. Methods In this systematic review and meta-analysis, we searched the PubMed, EmBase, Web of Science, and Cochrane Library databases from inception to May 2019 investigating the effect of open-chest cardiopulmonary resuscitation and closed-chest cardiopulmonary resuscitation in patients with cardiac arrest, without language restrictions. Statistical analysis was performed using Stata 12.0 software. The primary outcome was return of spontaneous circulation. The secondary outcome was survival to discharge. Results Seven observational studies were eligible for inclusion in this meta-analysis involving 8548 patients. No comparative randomized clinical trial was reported in the literature. There was no significant difference in return of spontaneous circulation and survival to discharge between open-chest cardiopulmonary resuscitation and closed-chest cardiopulmonary resuscitation in cardiac arrest patients. The odds ratio (OR) were 0.92 (95%CI 0.36–2.31, P > 0.05) and 0.54 (95%CI 0.17–1.78, P > 0.05) for return of spontaneous circulation and survival to discharge, respectively. Subgroup analysis of cardiac arrest patients with trauma showed that closed-chest cardiopulmonary resuscitation was associated with higher return of spontaneous circulation compared with open-chest cardiopulmonary resuscitation (OR = 0.59 95%CI 0.37–0.94, P < 0.05). And subgroup analysis of cardiac arrest patients with non-trauma showed that open-chest cardiopulmonary resuscitation was associated with higher ROSC compared with closed-chest cardiopulmonary resuscitation (OR = 3.12 95%CI 1.23–7.91, P < 0.05). Conclusions In conclusion, for patients with cardiac arrest, we should implement closed-chest cardiopulmonary resuscitation as soon as possible. However, for cardiac arrest patients with chest trauma who cannot perform closed-chest cardiopulmonary resuscitation, open-chest cardiopulmonary resuscitation should be implemented as soon as possible.
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Affiliation(s)
- Mao Wang
- Emergency Department, Affiliated Zhongshan Hospital of Dalian University, Dalian city, Liaoning Province, China
| | - Xiaoguang Lu
- Emergency Department, Affiliated Zhongshan Hospital of Dalian University, Dalian city, Liaoning Province, China.
| | - Ping Gong
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China
| | - Yilong Zhong
- Emergency Department, Affiliated Zhongshan Hospital of Dalian University, Dalian city, Liaoning Province, China
| | - Dianbo Gong
- Emergency Department, Affiliated Zhongshan Hospital of Dalian University, Dalian city, Liaoning Province, China
| | - Yi Song
- Emergency Department, Affiliated Zhongshan Hospital of Dalian University, Dalian city, Liaoning Province, China
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Kanlerd A, Sapsamarn N, Auksornchart K. Is Emergency Department Thoracotomy Effective in Trauma Resuscitation? The Retrospective Study of the Emergency Department Thoracotomy in Trauma Patients at Thammasat University Hospital, Thailand. J Emerg Trauma Shock 2019; 12:254-259. [PMID: 31798238 PMCID: PMC6883499 DOI: 10.4103/jets.jets_36_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/17/2019] [Accepted: 09/20/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction: The survival rate after the emergency department thoracotomy (EDT) in trauma patients varies from the previous study as 1.6% in blunt injury and 11.2% in penetrating injury. Most of the data came from Europe, the US, South Africa, and Japan. This study aims to identify the success of EDT of trauma patients at Thammasat University Hospital, Thailand, and to evaluate the effectiveness of EDT. This study may be representative data for Southeast Asia. Materials and Methods: This retrospective review of 21 consecutive EDT cases which performed by our staffs and chief of general surgery residents between June 2009 and July 2016. Age, gender, injury mechanisms, injury sites, patient transport methods, initial vital signs, fluids and blood component requirements, resuscitation times, laboratory results, and injury severity scores were all analyzed. Results: Of the 21 EDT cases, one patient was excluded due to being a nontraumatic case. The remaining twenty patients were primarily young (mean 36.5 years), male (85%), suffering from blunt injuries (75%), of which 45% were predominantly thoracic injuries. Most of the patients presented without any sign of life (75%), and the total time for resuscitation was 43.5 ± 19.6 min. Seven patients (35%) had the return of spontaneous circulation (ROSC) and were successful in being brought to the operating room. Unfortunately, all patients passed away within 24 h of the operation. Conclusions: The ROSC rate of EDT in this study was 35%, but with no survival benefit. Therefore, we cannot guarantee that EDT serves as an effective life-saving procedure. However, EDT may play a significant role in treating extremis injured patients.
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Affiliation(s)
- Amonpon Kanlerd
- Department of Surgery, Division of Trauma and Surgical Critical Care, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Nattida Sapsamarn
- Department of Surgery, Division of Trauma and Surgical Critical Care, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Karikarn Auksornchart
- Department of Surgery, Division of Trauma and Surgical Critical Care, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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Sadeghi M, Hörer TM, Forsman D, Dogan EM, Jansson K, Kindler C, Skoog P, Nilsson KF. Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA. Injury 2018; 49:2132-2141. [PMID: 30301556 DOI: 10.1016/j.injury.2018.09.052] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/02/2018] [Accepted: 09/27/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in exsanguinating torso hemorrhage, but causes ischemic injury to distal organs. The aim was to investigate whether blood pressure targeting by partial REBOA (pREBOA) is possible in porcine severe hemorrhagic shock and to compare pREBOA and total REBOA (tREBOA) regarding hemodynamic, metabolic and inflammatory effects. METHODS Eighteen anesthetized pigs were exposed to induced controlled hemorrhage to a systolic blood pressure (SBP) of 50 mmHg and randomized into three groups of thoracic REBOA: 30 min of pREBOA (target SBP 80-100 mmHg), tREBOA, and control. They were then resuscitated by autologous transfusion and monitored for 3 h. Hemodynamics, blood gases, mesenteric blood flow, intraperitoneal metabolites, organ damage markers, histopathology from the small bowel, and inflammatory markers were analyzed. RESULTS Severe hemorrhagic shock was induced in all groups. In pREBOA the targeted blood pressure was reached. The mesenteric blood flow was sustained in pREBOA, while it was completely obstructed in tREBOA. Arterial pH was lower, and lactate and troponin levels were significantly higher in tREBOA than in pREBOA and controls during the reperfusion period. Intraperitoneal metabolites, the cytokine response and histological analyses from the small bowel were most affected in the tREBOA compared to the pREBOA and control groups. CONCLUSION Partial REBOA allows blood pressure titration while maintaining perfusion to distal organs, and reduces the ischemic burden in a state of severe hemorrhagic shock. Partial REBOA may lower the risks of post-resuscitation metabolic and inflammatory impacts, and organ dysfunction.
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Affiliation(s)
- Mitra Sadeghi
- Department of Vascular Surgery, Västmanlands Hospital Västerås, Västerås, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Daniel Forsman
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Emanuel M Dogan
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kjell Jansson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Csaba Kindler
- Department of Pathology, Västmanlands Hospital Västerås, Västerås, Sweden
| | - Per Skoog
- Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Yoong IRW, Heng G, Mathur S, Lim WW, Goo TT. Outcomes of emergency thoracotomy for trauma in a general hospital in Singapore. Asian Cardiovasc Thorac Ann 2018; 26:285-289. [PMID: 29667900 DOI: 10.1177/0218492318772221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background An emergency thoracotomy can be performed either immediately at the site of trauma or in the emergency department or operating room for resuscitation of patients in extremis or life-saving treatment for patients with thoracic injury. It remains a procedure associated with high mortality rates, and there is a paucity of data from Asia. This study analyzed our six-year experience of emergency trauma thoracotomy in an acute general hospital in Singapore. Methods This retrospective analysis was based on experience in a single institution with all emergency trauma thoracotomies performed by general surgeons. All patients who underwent an emergency trauma thoracotomy in Khoo Teck Puat Hospital between January 2011 and December 2016 were studied. Data collected included patient demographics, mechanism of injury, Injury Severity Scores, surgical approach, and postoperative outcomes. Results Twenty-three patients underwent an emergency thoracotomy, 8 in the emergency department and 15 in the operating room. The mechanism of injury was blunt in 20 (87%) patients and penetrating in 3 (13%), with road traffic accidents the most common cause (70%). Six (40%) patients who underwent an emergency thoracotomy in the operating room survived beyond 24 h, and 4 (27%) survivors were eventually discharged from the hospital with no neurological deficit. No patient who underwent a thoracotomy in the emergency department survived beyond 24 h. Conclusions Emergency thoracotomy is associated with high mortality rates, especially when required in the emergency department or for blunt trauma. Nevertheless, it is a potentially life-saving procedure that offers a chance of survival in selected patients.
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Affiliation(s)
| | - Gregory Heng
- 2 Department of Surgery, 371018 Khoo Teck Puat Hospital , 90 Yishun Central, Singapore 768828
| | - Sachin Mathur
- 3 Department of General Surgery, Singapore General Hospital, Outram Road, Singapore 169608
| | - Woan Wui Lim
- 2 Department of Surgery, 371018 Khoo Teck Puat Hospital , 90 Yishun Central, Singapore 768828
| | - Tiong Thye Goo
- 2 Department of Surgery, 371018 Khoo Teck Puat Hospital , 90 Yishun Central, Singapore 768828
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16
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Mancini A, Bonne A, Pirvu A, Porcu P, Bouzat P, Abba J, Arvieux C. Retrospective study of thoracotomy performed in a French level 1-trauma center. J Visc Surg 2017; 154:401-406. [PMID: 29150222 DOI: 10.1016/j.jviscsurg.2017.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Resuscitative thoracotomy, a potentially life-saving procedure, is used exceptionally, and essentially for penetrating trauma. Most of the available literature is American while reports from Europe are sparse. We report our experience in a French level 1-trauma center. MATERIAL AND METHODS Patient records (patient age, gender, mechanism of injury, indication for emergency thoracotomy, anatomic injuries, interventions and survival) for all patients who underwent emergency thoracotomy between January 2005 and December 2015 were analyzed. RESULTS Twenty-two patients (19 males) underwent emergency thoracotomy. Median age was 27.5 (12-67) years. Twelve were performed for blunt trauma (55%) and 10 for penetrating injuries (45%). Thirteen patients presented with cardiac arrest, while nine had deep and refractory hypotension. Overall, survival was 32% (n=7). There were no survivors in the blunt trauma group while seven of ten with penetrating injuries survived. All patients presenting with cardiac arrest died. CONCLUSION The survival rate in this French retrospective study was in accordance with the literature.
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Affiliation(s)
- A Mancini
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - A Bonne
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - A Pirvu
- Service de chirurgie thoracique, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - P Porcu
- Service de chirurgie cardiaque, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - P Bouzat
- Service d'anesthésiologie et réanimation, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - J Abba
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - C Arvieux
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France.
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Barmparas G, Ko A, Dhillon NK, Tatum JM, Choi M, Ley EJ, Margulies DR. Extreme Interventions for Trauma Patients in Extremis: Variations among Trauma Centers. Am Surg 2017. [DOI: 10.1177/000313481708301004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although guidelines for the performance of an emergency department thoracotomy (EDT) are available, high level evidence remains scarce potentially leading to variation in decisions and practices among trauma surgeons. The National Trauma Databank was queried for all subjects who died in the emergency department (ED) between 2007 and 2011. Trauma centers were divided into four quartiles based on the rate of EDTamong ED deaths. A total of 31,623 subjects admitted to 729 trauma centers met inclusion criteria. Most of of these centers (n = 328, 53%) never performed an EDT during the study period. Very few outlier centers (1.1%) performed this procedure in 50.0 per cent or more of all patients who died in the ED. Trauma centers in the highest quartiles in performing EDT were more likely to intervene with both surgical and nonsurgical procedures in patients who died in the ED, independent of the performance of an EDT. There are significant variations among trauma centers in the management of trauma patients who expire in the ED. Further research at a national level toward standardizing the management of the trauma patient in extremis and the decision to perform an EDT is necessary, given the extremely low survival associated with this procedure.
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Affiliation(s)
- Galinos Barmparas
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Ara Ko
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Navpreet K. Dhillon
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - James M. Tatum
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Mark Choi
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Eric J. Ley
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Daniel R. Margulies
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
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Endo A, Shiraishi A, Otomo Y, Tomita M, Matsui H, Murata K. Open-chest versus closed-chest cardiopulmonary resuscitation in blunt trauma: analysis of a nationwide trauma registry. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:169. [PMID: 28673321 PMCID: PMC5496413 DOI: 10.1186/s13054-017-1759-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/19/2017] [Indexed: 11/30/2022]
Abstract
Background Although open-chest cardiopulmonary resuscitation (OCCPR) is often considered as the last salvage maneuver in critically injured patients, evidence on the effectiveness of OCCPR has been based only on the descriptive studies of limited numbers of cases or expert opinions. This study aimed to compare the effectiveness of OCCPR with that of closed-chest cardiopulmonary resuscitation (CCCPR) in an emergency department (ED). Methods A nationwide registry-based, retrospective cohort study was conducted. Patients with blunt trauma, undergoing cardiopulmonary resuscitation (CPR) in an ED between 2004 and 2015 were identified and divided into OCCPR and CCCPR groups. Their outcomes (survival to hospital discharge and survival over 24 hours following ED arrival) were compared with propensity score matching analysis and instrumental variable analysis. Results A total of 6510 patients (OCCPR, 2192; CCCPR, 4318) were analyzed. The in-hospital and 24-hour survival rates in OCCPR patients were 1.8% (40/2192) and 5.6% (123/2192), and those in CCCPR patients were 3.6% (156/4318) and 9.6% (416/4318), respectively. In the propensity score-matched subjects, OCCPR patients (n = 1804) had significantly lower odds of survival to hospital discharge (odds ratio (95% CI)) = 0.41 (0.25–0.68)) and of survival over 24 hours following ED arrival (OR (95% CI) = 0.59 (0.45–0.79)) than CCCPR patients (n = 1804). Subgroup analysis revealed that OCCPR was associated with a poorer outcome compared to CCCPR in patients with severe pelvis and lower extremity injury. Conclusions In this large cohort, OCCPR was associated with reduced in-hospital and 24-hour survival rates in patients with blunt trauma. Further comparisons between OCCPR and CCCPR using additional information, such as time course details in pre-hospital and ED settings, anatomical details regarding region of injury, and neurological outcomes, are necessary. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1759-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Akira Endo
- Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Atsushi Shiraishi
- Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,Emergency and Trauma Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Makoto Tomita
- Clinical Research Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Kiyoshi Murata
- Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg 2017; 81:409-19. [PMID: 27050883 DOI: 10.1097/ta.0000000000001079] [Citation(s) in RCA: 323] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Aortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers an emerging alternative. METHODS The American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry prospectively identified trauma patients requiring AO from eight ACS Level 1 centers. Presentation, intervention, and outcome variables were collected and analyzed to compare REBOA and open AO. RESULTS From November 2013 to February 2015, 114 AO patients were captured (REBOA, 46; open AO, 68); 80.7% were male, and 62.3% were blunt injured. Aortic occlusion occurred in the emergency department (73.7%) or the operating room (26.3%). Hemodynamic improvement after AO was observed in 62.3% [REBOA, 67.4%; open OA, 61.8%); 36.0% achieving stability (systolic blood pressure consistently >90 mm Hg, >5 minutes); REBOA, 22 of 46 (47.8%); open OA, 19 of 68 (27.9%); p =0.014]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) access was femoral cut-down (50%); US guided (10.9%) and percutaneous without imaging (28.3%). Deployment was achieved in Zones I (78.6%), II (2.4%), and III (19.0%). A second AO attempt was required in 9.6% [REBOA, 2 of 46 (4.3%); open OA, 9 of 68 (13.2%)]. Complications of REBOA were uncommon (pseudoaneurysm, 2.1%; embolism, 4.3%; limb ischemia, 0%). There was no difference in time to successful AO between REBOA and open procedures (REBOA, 6.6 ± 5.6 minutes; open OA, 7.2 ± 15.1; p = 0.842). Overall survival was 21.1% (24 of 114), with no significant difference between REBOA and open AO with regard to mortality [REBOA, 28.2% (13 of 46); open OA, 16.1% (11 of 68); p = 0.120]. CONCLUSION Resuscitative endovascular balloon occlusion of the aorta has emerged as a viable alternative to open AO in centers that have developed this capability. Further maturation of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database is required to better elucidate optimal indications and outcomes. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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Moore LJ, Martin CD, Harvin JA, Wade CE, Holcomb JB. Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis. Am J Surg 2016; 212:1222-1230. [PMID: 28340927 DOI: 10.1016/j.amjsurg.2016.09.027] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 09/10/2016] [Accepted: 09/15/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Noncompressible truncal hemorrhage is a leading cause of potentially preventable death in trauma and acute care surgery patients. These patients are at high risk of exsanguination before potentially life-saving surgical intervention may be performed. Temporary aortic occlusion is an effective means of augmenting systolic blood pressure and perfusion of the heart and brain in these patients. Aortic occlusion temporarily controls distal bleeding until permanent hemostasis can be achieved. The traditional method for temporary aortic occlusion is via resuscitative thoracotomy with cross clamping of the descending aorta. While effective, resuscitative thoracotomy is highly invasive and may worsen blood loss, hypothermia, and coagulopathy by opening an otherwise uninjured body cavity. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary aortic occlusion using an occlusive balloon catheter that is introduced into the aorta via endovascular access of the common femoral artery. For this reason it is thought that REBOA could provide a less-invasive method for temporary aortic occlusion. Our purpose is to describe our experience with the implementation of REBOA at our Level 1 trauma center. METHODS A retrospective case series describing all cases of REBOA performed at a prominent level 1 trauma center between October 2011 and September 2015. The study inclusion criteria were any patient that received a REBOA procedure in the acute phases after injury. There were no exclusion criteria. Data were collected from electronic medical records and the hospital's trauma registry. RESULTS A total of 31 patients underwent REBOA during the study period. The median age of REBOA patients was 47 (interquartile range [IQR] = 27 to 63) and 77% were male. A majority (87%) of patients sustained blunt trauma. The median injury severity score was 34 (IQR = 22 to 42). The overall survival rate was 32% but varied greatly between subgroups. Balloon inflation resulted in a median increase in systolic blood pressure of 55-mm Hg (IQR 33 to 60), in cases where the data were available (n = 20). A return to spontaneous circulation was noted in 60% of patients who had arrested before REBOA (n = 10). Overall, early death by hemorrhage was 28% with only 2 deaths in the emergency department before reaching the operating room. CONCLUSIONS REBOA is an effective method for achieving temporary aortic occlusion in trauma patients with noncompressible truncal hemorrhage. Balloon inflation correlated with increased blood pressure and temporary hemorrhage control in a vast majority of patients.
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Affiliation(s)
- Laura J Moore
- The Center for Translational Injury Research, The University of Texas McGovern Medical School - Department of Surgery, Houston, TX, USA.
| | - Clay D Martin
- Division of Acute Care Surgery, Department of Surgery, The University of Texas McGovern Medical School, Houston, TX, USA
| | - John A Harvin
- The Center for Translational Injury Research, The University of Texas McGovern Medical School - Department of Surgery, Houston, TX, USA
| | - Charles E Wade
- The Center for Translational Injury Research, The University of Texas McGovern Medical School - Department of Surgery, Houston, TX, USA
| | - John B Holcomb
- The Center for Translational Injury Research, The University of Texas McGovern Medical School - Department of Surgery, Houston, TX, USA
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Tsurukiri J, Akamine I, Sato T, Sakurai M, Okumura E, Moriya M, Yamanaka H, Ohta S. Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting. Scand J Trauma Resusc Emerg Med 2016; 24:13. [PMID: 26861070 PMCID: PMC4748599 DOI: 10.1186/s13049-016-0205-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 02/02/2016] [Indexed: 02/01/2023] Open
Abstract
Background Haemorrhagic shock is a major cause of death in the acute care setting. Since 2009, our emergency department has used intra-aortic balloon occlusion (IABO) catheters for resuscitative endovascular balloon occlusion of the aorta (REBOA). Methods REBOA procedures were performed by one or two trained acute care physicians in the emergency room (ER) and intensive care unit (ICU). IABO catheters were positioned using ultrasonography. Collected data included clinical characteristics, haemorrhagic severity, blood cultures, metabolic values, blood transfusions, REBOA-related complications and mortality. Results Subjects comprised 25 patients (trauma, n = 16; non-trauma, n = 9) with a median age of 69 years and a median shock index of 1.4. REBOA was achieved in 22 patients, but failed in three elderly trauma patients. Systolic blood pressure significantly increased after REBOA (107 vs. 71 mmHg, p < 0.01). Five trauma patients (20 %) died in ER, and mortality rates within 24 h and 60 days were 20 % and 12 %, respectively. No REBOA-related complications were encountered. The total occlusion time of REBOA was significantly lesser in survivors than that in non-survivors (52 vs. 97 min, p < 0.01). Significantly positive correlations were found between total occlusion time of REBOA and shock index (Spearman’s r = 0.6) and lactate concentration (Spearman’s r = 0.7) in survivors. Conclusion REBOA can be performed in ER and ICU with a high degree of technical success. Furthermore, correlations between occlusion time and initial high lactate levels and shock index may be important because prolonged occlusion is associated with a poorer outcome.
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Affiliation(s)
- Junya Tsurukiri
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan.
| | - Itsurou Akamine
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Takao Sato
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Masatsugu Sakurai
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Eitaro Okumura
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Mariko Moriya
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Hiroshi Yamanaka
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Shoichi Ohta
- Emergency and Disaster Medicine, Tokyo Medical University Hospital, 6-7-1 Nishi-shinjuku , Shinjuku, Tokyo, 160-0023, Japan
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Abstract
Pre-hospital care requires a broad skillset. One of the most challenging aspects of pre-hospital care is performing surgical procedures. The indications and evidence for performing pre-hospital surgical airway, thoracostomy, thoracotomy, caesarean section and amputation are discussed. Where evidence for the procedure is lacking from pre-hospital care, evidence from in-hospital experience is sought.
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Puchwein P, Sommerauer F, Clement HG, Matzi V, Tesch NP, Hallmann B, Harris T, Rigaud M. Clamshell thoracotomy and open heart massage--A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study. Injury 2015; 46:1738-42. [PMID: 26068645 DOI: 10.1016/j.injury.2015.05.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/29/2015] [Accepted: 05/19/2015] [Indexed: 02/02/2023]
Abstract
AIMS Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. METHODS We adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. RESULTS The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. CONCLUSION Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment.
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Affiliation(s)
- Paul Puchwein
- Medical University of Graz, Department for Traumatology, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - Florian Sommerauer
- Medical University of Graz, Department for Traumatology, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Hans G Clement
- Unfallkrankenhaus Graz, Göstinger Straße 24 8020 Graz, Austria
| | - Veronika Matzi
- Unfallkrankenhaus Graz, Göstinger Straße 24 8020 Graz, Austria
| | - Norbert P Tesch
- Medical University of Graz, Institute of Anatomy, Harrachgasse 21, 8010 Graz, Austria
| | - Barbara Hallmann
- Medical University of Graz, Department for Anaesthesiology and Intensive Care, Auenbruggerplatz 29, 8036 Graz, Austria
| | - Tim Harris
- Queen Mary University of London and Barts Health NHS Trust, Whitechapel, London, UK
| | - Marcel Rigaud
- Medical University of Graz, Department for Anaesthesiology and Intensive Care, Auenbruggerplatz 29, 8036 Graz, Austria
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Emergency resuscitative thoracotomy performed in European civilian trauma patients with blunt or penetrating injuries: a systematic review. Eur J Trauma Emerg Surg 2015; 42:677-685. [PMID: 26280486 PMCID: PMC5124032 DOI: 10.1007/s00068-015-0559-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/31/2015] [Indexed: 10/26/2022]
Abstract
PURPOSE Emergency resuscitative thoracotomy (ERT) is a lifesaving procedure in selected patients. Indications are still being debated, but outcome in blunt trauma is believed to be poor. Recent reports from European populations, where blunt trauma predominates, have suggested favorable outcome also in blunt trauma. Our aim was to identify all European studies reported over the last decade and compare reported outcomes to existing knowledge. METHODS We performed a systematic literature search according to PRISMA guidelines (January 1st, 2004 to December 31st, 2014). The "grey literature" was included by searching Google Scholar. Qualitative comparison of studies and outcomes was done. RESULTS A total of 8 articles from Europe were included originating from Croatia, Norway (n = 2), Denmark, Iceland, the Netherlands, Scotland, and Switzerland. Of 376 resuscitative thoracotomies, 193 (51.3 %) were for blunt trauma. Male:female distribution was 3.5:1. The collectively reported overall survival was 42.8 % (n = 161), with 25.4 % (49 of 193) blunt trauma and 61.2 % (112 of 183) penetrating injuries. When strictly including those ERTs designated as done in the emergency department for blunt mechanism (n = 139) only, a total of 18 patients survived (12.9 %). Survival after EDTs for penetrating trauma was 41.6 % (37 of 89). Neurological outcome (reported in 5 of 8 studies) reported favorable neurological long-term outcome in the majority of survivors, even after blunt trauma. None referred to Glasgow Outcome Score. Heterogeneity in the studies prevented outcome analyses by formal quantitative meta-analysis. CONCLUSION The reported outcome after ERT in European civilian trauma populations is favorable, with one in every four ERTs in the ED surviving. Notably, outcome is at variance with previously reported collective data, in particular for blunt trauma. Multicenter, prospective, observational data are needed to validate the modern role of ERT in blunt trauma.
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Khorsandi M, Skouras C, Prasad S, Shah R. Major cardiothoracic trauma: Eleven-year review of outcomes in the North West of England. Ann R Coll Surg Engl 2015; 97:298-303. [PMID: 26263939 PMCID: PMC4473869 DOI: 10.1308/003588415x14181254789169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Up to 15% of patients with cardiothoracic trauma require emergency surgery, and death can be prevented in a substantial proportion of this group. UK reports have emphasised the need for improvement in this field. We assessed major cardiothoracic trauma (MCT) outcomes in North West England over 11 years. METHODS The database from the Trauma Audit and Research Network was used to retrieve data for all patients who had suffered MCT between 2000 and 2011 in North West England and the findings analysed. Trauma that led to thoracotomy/thoracoscopy or sternotomy was defined as MCT. RESULTS A total of 146 patients were identified, and a considerable male predominance (88.4%) noted. A total of 54.1% had sustained penetrating cardiothoracic trauma. Also, 53.4% had been admitted to tertiary-care hospitals for trauma (TCHT) and 46.6% had been admitted to non-TCHT. Overall prevalence of mortality was 35.6%. No significant difference was found in mortality between TCHT vs non-TCHT. Prevalence of mortality was significantly higher in the subgroup of patients cared for exclusively in non-TCHT compared with patients transferred from non-TCHT to TCHT (41% vs 13.8%, p<0.05). CONCLUSIONS No significant difference was demonstrated in length of stay in hospital/length of stay in the intensive treatment unit and prevalence of mortality between patients originally presenting in TCHT and those presenting in non-TCHT. However, patients transferred from non-TCHT to TCHT had a lower prevalence of mortality. These findings may constitute a valuable benchmark for comparison with results arising after introduction of trauma centres in the UK.
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Affiliation(s)
- M Khorsandi
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh
| | - C Skouras
- Department of Clinical Surgery, Edinburgh University, Edinburgh
| | - S Prasad
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh
| | - R Shah
- Department of Cardio-Thoracic Surgery, University Hospital of South Manchester (Wythenshawe hospital)
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de Lesquen H, Avaro JP, Gust L, Ford RM, Beranger F, Natale C, Bonnet PM, D'Journo XB. Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg 2014; 20:399-408. [PMID: 25476459 DOI: 10.1093/icvts/ivu397] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.
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Affiliation(s)
- Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Lucile Gust
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | - Fabien Beranger
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Claudia Natale
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre-Mathieu Bonnet
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Xavier-Benoît D'Journo
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
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Paydar S, Moghaninasab A, Asiaei E, Sabetian Fard Jahromi G, Bolandparvaz S, Abbasi H. Outcome of Patients Underwent Emergency Department Thoracotomy and Its Predictive Factors. EMERGENCY (TEHRAN, IRAN) 2014; 2:125-9. [PMID: 26495363 PMCID: PMC4614577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Emergency department thoracotomy (EDT) may serve as the last survival chance for patients who arrive at hospital in extremis. It is considered as an effective tool for improvement of traumatic patients' outcome. The present study was done with the goal of assessing the outcome of patients who underwent EDT and its predictive factors. METHODS In the present study, medical charts of 50 retrospective and 8 prospective cases underwent emergency department thoracotomy (EDT) were reviewed during November 2011 to June 2013. Comparisons between survived and died patients were performed by Mann-Whitney U test and the predictive factors of EDT outcome were measured using multivariate logistic regression analysis. P < 0.05 considered statistically significant. RESULTS Fifty-eight cases of EDT were enrolled (86.2% male). The mean age of patients was 43.27±19.85 years with the range of 18-85. The mean time duration of CPR was recorded as 37.12±12.49 minutes. Eleven cases (19%) were alive to be transported to OR (defined as ED survived). The mean time of survival in ED survived patients was 223.5±450.8 hours. More than 24 hours survival rate (late survived) was 6.9% (4 cases). Only one case (1.7%) survived to discharge from hospital (mortality rate=98.3%). There were only a significant relation between ED survival and SBP, GCS, CPR duration, and chest trauma (p=0.04). The results demonstrated that initial SBP lower than 80 mmHg (OR=1.03, 95% CI: 1.001-1.05, p=0.04) and presence of chest trauma (OR=2.6, 95% CI: 1.75-3.16, p=0.02) were independent predictive factors of EDT mortality. CONCLUSION The findings of the present study showed that the survival rate of trauma patients underwent EDT was 1.7%. In addition, it was defined that falling systolic blood pressure below 80 mmHg and blunt trauma of chest are independent factors that along with poor outcome.
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Affiliation(s)
| | | | | | | | | | - Hamidreza Abbasi
- Corresponding author: Shahram Bolandparvaz; Trauma Research Center, Shahid Rajaei Trauma Hospital, Shahid Chamran blvd, Shiraz, Iran. Tel/Fax: +987116254206.
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