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Schreyer C, Schulz-Drost S, Markewitz A, Breuing J, Prediger B, Becker L, Spering C, Neudecker J, Thiel B, Bieler D. Surgical management of chest injuries in patients with multiple and/or severe trauma- a systematic review and clinical practice guideline update. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02556-1. [PMID: 38888790 DOI: 10.1007/s00068-024-02556-1] [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: 02/19/2024] [Accepted: 05/14/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Our aim was to update evidence-based and consensus-based recommendations for the surgical and interventional management of blunt or penetrating injuries to the chest in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS MEDLINE and Embase were systematically searched to May and June 2021 respectively for the update and new questions. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared interventions for the surgical management of injuries to the chest in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS One study was identified. This study compared wedge resection, lobectomy and pneumonectomy in the management of patients with severe chest trauma that required some form of lung resection. Based on the updated evidence and expert consensus, one recommendation was modified and two additional good practice points were developed. All achieved strong consensus. The recommendation on the amount of blood loss that is used as an indication for surgical intervention in patients with chest injuries was modified to reflect new findings in trauma care and patient stabilisation. The new good clinical practice points (GPPs) on the use of video-assisted thoracoscopic surgery (VATS) in patients with initial circulatory stability are also in line with current practice in patient care. CONCLUSION As has been shown in recent decades, the treatment of chest trauma has become less and less invasive for the patient as diagnostic and technical possibilities have expanded. Examples include interventional stenting of aortic injuries, video-assisted thoracoscopy and parenchyma-sparing treatment of lung injuries. These less invasive treatment concepts reduce morbidity and mortality in the primary surgical phase following a chest trauma.
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Affiliation(s)
- C Schreyer
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital, Koblenz, Germany
| | - S Schulz-Drost
- Department of Trauma Surgery, Schwerin Helios Hospital, Schwerin and Department of Trauma and Orthopaedic Surgery, Schwerin, Germany
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - A Markewitz
- German Society for Thoracic and Cardiovascular Surgery, Berlin, Germany
| | - J Breuing
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - B Prediger
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - L Becker
- Department of Trauma Surgery, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany
| | - C Spering
- Department of Trauma Surgery, Orthopaedics, and Plastic Surgery, Göttingen University Medical Centre, Göttingen, Germany
| | - J Neudecker
- Department of Surgery, Berlin Charité Hospital, Campus Charité Mitte and Campus Virchow, Berlin, Germany
| | - B Thiel
- Department of Thoracic Surgery, Klinikum Westfalen Knappschaft, Lünen, Germany
| | - D Bieler
- Department for Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery, Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany.
- Department for Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University, Duesseldorf, Germany.
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L'Huillier JC, Jalal K, Nohra E, Boccardo JD, Olafuyi O, Jordan MB, Myneni AA, Schwaitzberg SD, Flynn WJ, Brewer JJ, Noyes K, Cooper CA. Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database. J Surg Res 2024; 298:24-35. [PMID: 38552587 DOI: 10.1016/j.jss.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 02/06/2024] [Accepted: 02/29/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.
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Affiliation(s)
- Joseph C L'Huillier
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Kabir Jalal
- Department of Biostatistics, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Eden Nohra
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Joseph D Boccardo
- Department of Biostatistics, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Olatoyosi Olafuyi
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Marcy Bubar Jordan
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Ajay A Myneni
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Steven D Schwaitzberg
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - William J Flynn
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Jeffrey J Brewer
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Katia Noyes
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Clairice A Cooper
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York.
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Magagi A, Rabiou M, Maikassoua M, Habibou R, Hassan M, Boukari M, Chaibou M, Daddy H. Management of trauma White weapons penetrating Head and Neck in the anesthesia department of the national hospital of Zinder in Niger: About five reported cases. Ann Med Surg (Lond) 2022; 78:103840. [PMID: 35734682 PMCID: PMC9207114 DOI: 10.1016/j.amsu.2022.103840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 10/29/2022] Open
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Habarth-Morales TE, Rios-Diaz AJ, Gadomski SP, Stanley T, Donnelly JP, Koenig GJ, Cohen MJ, Marks JA. Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study. J Trauma Acute Care Surg 2022; 92:792-799. [PMID: 35045059 DOI: 10.1097/ta.0000000000003536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. METHODS We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. RESULTS Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). CONCLUSION The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. LEVEL OF EVIDENCE Therapeutic/Care Management, Level III.
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Affiliation(s)
- Theodore E Habarth-Morales
- From the Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Ben Abderrahim S, Turki E, Haddaji A, Ghzel R. Criminal death by stabbing in the region of Kairouan, Tunisia: A retrospective study, 2008-2018. LA TUNISIE MEDICALE 2022; 99:1167-1173. [PMID: 35288923 PMCID: PMC8974441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Homicides by stabbing are the most common forensic form of criminal death in Tunisia. These homicides represent a type of violent death that requires investigation in a forensic setting. AIM To describe the epidemiological and forensic profile of stab wounds in the region of Kairouan, Tunisia Methods: We conducted a retrospective study of stab-wounds autopsy cases collected at the Forensic Department at the Ibn El Jazzar University Hospital in Kairouan over eleven years (01/01/2008 to 31/12/2018). RESULTS Forty-seven cases of homicide were retained. A male predominance was observed with a sex ratio of 22 (45H/2F, 96%). The mean age of the victims was 33.3±10.84 with ages ranging from 12 to 63 years. Most victims (79%) were of rural origin, singles (62%), and daily-laborers (89%). The months that recorded the highest numbers of homicides were November and August. The most common reason for the assault was a settling-score on the street. The perpetrator was known by the victim in 90% of cases, having used a knife as a weapon in 90% of cases. The thorax was the most frequently affected area, resulting in fatal heart wounds in 28 cases. CONCLUSION Autopsy remains an essential tool for drawing up a detailed injury assessment in homicides by stabbing and determining the injury mechanism of the wounds. The comparison of the autopsy findings with the data of the judicial investigation is of great help in the legal qualification of the facts and the determination of the responsibility of the aggressors.
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Affiliation(s)
| | - Elyes Turki
- 2- Service de Médecine Légale, CHU Ibn El Jazzar, Kairouan, Faculté de Médecine de Sousse
| | - Arwa Haddaji
- 2- Service de Médecine Légale, CHU Ibn El Jazzar, Kairouan, Faculté de Médecine de Sousse
| | - Raja Ghzel
- 2- Service de Médecine Légale, CHU Ibn El Jazzar, Kairouan, Faculté de Médecine de Sousse
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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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Kim OH, Go SJ, Kwon OS, Park CY, Yu B, Chang SW, Jung PY, Lee GJ. Part 2. Clinical Practice Guideline for Trauma Team Composition and Trauma Cardiopulmonary Resuscitation from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Contemporary Utilization of Resuscitative Thoracotomy: Results From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Multicenter Registry. Shock 2019; 50:414-420. [PMID: 29280925 DOI: 10.1097/shk.0000000000001091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Several reviews of resuscitative thoracotomy (RT) use over the last five decades have been conducted, most recently the evidence-based practice management guideline (PMG) of the Eastern Association for the Surgery of Trauma (EAST). The present study was designed to examine contemporary RT utilization and outcomes compared with historical data (n = 10,238) from the EAST PMG review from published series 1974 to 2013. METHODS The American Association for the Surgery of Trauma Aortic Occlusion for Trauma and Acute Care Surgery (AORTA) registry was utilized to identify patients undergoing RT in the emergency department (ED) from November 2013 to December 2016. Demographics, injury data, physiologic presentation, and outcomes were reviewed and compared with those of the EAST PMG review. RESULTS Three-hundred ten RT patients from 16 contributing AORTA centers were identified. The majority were injured by penetrating mechanisms (197/310, 64% [gunshot (163/197, 83%)]). Signs of life (SOL) (organized electrical activity, pupillary response, spontaneous movement, or appreciable pulse/blood pressure) were present on arrival in 47% (147/310). When compared with the EAST PMG results, there was no difference in either hospital survival (5% vs. 8%) or neurologically intact survival between historical controls or AORTA registry patients in any category combination of mechanism/anatomic location/presenting signs of life. Blunt injuries W/O SOL on admission continue to constitute 14% (45/310) of RTs in the ED, without documented survivors. CONCLUSION Comparison of historical RT controls to more contemporary patients from the AORTA registry suggests that practices and outcomes following RT have not changed. Despite a wealth of accumulated data over several decades, RT continues to be performed for patients after blunt mechanisms of injury who present W/O SOL despite lack of demonstrated hope for survival benefit.
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Refaely Y, Koyfman L, Friger M, Ruderman L, Abu Saleh M, Klein M, Brotfain E. Predictors of survival after emergency department thoracotomy in trauma patients with predominant thoracic injuries in Southern Israel: a retrospective survey. Open Access Emerg Med 2019; 11:95-101. [PMID: 31114402 PMCID: PMC6497504 DOI: 10.2147/oaem.s192358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 02/21/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction: Emergency department thoracotomy (EDT), also termed "resuscitative thoracotomy", is indicated in some cases of life-threatening isolated thoracic injury, or as a part of CPR (cardiopulmonary resuscitation) in multiple trauma patients, or in thoracic trauma patients with massive bleeding (such as intra-abdominal exsanguination or injury to the great vessels). There is a lack of information in the literature concerning predictors of survival after EDT in patients with predominant or isolated thoracic trauma. Patients and methods: The study was retrospective and single-center. We collected clinical and laboratory data from all civil and military trauma patients admitted to our emergency department (ED) with predominant thoracic injuries who underwent EDT at Soroka Medical Center. A total of 31 patients were included in the study. Results: Of the patients in the study group, 58% presented with penetrating thoracic injuries and 42% presented with blunt thoracic injuries. 13 patients (42%) survived the EDT procedure. The following parameters predicted survival after EDT: signs of life and the presence of sinus rhythm on admission to the ED; heart rate at the end of the EDT procedure; short duration of EDT; and total positive balance (fluid and blood products) after EDT. Patients who sustained penetrating stab wound injuries had a better immediate post-operative survival rate after EDT than those who sustained penetrating gunshot wounds or predominant blunt chest trauma (30.8% vs 11.1%; p-0.034). Six patients (19%) survived until discharge from the hospital: 3 with penetrating injuries and 3 with blunt thoracic injuries. Conclusion: In patients undergoing EDT after thoracic injury we found that the clinical status on admission to the ED, the duration of the EDT procedure and the heart rate at the end of procedure were predictors of survival after EDT. We demonstrated a higher survival rate after EDT in patients with predominant penetrating thoracic trauma.
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Affiliation(s)
- Yael Refaely
- Department of Cardiothoracic Surgery, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Leonid Koyfman
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Michael Friger
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Leonid Ruderman
- Department of Cardiothoracic Surgery, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Mahmud Abu Saleh
- Department of Cardiothoracic Surgery, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Moti Klein
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Evgeni Brotfain
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Bertoglio P, Guerrera F, Viti A, Terzi AC, Ruffini E, Lyberis P, Filosso PL. Chest drain and thoracotomy for chest trauma. J Thorac Dis 2019; 11:S186-S191. [PMID: 30906584 DOI: 10.21037/jtd.2019.01.53] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Traumas are the leading cause of death in the first four decades of life. Nevertheless, thoracic traumas only seldom require invasive procedures. In particular, chest drain placement is required in case of pleural disruption causing haemothorax, pneumothorax or haemopneumothorax. Although large-bore chest drains have been traditionally used in case of haemothorax, recent evidences seem to question this routine, showing good performances of small-bore and pig tail drains. Although it is a common procedures, experience and training is needed to avoid complications which might be even lethal. Surgical exploration after thoracic trauma is rare, accounting for less than 3% of traumas. Penetrating traumas more likely require surgical exploration compared to blunt trauma. Anterolateral thoracotomy is usually performed in this setting, but also clamshell or hemi-clamshell approach can be used. In selected patients, minimally invasive techniques can be performed. Large randomized trials are still needed to assess and standardized the role of new tools and procedures in the thoracic trauma setting.
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Affiliation(s)
- Pietro Bertoglio
- Division of Thoracic Surgery, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Francesco Guerrera
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Andrea Viti
- Division of Thoracic Surgery, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Alberto Claudio Terzi
- Division of Thoracic Surgery, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Enrico Ruffini
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Paraskevas Lyberis
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pier Luigi Filosso
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Torino, Torino, Italy
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Monaco F, Belletti A, Bove T, Landoni G, Zangrillo A. Extracorporeal Membrane Oxygenation: Beyond Cardiac Surgery and Intensive Care Unit: Unconventional Uses and Future Perspectives. J Cardiothorac Vasc Anesth 2018; 32:1955-1970. [DOI: 10.1053/j.jvca.2018.03.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Indexed: 02/06/2023]
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Nevins EJ, Bird NTE, Malik HZ, Mercer SJ, Shahzad K, Lunevicius R, Taylor JV, Misra N. A systematic review of 3251 emergency department thoracotomies: is it time for a national database? Eur J Trauma Emerg Surg 2018; 45:231-243. [PMID: 30008075 DOI: 10.1007/s00068-018-0982-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/10/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world. METHODS Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications. RESULTS Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012). CONCLUSIONS Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.
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Affiliation(s)
- Edward John Nevins
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.
| | - Nicholas Thomas Edward Bird
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Hassan Zakria Malik
- Liverpool Medical School, University of Liverpool, Liverpool, UK.,North West Hepatobiliary Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Simon Jude Mercer
- Liverpool Medical School, University of Liverpool, Liverpool, UK.,Department of Anaesthesia, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Khalid Shahzad
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - Raimundas Lunevicius
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - John Vincent Taylor
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - Nikhil Misra
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
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13
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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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14
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Is extracorporeal cardiopulmonary resuscitation practical in severe chest trauma? A systematic review in single center of developing country. J Trauma Acute Care Surg 2017; 83:903-907. [DOI: 10.1097/ta.0000000000001680] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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DiGiacomo JC, Angus LG. Thoracotomy in the emergency department for resuscitation of the mortally injured. Chin J Traumatol 2017; 20:141-146. [PMID: 28550970 PMCID: PMC5473713 DOI: 10.1016/j.cjtee.2017.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/24/2017] [Accepted: 03/08/2017] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Emergency department resuscitative thoracotomy is an intervention of last resort for the acutely dying victim of trauma. In light of improvements in pre-hospital emergency systems, improved operative strategies for survival such as damage control and improvements in critical care medicine, the most extreme of resuscitation efforts should be re-evaluated for the potential survivor, with success properly defined as the return of vital signs which allow transport of the patient to the operating room. METHODS A retrospective review of all patients at a suburban level I trauma center who underwent emergency department resuscitative thoracotomy as an adjunct to the resuscitation efforts normally delivered in the trauma receiving area over a 22 year period was performed. Survival of emergency department resuscitative thoracotomy was defined as restoration of vital signs and transport out of the trauma resuscitation area to the operating room. RESULTS Sixty-eight patients were identified, of whom 27 survived the emergency department resuscitative thoracotomy and were transported to the operating room. Review of pre-hospital and initial hospital data between these potential long term survivors and those who died in the emergency department failed to demonstrate trends which were predictive of survival of emergency department resuscitative thoracotomy. The only subgroup which failed to respond to emergency department resuscitative thoracotomy was patients without signs of life at the scene who arrived to the treatment facility without signs of life. CONCLUSION The patient population of the "potential survivor" has been expanded due to advances in critical care practices, technology, and surgical technique and every opportunity for survival should be provided at the outset. Emergency department resuscitative thoracotomy is warranted for any patient with thoracic or subdiaphragmatic trauma who presents in extremis with a history of signs of life at the scene or organized cardiac activity upon arrival. Patients who have no evidence of signs of life at the scene and have no organized cardiac activity upon arrival should be pronounced.
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16
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Abstract
Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.
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Affiliation(s)
- Corinna Ludwig
- Department of Thoracic Surgery, Florence Nightingale Hospital, Düsseldorf, Germany
| | - Aris Koryllos
- Department of Thoracic Surgery, Private University Witten-Herdecke, Metropolitan Hospital of Cologne Merheim, Cologne, Germany
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17
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Guimarães MB, Winckler DC, Rudnick NG, Breigeiron R. Critical analysis of thoracotomies performed in the emergency room in 10 years. Rev Col Bras Cir 2016; 41:263-6. [PMID: 25295987 DOI: 10.1590/0100-69912014004007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/02/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To conduct a critical analysis of thoracotomies performed in the emergency rooms. METHODS We analyzed mortality rates and survival as outcome variables, mechanism of injury, site of injury and anatomic injury as clinical variables, and gender and age as demographic variables of patients undergoing thoracotomy in the emergency room after traumatic injury. RESULTS Of the 105 patients, 89.5% were male. The average age was 29.2 years. Penetrating trauma accounted for 81% of cases. The most common mechanism of trauma was wound by a firearm projectile (gunshot), in 64.7% of cases. Patients with stab wounds (SW) accounted for 16.2% of cases. Overall survival was 4.7%. Survival by gunshot was 1.4%, and by SW, 23.5%. The ERT following blunt trauma showed a 100%mortality. CONCLUSION The results obtained in the Emergency Hospital of Porto Alegre POA-HPS are similar to those reported in the world literature.
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Affiliation(s)
| | - Diego Carrão Winckler
- Porto Alegre Emergency Room, HPS-POA, Porto Alegre, State of Rio Grande do Sul, Brasil
| | | | - Ricardo Breigeiron
- Porto Alegre Emergency Room, HPS-POA, Porto Alegre, State of Rio Grande do Sul, Brasil
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18
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Abstract
The resuscitative thoracotomy (RT) is an important procedure in the management of penetrating trauma. As it is performed only in patients with peri-arrest physiology or overt cardiac arrest, survival is low. Experience is also quite variable depending on volume of penetrating trauma in a particular region. Survival ranges from 0% to as high as 89% depending on patient selection, available resources, and location of RT (operating or emergency rooms). In this article, published guidelines are reviewed as well as outcomes. Technical considerations of RT and well as proper training, personnel, and location are also discussed.
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Affiliation(s)
- Lindsay M Fairfax
- Auckland City Hospital Trauma Services, Park Road Grafton, Auckland, 1023, New Zealand
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19
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Operative Management of Lung Injuries. CURRENT TRAUMA REPORTS 2015. [DOI: 10.1007/s40719-015-0030-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Ann Surg 2015; 262:512-8; discussion 516-8. [PMID: 26258320 DOI: 10.1097/sla.0000000000001421] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to examine the ability of Focused Assessment Using Sonography for Trauma (FAST) to discriminate between survivors and nonsurvivors undergoing resuscitative thoracotomy (RT). BACKGROUND RT is a high-risk, low-salvage procedure performed in arresting trauma patients with poorly defined indications. METHODS Patients undergoing RT from 10/2010 to 05/2014 were prospectively enrolled. A FAST examination including parasternal/subxiphoid cardiac views was performed before or concurrent with RT. The result was captured as adequate or inadequate with presence or absence of pericardial fluid and/or cardiac motion. A sensitivity analysis utilizing the primary outcome measure of survival to discharge or organ donation was performed. RESULTS Overall, 187 patients arrived in traumatic arrest and underwent FAST. Median age 31 (1-84), 84.5% male, 51.3% penetrating. Loss of vital signs occurred at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. Emergent left thoracotomy was performed in 77.5% and clamshell thoracotomy in 22.5%. Sustained cardiac activity was regained in 48.1%. However, overall survival was only 3.2%. An additional 1.6% progressed to organ donation. FAST was inadequate in 3.7%, 28.9% demonstrated cardiac motion and 8.6% pericardial fluid. Cardiac motion on FAST was 100% sensitive and 73.7% specific for the identification of survivors and organ donors. CONCLUSIONS With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.
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21
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Flaris AN, Simms ER, Prat N, Reynard F, Caillot JL, Voiglio EJ. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg 2015; 39:1306-11. [PMID: 25561192 DOI: 10.1007/s00268-014-2924-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The clamshell incision (CI) offers a better exposure than the left anterolateral thoracotomy (LAT) as a resuscitative thoracotomy. Most surgeons will have to manage a heart wound only once or twice in their career. The patient's survival depends on how fast the surgeon can control the heart wound; however, it is unclear which of the two incisions allows for faster control in the hands of inexperienced surgeons. The aim of this study was to compare the time needed to access and control a standardized stab wound to the right ventricle, by inexperienced surgical trainees, by LAT or CI; we hypothesized that the CI does not take longer than the LAT. METHODS Sixteen residents were shown a video on how to perform both procedures. They were randomly assigned to control a standardized stab wound of the right ventricle on perfused human cadavers by LAT (n = 8) or CI (n = 8). Access time (skin to maximal exposure), control time (maximal exposure until control of the heart wound) and total time (the sum of access and control times) were recorded. RESULTS Total time was 6.62 min [3.20-8.14] (median [interquartile range]) for LAT and 4.63 min [3.17-6.73] for CI (p = 0.46). Access time was 2.39 min [1.21-2.76] for LAT and 2.33 min [1.58-4.86] for CI (p = 0.34). Control time was 4.16 min [2.32-5.49] for LAT and 1.85 min [1.38-2.23] for CI (p = 0.018). CONCLUSIONS The time needed from skin incision until cardiac wound control via CI was not longer than via LAT and the easier control of the cardiac wound when using CI was confirmed.
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Affiliation(s)
- Alexandros N Flaris
- Faculté de Médecine Lyon Est, Université Lyon 1, UMR T9405, 69003, Lyon, France,
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22
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An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015; 79:159-73. [PMID: 26091330 DOI: 10.1097/ta.0000000000000648] [Citation(s) in RCA: 187] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival? METHODS All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest. RESULTS The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825). CONCLUSION We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury. LEVEL OF EVIDENCE Systematic review/guideline, level III.
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23
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Dayama A, Sugano D, Spielman D, Stone ME, Kaban J, Mahmoud A, McNelis J. Basic data underlying clinical decision-making and outcomes in emergency department thoracotomy: tabular review. ANZ J Surg 2015; 86:21-6. [PMID: 26178013 DOI: 10.1111/ans.13227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Emergency department thoracotomy (EDT) is a formidable and dramatic last attempt by the trauma surgeon to save the life of a patient in extremis. The aim of this report is to provide a benchmark for comparison with past results by reviewing all available published data since the American College of Surgeons Committee on Trauma review article in 2001, which reviewed literature from 1966 to 1999 regarding indications for and outcomes of EDT. METHODS A comprehensive literature search in MEDLINE Library databases was performed for EDT. Data were extracted by three independent reviewers. RESULTS We identified 37 papers with a total of 3466 patients. A total of 85.2% (1720 of the 2018) had penetrating trauma, 58.3% (372 of the 638) had cardiac injuries, 43.0% (251 of the 584) had thoracic injuries and 26.2% (143 of the 546) had abdominal injuries. The overall rate survival in this review was 8% (267 of the 3466, range 0-33.3%). Of 25 papers reporting cases of EDT for penetrating traumas, their survival rate was 9.8% (169 of the 1719, range 0-45.5); similarly, of 14 papers assessing EDT for blunt injuries, the survival rate was 5.2% (24 of the 460, range 0-12.2). Of 15 papers reporting neurological outcomes 84.6% (143 of the 169, range 50-100%) of patients returned to baseline. The survival outcome of EDT in US experience versus non-US experiences was 6.3% (164 of the 2612, range 0-14.9) versus 11.9% (89 of the 745, range 0-33.3) respectively. CONCLUSION The authors intend this review to serve as a practical and prompt literature search tool for all surgeons who encounter resuscitative thoracotomy in their practice.
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Affiliation(s)
- Anand Dayama
- San Joaquin General Hospital, University of California, Davis, French Camp, California, USA
| | - Dordaneh Sugano
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel Spielman
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Melvin E Stone
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jody Kaban
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ahmed Mahmoud
- San Joaquin General Hospital, University of California, Davis, French Camp, California, USA
| | - John McNelis
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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24
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Abstract
The management of patients with exsanguinating torso hemorrhage is challenging. Emergency surgery, with the occasional use of resuscitative thoracotomy for patient in extremis, is the current standard. Recent reports of REBOA (resuscitative endovascular balloon occlusion of the aorta) have led to discussions about changing paradigms in the management of patients in both civilian and military are nas. We submit that broad and liberal application of this technique is premature given the current data and in light of historical experience. We propose an algorithm for the management of patients with exsanguinating torso hemorrhage, as well as a set of research questions that we feel can help clarify the role of REBOA in modern trauma care in a variety of trauma settings.
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Abstract
Damage control surgery involves an abbreviated operation followed by resuscitation with planned re-exploration. Damage control techniques can be used in thoracic trauma but has been infrequently reported. Our goal is to describe our experience with the use of damage control techniques in treating thoracic trauma. A retrospective analysis of all patients undergoing damage control thoracic surgery related to trauma from January 1, 2010, to January 1, 2013, at University of Louisville Hospital, a Level I trauma center. Variables studied included injury characteristics, Injury Severity Score, surgery performed, duration of packing, length of stay (LOS), ventilator days, transfusion requirements, complications, and mortality. Twenty-five patients underwent damage control surgery in the chest with packing, temporary closure, and planned re-exploration after stabilization. Seventeen patients underwent anterolateral thoracotomy, and eight patients underwent sternotomy. The mean LOS and duration of temporary packing was 20.6 and 1.4 days in the thoracotomy group, respectively, and 19.5 and 1 day in the sternotomy group, respectively. The overall mortality rate was 40 per cent, 35 per cent in the thoracotomy group and 50 per cent in the sternotomy group. Like in severe abdominal trauma, damage control techniques can be used in the management of severe thoracic injuries with acceptable results.
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Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study. World J Surg 2013; 37:1277-85. [DOI: 10.1007/s00268-013-1961-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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27
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Van Waes OJF, Van Riet PA, Van Lieshout EMM, Hartog DD. Immediate thoracotomy for penetrating injuries: ten years' experience at a Dutch level I trauma center. Eur J Trauma Emerg Surg 2012; 38:543-51. [PMID: 23162671 PMCID: PMC3495272 DOI: 10.1007/s00068-012-0198-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 05/18/2012] [Indexed: 10/31/2022]
Abstract
BACKGROUND An emergency department thoracotomy (EDT) or an emergency thoracotomy (ET) in the operating theater are both beneficial in selected patients following thoracic penetrating injuries. Since outcome-descriptive European studies are lacking, the aim of this retrospective study was to evaluate ten years of experience at a Dutch level I trauma center. METHOD Data on patients who underwent an immediate thoracotomy after sustaining a penetrating thoracic injury between October 2000 and January 2011 were collected from the trauma registry and hospital files. Descriptive and univariate analyses were performed. RESULTS Among 56 patients, 12 underwent an EDT and 44 an ET. Forty-six patients sustained one or multiple stab wounds, versus ten with one or multiple gunshot wounds. Patients who had undergone an EDT had a lower GCS (p < 0.001), lower pre-hospital RTS and hospital triage RTS (p < 0.001 and p = 0.009, respectively), and a lower SBP (p = 0.038). A witnessed loss of signs of life generally occurred in EDT patients and was accompanied by 100 % mortality. Survival following EDT was 25 %, which was significantly lower than in the ET group (75 %; p = 0.002). Survivors had lower ISS (p = 0.011), lower rates of pre-hospital (p = 0.031) and hospital (p = 0.003) hemodynamic instability, and a lower prevalence of concomitant abdominal injury (p = 0.002). CONCLUSION The overall survival rate in our study was 64 %. The outcome of immediate thoracotomy performed in this level I trauma center was similar to those obtained in high-incidence regions like the US and South Africa. This suggests that trauma units where immediate thoracotomies are not part of the daily routine can achieve similar results, if properly trained.
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Affiliation(s)
- O. J. F. Van Waes
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - P. A. Van Riet
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - E. M. M. Van Lieshout
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - D. D. Hartog
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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28
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Societal Costs of Inappropriate Emergency Department Thoracotomy. J Am Coll Surg 2012; 214:18-25. [DOI: 10.1016/j.jamcollsurg.2011.09.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 08/01/2011] [Accepted: 09/29/2011] [Indexed: 11/21/2022]
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Lustenberger T, Labler L, Stover JF, Keel MJB. Resuscitative emergency thoracotomy in a Swiss trauma centre. Br J Surg 2011; 99:541-8. [PMID: 22139553 DOI: 10.1002/bjs.7706] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND Resuscitative emergency thoracotomy (ET) is performed as a salvage manoeuvre for selected patients with trauma. However, reports from European trauma centres are scarce. METHODS A retrospective analysis was undertaken of injured patients who underwent resuscitative ET in the emergency department (ED) or operating room (OR) between January 1996 and September 2008. Survival in the ED and to hospital discharge was analysed using logistic regression. RESULTS During the study interval 121 patients required a resuscitative thoracotomy, of which 49 (40·5 per cent) were performed in the ED and 72 (59·5 per cent) in the OR. Patients in the OR had higher blood pressure on arrival (median 110 versus 60 mmHg; P < 0·001), were less often in severe haemorrhagic shock (63 versus 94 per cent; P < 0·001), had fewer serious head injuries (Abbreviated Injury Score of 3 or above in 33 versus 53 per cent; P = 0·031) and more often had a penetrating stab wound as the dominating mechanism (25 versus 10 per cent; P = 0·042) compared with those in the ED. Ten patients (20 per cent) survived to hospital discharge after ED thoracotomy, compared with 53 (74 per cent) of those treated in the OR. Penetrating injury and Glasgow Coma Scale score above 8 were independent predictors of hospital survival following ED thoracotomy. No patient with a blunt injury and no detectable signs of life on admission survived. Three of 26 patients with blunt trauma and signs of life on admission survived to hospital discharge. CONCLUSION Resuscitative ET may be life-saving in selected patients. Location of the procedure is dictated by injury severity and vital parameters. Outcome is best when signs of life are present on admission, even for blunt injuries.
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Affiliation(s)
- T Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital, Goethe University, Frankfurt am Main, Germany.
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Onat S, Ulku R, Avci A, Ates G, Ozcelik C. Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center. Injury 2011; 42:900-4. [PMID: 22081815 DOI: 10.1016/j.injury.2010.02.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality. METHODS A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded. RESULTS A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 9.33 (range, 15–54) years. The mean LOS was 10.65 8.30 (range, 5–65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 9.92 days; stab wound, 8.76 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 36.702 mm Hg) compared with those who survived (83.96 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% (n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01), ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01) and SBP (p = 0.001) were associated with mortality. CONCLUSION Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.
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Affiliation(s)
- Serdar Onat
- Department of Thoracic Surgery, Faculty of Medicine Dicle University, 21280 Diyarbakir, Turkey.
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Appropriate use of emergency department thoracotomy: implications for the thoracic surgeon. Ann Thorac Surg 2011; 92:455-61. [PMID: 21704969 DOI: 10.1016/j.athoracsur.2011.04.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Revised: 04/01/2011] [Accepted: 04/06/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Practice guidelines for the appropriate use of emergency department thoracotomy (EDT) according to current national resuscitative guidelines have been developed by the American College of Surgeons Committee on Trauma (ACS-COT) and published. At an urban level I trauma center we analyzed how closely these guidelines were followed and their ability to predict mortality. METHODS Between January 2003 and July 2010, 120 patients with penetrating thoracic trauma underwent EDT at Mount Sinai Hospital (MSH). Patients were separated based on adherence (group 1, n=70) and nonadherence (group 2, n=50) to current resuscitative guidelines, and group survival rates were determined. These 2 groups were analyzed based on outcome to determine the effect of a strict policy of adherence on survival. RESULTS Of EDTs performed during the study period, 41.7% (50/120) were considered outside current guidelines. Patients in group 2 were less likely to have traditional predictors of survival. There were 6 survivors in group 1 (8.7%), all of whom were neurologically intact; there were no neurologically intact survivors in group 2 (p=0.04). The presence of a thoracic surgeon in the operating room (OR) was associated with increased survival (p=0.039). CONCLUSIONS A policy of strict adherence to EDT guidelines based on current national guidelines would have accounted for all potential survivors while avoiding the harmful exposure of health care personnel to blood-borne pathogens and the futile use of resources for trauma victims unable to benefit from them. Cardiothoracic surgeons should be familiar with current EDT guidelines because they are often asked to contribute their operative skills for those patients who survive to reach the OR.
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Morgan BS, Garner JP. Emergency thoracotomy--the indications, contraindications and evidence. J ROY ARMY MED CORPS 2011; 155:87-93. [PMID: 20095172 DOI: 10.1136/jramc-155-02-02] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Emergency thoracotomy is a dramatic and controversial intervention which may be life saving after major torso trauma. Success rates are variable and differ widely according to mechanism of injury. This article outlines the current indications and contraindications to emergency thoracotomy and examines the evidence to support it accumulated over 40 years.
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Affiliation(s)
- B S Morgan
- Northern General Hospital, Herries Road, Sheffield.
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Özyurtkan MO, Balcı AE, Çakmak M. Thoracotomy in Thoracic Injuries: Results from a Tertiary Referral Hospital. Eur J Trauma Emerg Surg 2010; 36:233-9. [PMID: 26815866 DOI: 10.1007/s00068-009-9149-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 10/05/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Critically injured patients may require thoracotomy after a thoracic injury. This study is a retrospective analysis of the results of thoracotomy in patients with thoracic injury. MATERIALS AND METHODS Injured patients with detectable signs of life on arrival at the hospital and who underwent thoracotomy within 4 h of the injury were investigated. Demographic data and medical records were reviewed for associated injuries, indications, intraoperative findings, and outcomes. The factors affecting the mortality were analyzed. RESULTS Between April 2003 and January 2009, 488 patients with thoracic injury (blunt/penetrating = 73.7%/26.3%) were treated, and 20 (4.1%) underwent thoracotomy (male/female = 17/3, mean age = 27 ± 9 years). The injury was penetrating in 15 (11.7%) and blunt in five (1.4%). None of them required an endotracheal intubation at the scene or in transit. The mean transport time was 58 min. Severe and continuous hemothorax (80%), massive air leak, major vessel injury, and trauma causing an open chest wall defect with bleeding were indications of the thoracotomy. Eighty-five percent survived after the surgery (penetrating/ blunt = 86.6%/80%). The mean injury severity score (ISS) of the survivors was lower (21 ± 9 vs. 39 ± 10, p = 0.05). Mortality was associated with a lower Glasgow coma scale (GCS) (p = 0.03), a higher ISS (p = 0.05), and a longer transport time (p = 0.05). CONCLUSIONS Thoracotomy after thoracic injury is a life-saving procedure in selected cases. Lower GCS and higher ISS are associated with increased mortality. Early transport and quick attempts to diagnose the indications necessitating thoracotomy play a significant role in improving the outcome.
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Affiliation(s)
- Mehme Oğuzhan Özyurtkan
- Department of Thoracic Surgery, Firat University Hospital, Firat University Faculty of Medicine, Elaziğ, Turkey.
| | - Akın Eraslan Balcı
- Department of Thoracic Surgery, Firat University Hospital, Firat University Faculty of Medicine, Elaziğ, Turkey
| | - Muharrem Çakmak
- Department of Thoracic Surgery, Firat University Hospital, Firat University Faculty of Medicine, Elaziğ, Turkey
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Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. ACTA ACUST UNITED AC 2010; 67:1250-7; discussion 1257-8. [PMID: 20009674 DOI: 10.1097/ta.0b013e3181c3fef9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Historically, patients with penetrating cardiac injuries have enjoyed the best survival after emergency department thoracotomy (EDT), but further examination of these series reveals a preponderance of cardiac stab wound (SW) survivors with only sporadic cardiac gunshot wound (GSW) survivors. Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable. METHODS All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival. RESULTS The study population (n = 283) comprised young (mean age, 27.1 years +/- 10.1 years) men (96.1%) injured by gunshot (GSW, 88.3%) or SWs (11.7%). Patients were compared by injury mechanism and number of CGV wounds with respect to survival (SW, 24.2%; GSW, 2.8%; p < 0.001; single, 9.5%; multiple, 1.4%; p = 0.003). Three predictors-injury mechanism, ED SOL, and number of CGV wounds-were then analyzed alone and in combination with respect to hospital survival. Only one patient (0.8%) with multiple CGV GSW survived EDT. CONCLUSION When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival.
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Braathen B, Bøen A, Thorsen T, Tønnessen T. Gunshot through the left ventricle. Resuscitation 2009; 80:615-6. [PMID: 19406553 DOI: 10.1016/j.resuscitation.2009.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 02/23/2009] [Accepted: 02/25/2009] [Indexed: 11/26/2022]
Affiliation(s)
- Bjørn Braathen
- Department of Cardiothoracic Surgery, Ullevål University Hospital, Oslo, Norway
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Benkhadra M, Honnart D, Lenfant F, Trouilloud P, Girard C, Freysz M. [Open chest cardiopulmonary resuscitation: is there an interest in France?]. ACTA ACUST UNITED AC 2008; 27:920-33. [PMID: 19013750 DOI: 10.1016/j.annfar.2008.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 06/10/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To expose and clarify indications, techniques, results, complications and cost for open chest cardiopulmonary resuscitation manoeuvres (OCCRM) in traumatic or nontraumatic cardiac arrest. DATA SOURCES References were obtained from Pubmed data bank using the following keywords: "emergency thoracotomy", "resuscitative thoracotomy". STUDY SELECTION We focused on publications in English language, from 2000 to 2007. DATA SYNTHESIS OCCRM are useful especially in case of traumatic cardiac arrest, penetrating trauma, but also in blunt trauma. Time between cardiac arrest and realisation of the thoracotomy seems to be the most important factor for the prognosis. CONCLUSION According to the French "physician in ambulance" prehospital system, OCCRM might be promising in France, because this system favours the fastness of care and therefore would minimize the time factor.
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Affiliation(s)
- M Benkhadra
- Service d'anesthésie-réanimation, hôpital Le-Bocage, CHU de Dijon, 2, boulevard Maréchal-de-Lattre-de-Tassigny, BP 77908, 21079 Dijon cedex, France.
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Huber-Wagner S, Lefering R, Qvick M, Kay MV, Paffrath T, Mutschler W, Kanz KG. Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest. Resuscitation 2007; 75:276-85. [PMID: 17574721 DOI: 10.1016/j.resuscitation.2007.04.018] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Revised: 04/13/2007] [Accepted: 04/20/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND Resuscitation of traumatic cardiorespiratory arrest patients (TCRA) is generally associated with poor outcome, however some authors report survival rates of more than 10% in blunt trauma patients. The purpose of this investigation was to determine predictive factors for mortality in trauma patients having received external chest compressions (ECC). PATIENTS AND METHODS Twenty thousand eight hundred and fifteen patients from the Trauma Registry of the German Trauma Society were analysed (mean ISS=24.0). Inclusion criteria were ISS>/=16 and available information on ECC either on-scene and/or during trauma room treatment. Included into the Trauma Registry were only patients with ECC and transportation into a hospital. Patients declared dead on-scene without transportation to a hospital were not recorded in the data base. A Logistic regression was performed to find out predictive factors for mortality. RESULTS Ten thousand three hundred and fifty nine patients fulfilled the inclusion criteria. N=757 patients received ECC, 415 prehospital, 538 during trauma room (TR) treatment and 196 prehospital and in-hospital. Blunt trauma occurred in 93.2%, mean age was 40.3 and median ISS was 41.0. 23.2% of the patients were treated with a chest tube, 5.7% had a tension pneumothorax and 10.2% underwent emergency thoracotomy. The overall survival rate was 17.2%. 9.7% of the TCRA patients with ECC achieved good recovery or moderate disability (Glasgow outcome scale>/=4). Logistic regression showed thromboplastin time lower than 50% to be the strongest predictor for non-survival (OR 5.2, 95% CI 2.3-11.9), followed by massive blood transfusion of more than 10 units of packed red blood cells (OR 4.8, 95% CI 2.0-11.5), on-scene blood pressure of 0 (OR 4.3, 95% CI 1.6-11.3), age over 55 (OR 2.9, 95% CI 1.1-7.3), base excess lower than -8 (OR 2.7, 95% CI 1.2-5.9). The insertion of a chest tube on-scene could be detected as a factor significantly increasing the probability of survival (OR 0.3, 95% CI 0.13-0.8). CONCLUSIONS Prehospital chest tube insertion was found to be a strong predictor for survival. On-scene chest decompression of TCRA patients is recommended in case of the decision to start with ECC. Based on our data, resuscitation after severe trauma seems to be more justified than the current guidelines state.
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Affiliation(s)
- Stefan Huber-Wagner
- Klinikum der Universität München, Chirurgische Klinik und Poliklinik, Campus Innenstadt, Nussbaumstrasse 20, D-80336 München, Germany.
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Szentkereszty Z, Trungel E, Pósán J, Sápy P, Szerafin T, Sz Kiss S. [Current issues in the diagnosis and treatment of penetrating chest trauma]. Magy Seb 2007; 60:199-204. [PMID: 17931996 DOI: 10.1556/maseb.60.2007.4.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Successful treatment of penetrating chest trauma largely depends on the accurate and rapid diagnostic work-up, as well as the adequate surgical management. The authors discuss current issues in the diagnosis and the treatment of penetrating chest injuries based on the analysis of 109 cases. PATIENTS AND METHODS 82 men and 27 women with penetrating chest trauma were studied. The average age of the patients was 37.8 years. The injury was caused by stabbing in 104 cases (95.4%), gunshot in 4 patients (3.7%) and explosion in one case (0.9%). 41 patients had cardiac and pericardial injuries. In those, 19 (46.3%) patients had a chest X-ray, echocardiography was done in nine cases (22%), while CT scan and diagnostic VATS were performed in two patients, respectively. All patients underwent surgery except one, who was treated conservatively.In all of the 68 patients, who had no cardiac injuries, a chest X-ray was performed. Echocardiography was done in six (8.8%) cases, diagnostic VATS in four (5.9%) patients, and abdominal ultrasound scan in 3 (4.4%) cases. Chest tube was inserted in 13 patients (19.1%), an open surgery was performed in 51 cases, while in 4 cases VATS was carried out. RESULTS In the group of patients with cardiac and pericardial injuries, the sensitivity of the chest X-ray, echocardiography and VATS were 57.9%, 88.9% and 100%, respectively. Further, specificity of the above were 26.3%, 88.9% and 100%, respectively. However, in patients with non-cardiac injuries, the sensitivity of the chest X-ray was 100%, and both the specificity and sensitivity of VATS was 100%. Postoperative complication rate was 12.6% overall (15% in cases with cardiac injury and 10.9% in the non-cardiac subgroup). Mortality rate was 7.3% among the patients with cardiac injury, while there was no mortality detected in the non-cardiac subgroup. The average mortality rate was 2.8%. CONCLUSION Patients with penetrating chest trauma should undergo a rapid and accurate diagnostic work-up followed by an adequate surgical management in order to keep their prognosis relatively good.
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Affiliation(s)
- Zsolt Szentkereszty
- DE OEC Sebészeti Intézet, Auguszta Sebészeti Központ, 4004 Debrecen, Móricz Zs. krt. 22.
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Abstract
Emergency department thoracotomy (EDT) may serve as a life-saving tool when performed for the right indications, in selected patients, and in the hands of a trained surgeon. Critically injured patients 'in extremis' arrive at an increasing rate in the trauma bay, as an effect of improved pre-hospital trauma systems and rapid transport. Any patient in near, or full cardiovascular shock prompts the trauma surgeon to rapidly perform a thoracotomy. The EDT procedure is managed best by surgeons familiar with, and experienced in, penetrating cardiothoracic injuries. However, the geographical differences in trauma epidemiology lends no, or only scarce, experience with this procedure in most European trauma centres. Consequently, mandatory training is imperative for success. The rationale for performing an EDT is to: (I) resuscitate the agonal patient with penetrating cardiothoracic injuries; (II) release cardiac tamponade by evacuation of pericardial blood; (III) immediately control hemorrhage and repair cardiac or pulmonary injury; (IV) perform open cardiac massage; and (V) place a thoracic aortic cross-clamp to redistribute the remaining blood volume, and perfuse the carotids and coronary arteries. The prevalence rates of blood-borne viruses reported in critically injured patients in the USA (10-20%) exceed the prevalence in the Nordic countries (HIV prevalence < 1% in general population). However, risk is not negligible and mandated universal precautions are needed. The literature is rich in series describing the use of EDT, however, the best evidence is derived from a few prospective trials. EDT saves about one in every five patients with isolated penetrating cardiac injury, while > 98% die after blunt injury. Based on an updated review of the current available literature, this paper presents the current evidence regarding the rationale, risk, and outcomes for employing EDT in the field of trauma surgery.
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Affiliation(s)
- K Søreide
- Department of Surgery, Stavanger University Hospital, Acute Care Medicine Research Network, Department of Health Studies, University of Stavanger, Norway.
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Søreide K, Søiland H, Lossius HM, Vetrhus M, Søreide JA, Søreide E. Resuscitative emergency thoracotomy in a Scandinavian trauma hospital--is it justified? Injury 2007; 38:34-42. [PMID: 17083941 DOI: 10.1016/j.injury.2006.06.125] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2006] [Accepted: 06/12/2006] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Resuscitative emergency thoracotomy (ET) is of value in selected (penetrating) trauma patients. Current survival-estimates and recommended guidelines are based on data from the United States. However, reports from European trauma centres are lacking. We report the current experience from a Scandinavian trauma hospital. METHODS Identification of all consecutive ETs performed during a 5-year period. Data on demographics, and injury severity score (ISS), mechanism and location were recorded. Physiological status on admission (revised trauma score, RTS) and probability of survival (Ps) were calculated. Signs of life (SOL) and need for closed-chest cardiopulmonary resuscitation (CC-CPR) were recorded through the post-injury phase. RESULTS Ten patients underwent ET with no survivors. The annual incidence of ET was 0.7 per 100,000 inhabitants during the study period, with an increasing trend during the last years (r=0.74, p=0.014). ETs were performed in 0.7% of all trauma admissions, and in 2.5% of all severely injured patients (ISS>or=16). Blunt mechanism dominated; only three had penetrating injuries. Most frequent location of major injury was "multiple" (n=4) and "thoracic" (n=4). The male to female ratio was 7:3. Median age was 51 years (range 21-77). Median ISS was 34.5 (range 26-75), indicating severely injured patients, with seriously deranged physiology (median RTS of 0.0, range 0-6.1) with poor chance of survival (median Ps of 4.4%, range 0-89.5%). Males had significantly lower RTS and Ps (p=0.007 and 0.03, respectively) than females. Eight patients had signs of life at some time post-injury, but only four in the emergency room. Six patients had both pre- and in-hospital CC-CPR. Four patients had additional surgery to ET. Two possible preventable deaths were identified (Ps) of 51 and 89%), one in a third trimester pregnancy. CONCLUSION Emergency thoracotomy is a rarely performed procedure in a rather busy Scandinavian trauma hospital, and outcome is dismal. Reevaluation of our decision-making process concerning the use of emergency thoracotomy is needed. How survival data and clinical experience in Europe compare to current figures from North America deserves further attention.
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Affiliation(s)
- K Søreide
- Department of Surgery, Stavanger University Hospital, Norway.
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Fraga GP, Genghini EB, Mantovani M, Cortinas LGDO, Prandi Filho W. Toracotomia de reanimação: racionalização do uso do procedimento. Rev Col Bras Cir 2006. [DOI: 10.1590/s0100-69912006000600005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Contesta-se a aplicação indiscriminada da toracotomia de reanimação (TR) no trauma. Este estudo objetiva reavaliar as indicações de TR na nossa instituição. MÉTODO: Estudo retrospectivo envolvendo 126 pacientes submetidos à TR entre janeiro de 1995 e dezembro de 2004. Definiram-se quatro grupos considerando os sinais vitais dos pacientes na admissão: morto ao chegar, fatal, agônico e choque profundo. O protocolo incluiu dados como mecanismo de trauma, sinais vitais, Escore de Trauma Revisado (Revised Trauma Score ou RTS), locais de lesão (identificados durante cirurgia ou autópsia), Índice de Gravidade da Lesão (Injury Severity Score ou ISS) e sobrevida. RESULTADOS: Setenta e dois (57,2%) pacientes apresentavam ferimento por projétil de arma de fogo, 11 (8,7%) ferimento por arma branca e 43 (34,1%) por trauma fechado. Nenhum dos sessenta pacientes (47,6%) dos grupos fatal e morto ao chegar sobreviveu, mas 13 (39,4%) dos pacientes fatais foram encaminhados ao centro cirúrgico (CC) para tratamento definitivo. Dos 66 pacientes dos grupos agônico e choque profundo, 44 (66,7%) foram submetidos a TR no prontosocorro (PS) e 31 (70,5%) destes foram transferidos até o CC. Nos 22 restantes, a parada cardiorrespiratória ocorreu já no CC, onde foi feita a TR. Dois pacientes do grupo choque profundo sobreviveram (1,6% do total) e receberam alta com função cerebral normal. O ISS médio foi 33, sendo exsangüinação a causa mais freqüente de óbito. CONCLUSÕES: Resultados ruins enfatizam a necessidade de uma abordagem mais seletiva para aplicar a TR. Um algoritmo baseado no mecanismo de trauma e nos sinais vitais na admissão é proposto para otimizar as indicações de TR.
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