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

Survival predictor in emergency resuscitative thoracotomy for blunt trauma patients: Insights from a Chinese trauma center

PURPOSE

Emergency resuscitative thoracotomy (ERT) is a final salvage procedure for critically injured trauma patients. Given its low success rate and ambiguous indications, its use in blunt trauma scenarios remains highly debated. Consequently, our study seeks to ascertain the overall survival rate of ERT in blunt trauma patients and determine which patients would benefit most from this procedure.

METHODS

A retrospective case-control study was conducted for this research. Blunt trauma patients who underwent ERT between January 2020 and December 2023 in our trauma center were selected for analysis, with the endpoint outcome being in-hospital survival, divided into survival and non-survival groups. Inter-group comparisons were conducted using Chi-square and Fisher's exact tests, the Kruskal-Wallis test, Student's t-test, or the Mann-Whitney U test. Univariate and multivariate logistic regression analyses were conducted to assess potential predictors of survival. Then, the efficacy of the predictors was assessed through sensitivity and specificity analysis.

RESULTS

A total of 33 patients were included in the study, with 4 survivors (12.12%). Multivariate logistic regression analysis indicated a significant association between cardiac tamponade and survival, with an adjusted odds ratio of 33.4 (95% CI: 1.31 - 850, p = 0.034). Additionally, an analysis of sensitivity and specificity, targeting cardiac tamponade as an indicator for survivor identification, showed a sensitivity rate of 75.0% and a specificity rate of 96.6%.

CONCLUSION

The survival rate among blunt trauma patients undergoing ERT exceeds traditional expectations, suggesting that select individuals with blunt trauma can significantly benefit from the procedure. Notably, those presenting with cardiac tamponade are identified as the subgroup most likely to derive substantial benefits from ERT.

Eastern Association for the Surgery of Trauma (EAST) vs Western Trauma Association (WTA): How a Level 1 Trauma Center Splits the Difference in Resuscitative Thoracotomy

Background Resuscitative thoracotomy (RT) is performed in severe trauma cases as a final lifesaving effort. Prominent, yet differing, practice management guidelines exist from Eastern Association for the Surgery of Trauma (EAST) and Western Trauma Association (WTA). This study evaluates all RTs performed from 2012 to 2019 at an urban Level 1 trauma center for management guideline indication and subsequent outcomes. Methods Our trauma registry was queried to identify RT cases from 2012 to 2019. Data was collected on patient demographics, prehospital presentation, cardiopulmonary resuscitation (CPR) requirements, and resuscitation provided. Survival to the operating room, intensive care unit, and overall were recorded. Information was compared with regard to EAST and WTA criteria. Results Eighty-seven patients who underwent RTs were included. WTA guidelines were met in 78/87 (89.7%) of cases, comparatively EAST guidelines were met in every case. Within the EAST criteria, conditional and strong recommendations were met in 70/87 (80.4%) and 17/87 (19.5%) of cases, respectively. In nine cases (10.3%) indications were discordant, each meeting conditional indication by EAST and no indication by WTA. All patients that survived to the operating room (OR), ICU admission, and overall met EAST criteria. Conclusion All RTs performed at our Level 1 trauma center met indications provided by EAST criteria. WTA guidelines were not applicable in nine salvaging encounters due to the protracted duration of CPR before proceeding to RT. Furthermore, more patients that survived to OR and ICU admission met EAST guidelines suggesting an improved potential for patient survivability. As increased data is derived, management guidelines will likely be re-established for optimized patient outcomes.

Can absence of cardiac activity on point-of-care echocardiography predict death in out-of-hospital cardiac arrest? A systematic review and meta-analysis

AIM

The purpose of this systematic review and meta-analysis was to evaluate the accuracy of the absence of cardiac motion on point-of-care echocardiography (PCE) in predicting termination of resuscitation (TOR), short-term death (STD), and long-term death (LTD), in adult patients with cardiac arrest of all etiologies in out-of-hospital and emergency department setting.

METHODS

A systematic review and meta-analysis was conducted based on PRISMA guidelines. A literature search in Medline, EMBASE, Cochrane, WHO registry, and ClinicalTrials.gov was performed from inspection to August 2022. Risk of bias was evaluated using QUADAS-2 tool. Meta-analysis was divided into medical cardiac arrest (MCA) and traumatic cardiac arrest (TCA). Sensitivity and specificity were calculated using bivariate random-effects, and heterogeneity was analyzed using I2 statistic.

RESULTS

A total of 27 studies (3657 patients) were included in systematic review. There was a substantial variation in methodologies across the studies, with notable difference in inclusion criteria, PCE timing, and cardiac activity definition. In MCA (15 studies, 2239 patients), the absence of cardiac activity on PCE had a sensitivity of 72% [95% CI 62-80%] and specificity of 80% [95% CI 58-92%] to predict LTD. Although the low numbers of studies in TCA preluded meta-analysis, all patients who lacked cardiac activity on PCE eventually died.

CONCLUSIONS

The absence of cardiac motion on PCE for MCA predicts higher likelihood of death but does not have sufficient accuracy to be used as a stand-alone tool to terminate resuscitation. In TCA, the absence of cardiac activity is associated with 100% mortality rate, but low number of patients requires further studies to validate this finding. Future work would benefit from a standardized protocol for PCE timing and agreement on cardiac activity definition.

POCUS literature primer: key papers on POCUS in cardiac arrest and shock

OBJECTIVE

The objective of this study is to identify the top five most influential papers published on the use of point-of-care ultrasound (POCUS) in cardiac arrest and the top five most influential papers on the use of POCUS in shock in adult patients.

METHODS

An expert panel of 14 members was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. The members of the panel are ultrasound fellowship trained or equivalent, are engaged in POCUS research, and are leaders in POCUS locally and nationally in Canada. A modified Delphi process was used, consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for the use of POCUS in cardiac arrest and shock.

RESULTS

The panel identified 39 relevant papers on POCUS in cardiac arrest and 42 relevant papers on POCUS in shock. All panel members participated in all three rounds of the modified Delphi process, and we ultimately identified the top five most influential papers on POCUS in cardiac arrest and also on POCUS in shock. Studies include descriptions and analysis of safe POCUS protocols that add value from a diagnostic and prognostic perspective in both populations during resuscitation.

CONCLUSION

We have developed a reading list of the top five influential papers on the use of POCUS in cardiac arrest and shock to better inform residents, fellows, clinicians, and researchers on integrating and studying POCUS in a more evidence-based manner.

The Impact of Out-of-Hospital Time and Prehospital Intubation on Return of Spontaneous Circulation following Resuscitative Thoracotomy in Traumatic Cardiac Arrest

INTRODUCTION

Resuscitative thoracotomy (RT) is a critical procedure performed in certain trauma patients in extremis, with extremely low survival rates. Currently, there is a paucity of data pertaining to prehospital variables and their predictive role in survival outcomes in traumatic cardiac arrest (TCA) patients requiring RT. The aim of the study was to determine the impact of prehospital intubation and out-of-hospital time (OOHT) on return of spontaneous circulation (ROSC) and survival in TCA requiring RT.

METHODS

This was a retrospective cohort study of trauma patients presenting to two level-1 trauma centers, St. Michael's Hospital and Sunnybrook Health Sciences Center, in Toronto, Canada (January 1, 2005-December 31, 2020). Our exposures of interest were any prehospital intubation attempt and OOHT. Primary and secondary outcome measures were ROSC post-RT and survival to hospital discharge, respectively, and data analysis was performed using univariate logistic regression.

RESULTS

A total of 195 patients were included, of which 86% were male, and the mean age was 33 years. ROSC and survival to hospital discharge were achieved in 30% and 5% of patients, respectively. Of those who survived to discharge, 89% sustained penetrating trauma. There was no association between OOHT and ROSC (OR = 1.00, 95% CI 0.97-1.03) or survival (OR = 0.99, 95% CI 0.94-1.05). The odds of ROSC were lower in penetrating trauma in the presence of any prehospital intubation attempt (OR = 0.39, 95% CI 0.19-0.82, p = 0.01). ROSC was less likely among all patients with no prehospital signs of life (SOL) compared to those who had prehospital SOL (OR = 0.30, 95% CI 0.13-0.69, p < 0.01).

CONCLUSIONS

There was a significant association between prehospital intubation and lower likelihoods of ROSC in the penetrating TCA population requiring RT, as well as with the absence of prehospital SOL in all patients. OOHT did not appear to significantly impact ROSC or survival.

Predicting Futility in Severely Injured Patients: Using Arrival Lab Values and Physiology to Support Evidence-Based Resource Stewardship

BACKGROUND

The recent pandemic exposed a largely unrecognized threat to medical resources, including daily available blood products. Some of the most severely injured patients who arrive in extremis consume tremendous resources yet succumb shortly after arrival. We sought to identify cut points available early in the patient's resuscitation that predicted 100% mortality.

STUDY DESIGN

Cut points were developed from a previously collected data set of all level 1 trauma patients admitted January 2010 to December 2016. Objective values available on or shortly after arrival were evaluated. Once generated, we then validated these variables against (1) a prospective data set November 2017 to October 2021 of severely injured patients and (2) a multicenter, randomized trial of hemorrhagic shock patients. Analyses were conducted using STATA 17.0 (College Station, TX), generating positive predictive value (PPV), negative predictive value, sensitivity, and specificity.

RESULTS

The development data set consisted of 9,509 patients (17% mortality), with 2,137 (24%) and 680 (24%) in the two validation data sets. Several combinations of arrival vitals and labs had 100% PPV. Patients undergoing CPR in the field or on arrival (with subsequent return of spontaneous circulation) required lower fibrinolysis LY-30 (30%) than those with systolic blood pressures of ≤50 (30 to 50%), ≤70 (80 to 90%), and ≤90 mmHg (90%). Using a combination of these validated variables, the Suspension of Transfusions and Other Procedures (STOP) criteria were developed, with each element predicting 100% mortality, allowing physicians to cease further resuscitative efforts.

CONCLUSIONS

The use of evidence-based STOP criteria provides cut points of futility to help guide early decisions for discontinuing aggressive treatment of severely injured patients arriving in extremis.

Predictors of survival in trauma patients requiring resuscitative thoracotomy: A scoping review

Introduction

Resuscitative thoracotomy (RT) is an emergent procedure to gain access to the thoracic cavity to control hemorrhage and other life-threatening injuries. Data predicting survival is variable. This review aims to highlight key predictors of survival and mortality following RT.

Methods

The EMBASE database was searched using the following terms: [exp. Thoracotomy] AND [Trauma.mp] AND [exp. Survival OR exp. Mortality]. The search was limited to full-text articles in the English language and publications released up to February 27, 2022. Reference lists of included articles were reviewed to identify other studies meeting inclusion criteria.

Results

Thirty-seven studies were included. Seventy-six outcome predictors were identified. Prehospital outcome predictors included prehospital vital signs, police transport, cardiopulmonary resuscitation, application of a cervical spine collar, and the number of total prehospital procedures performed. In-hospital variables associated with survival included traumatic cardiac arrest (TCA) in the emergency department (ED), initial ED vital signs and cardiac rhythm, Shock Index Pediatric Age-Adjusted score, location of RT, duration of RT, Focused Assessment with Sonography in Trauma findings, amount of blood products, and amount of administered fluids.

Conclusions

Our study highlights the disparity of data regarding prehospital outcome predictors for trauma patients requiring RT. Most studies focus on injury-specific and in-hospital variables and do not explicitly look at the TCA population. Further work is needed to better define specific variables implicated in enhanced survival across different care settings and to inform management guidelines within these clinical areas.

Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden

BACKGROUND

Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy.

METHODS

Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors.

RESULTS

Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min.

CONCLUSION

Survival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines.

Point of Care Ultrasound Literature Primer: Key Papers on Focused Assessment With Sonography in Trauma (FAST) and Extended FAST

Objective

The objective of this study is to identify the top five most influential papers published on focused assessment with sonography in trauma (FAST) and the top five most influential papers on the extended FAST (E-FAST) in adult patients.

Methods

An expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. These experts are ultrasound fellowship-trained or equivalent, are involved with point-of-care ultrasound (POCUS) research and scholarship, and are leaders in both the POCUS program at their local site and within the national Canadian POCUS community. This 14-member expert group used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for FAST and E-FAST.

Results

The expert panel identified 56 relevant papers on FAST and 40 relevant papers on E-FAST. After completing all three rounds of the modified Delphi process, the authors identified the top five most influential papers on FAST and the top five most influential papers on E-FAST.

Conclusion

We have developed a reading list of the top five influential papers for FAST and E-FAST that will benefit residents, fellows, and clinicians who are interested in using POCUS in an evidence-informed manner.

Characterization of cerebral blood flow during open cardiac massage in swine: Effect of volume status

Introduction: Patients in cardiac arrest treated with resuscitative thoracotomy and open cardiac massage (OCM) have high rates of mortality with poor neurological outcomes. The aim of this study is to quantitate cerebral perfusion during OCM using computed tomography perfusion (CTP) imaging in a swine model of normo- and hypovolemia.

Methods: Anesthetized swine underwent instrumentation with right atrial and aortic pressure catheters. A catheter placed in the ascending aorta was used to administer iodinated contrast and CTP imaging acquired. Cerebral blood flow (CBF; ml/100 g of brain) and time to peak (TTP; s) were measured. Animals were then euthanized by exsanguination (hypovolemic group) or potassium chloride injection (normovolemic group) and subjected to a clamshell thoracotomy, aortic cross clamping, OCM, and repeated CTP. Data pertaining to peak coronary perfusion pressure (pCoPP; mmHg) were collected and % CoPP > 15 mmHg (% CoPP; s) calculated post hoc.

Results: Normovolemic animals (n = 5) achieved superior pCoPP compared to the hypovolemic animals (n = 5) pCoPP (39.3 vs. 12.3, p < 0.001) and % CoPP (14.5 ± 1.9 vs. 30.9 ± 6.5, p < 0.001). CTP acquisition was successful and TTP elongated from spontaneous circulation, normovolemia to hypovolemia (5.7 vs. 10.8 vs. 14.8, p = 0.01). CBF during OCM was similar between hypovolemic and normovolemic groups (7.5 ± 8.1 vs. 4.9 ± 6.0, p = 0.73) which was significantly lower than baseline values (51.9 ± 12.1, p < 0.001).

Conclusion: OCM in normovolemia generates superior coronary hemodynamics compared to hypovolemia. Despite this, neither generates adequate CBF as measured by CTP, compared to baseline. To improve the rate of neurologically intact survivors, novel resuscitative techniques need to be investigated that specifically target cerebral perfusion as existing techniques are inadequate.

Application of Focused Assessment with Sonography for Trauma in the Intensive Care Unit

The Extended-Focused Assessment with Sonography for Trauma (E-FAST) allows clinicians to rapidly diagnose traumatic thoracoabdominal injuries at the bedside without ionizing radiation. It has high specificity and is extremely useful as an initial test to rule in dangerous diagnoses such as hemoperitoneum, pericardial effusion, hemothorax, and pneumothorax. Its moderate sensitivity means that it should not be used alone as a tool to rule out dangerous thoracoabdominal injuries. In patients with a concerning mechanism or presentation, additional imaging should be obtained despite a negative FAST examination.

Whole Blood Selective Aortic Arch Perfusion for Exsanguination Cardiac Arrest: Assessing Myocardial Tolerance to the Duration of Cardiac Arrest

INTRODUCTION

Selective aortic arch perfusion (SAAP) is an endovascular technique that consists of aortic occlusion with perfusion of the coronary and cerebral circulation. It been shown to facilitate return of spontaneous circulation (ROSC) after exanguination cardiac arrest (ECA), but it is not known how long arrest may last before the myocardium can no longer be durably recovered. The aim of this study is to assess the myocardial tolerance to exsanguination cardiac arrest before successful ROSC with SAAP.

METHODS

Male adult swine (n = 24) were anesthetized, instrumented, and hemorrhaged to arrest. Animals were randomized into three groups: 5, 10, and 15 min of cardiac arrest before resuscitation with SAAP. Following ROSC, animals were observed for 60 min in a critical care environment. Primary outcomes were ROSC, and survival at 1-h post-ROSC.

RESULTS

Shorter cardiac arrest time was associated with higher ROSC rate and better 1-h survival. ROSC was obtained for 100% (8/8) of the 5-min ECA group, 75% (6/8) of the 10-min group, 43% (3/7) of the 15-min group (P = 0.04). One-hour post-ROSC survival was 75%, 50%, and 14% in 5-, 10-, and 15-min groups, respectively (P = 0.02). One-hour survivors in the 5-min group required less norepinephrine (1.31 mg ± 0.83 mg) compared with 10-SAAP (0.76 mg ± 0.24 mg), P = 0.008.

CONCLUSION

Whole blood SAAP can accomplish ROSC at high rates even after 10 min of unsupported cardiac arrest secondary to hemorrhage, with some viability beyond to 15 min. This is promising as a tool for ECA, but requires additional optimization and clinical trials.Animal Use Protocol, IACUC: 0919015.

No Resuscitative Thoracotomy? When to Stop Chest Compressions After Prehospital Traumatic Cardiac Arrest

INTRODUCTION

Although indications and outcomes for trauma patients who require resuscitative thoracotomies are well studied, little is known about how prehospital chest compressions support survival in patients who do not meet criteria for subsequent resuscitative thoracotomy.

METHODS

Data from a single institutional retrospective review of trauma patients who required prehospital chest compressions from 1/2015 to 12/2020 were collected. Patients who underwent compressions only were compared to those who underwent subsequent resuscitative thoracotomy. The primary outcome was in-hospital mortality.

RESULTS

Fifty-two patients were identified, 22 of whom underwent compressions only and 30 of whom went on to undergo thoracotomy. Patients who underwent compressions only were more likely to be female (36% vs 10%, P = .04), older (mean 46 vs 35 years, P = .04), and to experience blunt trauma (78% vs 43%, P = .01). Injury severity score was similar between the cohorts (mean 18 vs 28, P = .11). One patient in the compressions only cohort had a REBOA placed compared to two in the thoracotomy cohort (1.9% vs 3.67%, P > .99). Return of spontaneous circulation (ROSC) was achieved in 17% of the compressions only cohort compared to 45% of the thoracotomy cohort (P = .03). In-hospital mortality in the compressions only cohort was 100%, whereas in-hospital mortality in the thoracotomy cohort was 94% (P = .50), with a mean of zero survival days in both groups (P = .33).

CONCLUSION

Prehospital chest compressions without thoracotomy were uniformly fatal, even if transient ROSC was obtained. Our findings support termination of chest compressions for those trauma patients who do not meet criteria for resuscitative thoracotomy.

The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA

Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is used for aortic control in hemorrhagic shock despite little quantification of its mechanism of resuscitation or cardiac injury. The goal of this study was to use pressure-volume (PV) loop analysis and direct coronary blood flow measurements to describe the physiologic changes associated with the clinical use of REBOA. Methods: Swine underwent surgical and vascular access to measure left ventricular PV loops and left coronary flow in hemorrhagic shock and subsequent placement of occlusive REBOA, partial REBOA, and no REBOA. PV loop characteristics and coronary flow are compared graphically with PV loops and coronary waveforms, and quantitatively with measures of the end systolic and end pressure volume relationship, and coronary flow parameters, with accounting for multiple comparisons. Results: Hemorrhagic shock was induced in five male swine (mean 53.6 ± 3.6 kg) as demonstrated by reduction of stroke work (baseline: 3.1 vs. shock: 1.2 L*mmHg, p < 0.01) and end systolic pressure (ESP; 109.8 vs. 59.6 mmHg, p < 0.01). ESP increased with full REBOA (178.4 mmHg; p < 0.01), but only moderately with partial REBOA (103.0 mmHg, p < 0.01 compared to shock). End systolic elastance was augmented from baseline to shock (1.01 vs. 0.39 ml/mmHg, p < 0.01) as well as shock compared to REBOA (4.50 ml/mmHg, p < 0.01) and partial REBOA (3.22 ml/mmHg, p = 0.01). Percent time in antegrade coronary flow decreased in shock (94%-71.8%, p < 0.01) but was rescued with REBOA. Peak flow increased with REBOA (271 vs. shock: 93 ml/min, p < 0.01) as did total flow (peak: 2136, baseline: 424 ml/min, p < 0.01). REBOA did not augment the end diastolic pressure volume relationship. Conclusion: REBOA increases afterload to facilitate resuscitation, but the penalty is supraphysiologic coronary flows and imposed increase in LV contractility to maintain cardiac output. Partial REBOA balances the increased afterload with improved aortic system compliance to prevent injury.

Performance of Focused Assessment with Sonography for Trauma Following Resuscitative Thoracotomy for Traumatic Cardiac Arrest

BACKGROUND

In patients undergoing resuscitative thoracotomy (RT) for traumatic cardiac arrest, focused assessment with sonography for trauma (FAST) is often used to look for intraperitoneal fluid. These findings can help determine whether abdominal exploration is warranted once return of spontaneous circulation is achieved; however, the diagnostic accuracy of FAST in this clinical scenario has yet to be evaluated. The purpose of this study was to assess the performance of FAST in identifying intra-abdominal hemorrhage following RT.

METHODS

We performed a 3-year retrospective study at a high-volume level 1 trauma center from 2014 to 2016. We included patients who underwent RT in the Emergency Department. All FAST examinations were performed by non-radiologists. Operative findings, computed tomography reports, diagnostic peritoneal aspirate (DPA) results, and autopsy findings were used as reference standards to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the FAST.

RESULTS

A total of 158 patients met our inclusion criteria. The median age was 35 years (interquartile range [IQR]: 23-53), 86.1% were male, and 60.1% sustained blunt trauma. Most patients suffered severe injuries with a median injury severity score of 27 (IQR: 18-38). The sensitivity, specificity, PPV, NPV, and accuracy of FAST for identifying intra-abdominal hemorrhage were 66.0%, 84.8%, 68.6%, 83.2%, and 78.5%, respectively. Among the 107 patients with a negative FAST, 22 (20.6%) underwent DPA, which was positive in 5 patients.

CONCLUSIONS

FAST can be utilized in the diagnostic workup of trauma patients after RT. In patients with a positive FAST, exploratory laparotomy is warranted, whereas other diagnostic adjuncts such as DPA or mandatory abdominal exploration may be considered in patients with a negative FAST.

Is point-of-care ultrasound a reliable predictor of outcome during traumatic cardiac arrest? A systematic review and meta-analysis from the SHoC investigators

AIM

Point-of-care ultrasound (POCUS) has been shown to assist in predicting outcomes in cardiac arrest. We evaluated the test characteristics of POCUS in predicting poor outcomes: failure of return of spontaneous circulation (ROSC), survival to hospital admission (SHA), survival to hospital discharge (SHD) and neurologically intact survival to hospital discharge (NISHD) in adult and paediatric patients with blunt and penetrating traumatic cardiac arrest (TCA) in out-of-hospital or emergency department settings.

METHODS

We conducted a systematic review and meta-analysis using the PRISMA guidelines. We searched Clinicaltrials.gov, CINAHL, Cochrane library, EMBASE, Medline and the World Health Organization-International Clinical Trials Registry from 1974 to November 9, 2020. Risk of bias was assessed using QUADAS-2 tool. We used a random-effects meta-analysis model with 95% confidence intervals with I² statistics for heterogeneity.

RESULTS

We included 8 studies involving 710 cases of TCA. For all blunt and penetrating TCA patients who failed to achieve ROSC, the specificity (proportion of patients with cardiac activity on POCUS who achieved ROSC) was 98% (95% CI 0.13 to 1.0). The sensitivity (proportion of patients with cardiac standstill on POCUS who failed to achieve ROSC) was 91% (95% CI 0.67 to 0.98). No patient with cardiac standstill survived. Substantial level of heterogeneity was noted.

CONCLUSIONS

Patients in TCA without cardiac activity on POCUS have a high likelihood of death and negligible chance of SHD. The numbers of patients included in published studies remains too low for practice recommendations for termination of resuscitation based solely upon the absence of cardiac activity on POCUS.

Outcomes after Prehospital Traumatic Cardiac Arrest in the Netherlands: a Retrospective Cohort Study

BACKGROUND

Traumatic cardiac arrest (TCA) is a severe and life-threatening situation that mandates urgent action. Outcomes after on-scene treatment of TCA in the Netherlands are currently unknown. The aim of the current study was to investigate the rate of survival to discharge in patients who suffered from traumatic cardiac arrest and who were subsequently treated on-scene by the Dutch Helicopter Emergency Medical Services (HEMS).

METHODS

A retrospective cohort study was performed including patients ≥ 18 years with TCA for which the Dutch HEMS were dispatched between January 1^st 2014 and December 31^st 2018. Patients with TCA after hanging, submersion, conflagration or electrocution were excluded. The primary outcome measure was survival to discharge after prehospital TCA. Secondary outcome measures were return of spontaneous circulation (ROSC) on-scene and neurological status at hospital discharge.

RESULTS

Nine-hundred-fifteen patients with confirmed TCA were included. ROSC was achieved on-scene in 261 patients (28.5%). Thirty-six (3.9%) patients survived to hospital discharge of which 17 (47.2%) had a good neurological outcome. Age < 70 years (0.7% vs. 5.2%; p=0.041) and a shockable rhythm on first ECG (OR 0.65 95%CI 0.02-0.28; p<0.001) were associated with increased odds of survival.

CONCLUSION

Neurologic intact survival is possible after prehospital traumatic cardiac arrest. Younger patients and patients with a shockable ECG rhythm have higher survival rates after TCA.

LEVEL OF EVIDENCE

prognostic study, level III.

Penetrating injury to the cardiac box

BACKGROUND

A penetrating injury to the "cardiac box" is thought to be predictive of an injury to the heart; however, there is very little evidence available to support this association. This study aims to evaluate the relationship between penetrating trauma to the cardiac box and a clinically significant injury.

METHODS

All patients presenting to a Level I trauma center from January 2009 to June 2015 who sustained a penetrating injury isolated to the thorax were retrospectively identified. Patients were categorized according to the location of injury: within or outside the historical cardiac box. Patients with concurrent injuries both inside and outside the cardiac box were excluded. Clinical demographics, injuries, procedures, and outcomes were compared.

RESULTS

During this 7-year period, 330 patients (92% male; median age, 28 years) sustained penetrating injuries isolated to the thorax: 138 (42%) within the cardiac box and 192 (58%) outside the cardiac box. By mechanism, 105 (76%) were stab wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125 (65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or sternotomy (35/138 [25.4%] vs. 15/192 [7.8%], p < 0.001) and the incidence of cardiac injury (18/138 [13%] vs. 5/192 [2.6%], p < 0.001) were significantly higher in patients with penetrating trauma within the cardiac box. This was, however, dependent on mechanism with SW demonstrating a higher incidence of cardiac injury (15/105 [14.3%] vs. 3/125 [2.4%], p = 0.001) and GSW showing no significant difference (3/33 [9.1%] vs. 2/67 [3%], p = 0.328]. There was no difference in overall mortality (9/138 [6.5%] vs. 6/192 [3.1%], p = 0.144).

CONCLUSION

The role of the cardiac box in the clinical evaluation of a patient with a penetrating injury to the thorax has remained unclear. In this analysis, mechanism is important. Stab wounds to the cardiac box were associated with a higher risk of cardiac injury. However, for GSW, injury to the cardiac box was not associated with a higher incidence of injury. The diagnostic interaction between clinical examination and ultrasound, for the diagnosis of clinically significant cardiac injuries, warrants further investigation.

LEVEL OF EVIDENCE

Prognostic study, Level IV, Therapeutic V.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review

BACKGROUND

Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries.

METHODS

Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints.

RESULTS

A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT.

CONCLUSIONS

EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

Improving out-of-hospital notification in traumatic cardiac arrests with novel usage of smartphone application

INTRODUCTION

Timely out-of-hospital notifications in patients with traumatic cardiac arrest are associated improvements in mortality. Details surrounding these events are often limited, and decisions to perform advanced resuscitative procedures must be made based on limited data. This study evaluated the ability of a mobile application (app) called Citizen (sp0n Inc., New York, NY) to address these issues by providing a novel, secondary source of out-of-hospital information in traumatic cardiac arrest. Citizen sends notifications to mobile devices in response to nearby detected public safety events, and we sought to evaluate its utility in prenotification for traumatic cardiac arrest.

METHODS

This was a retrospective observational study. Patients ≥ 15 years of age with traumatic cardiac arrest attributed to penetrating trauma were included. The 2 coprimary outcomes observed were the time difference between the app notification and emergency medical services notification, and the app's success rate in generating a notification for each patient in traumatic cardiac arrest.

RESULTS

From February 2, 2019 to October 10, 2019, there were 43 patients who met the criteria for this study. On average, the Citizen app notification arrived 12.9 minutes before emergency medical services radio notification (95% confidence interval, 9.2-16.6; P < 0.001). Citizen generated a notification for 36 of 43 patients (84%).

CONCLUSION

The Citizen app generates earlier notifications in traumatic cardiac arrest compared with standard radio communications. It also provides a previously unavailable secondary source of information for making rapid resuscitative decisions upon the arrival of the arresting patient to the emergency department. Further research is needed to determine how to optimally integrate the app into existing trauma systems.

Pre-arrest and intra-arrest prognostic factors associated with survival following traumatic out-of-hospital cardiac arrest - A systematic review and meta-analysis

AIM

To summarize the prognostic associations of pre- and intra-arrest factors with return of spontaneous circulation (ROSC) and survival (in-hospital or 30 days) after traumatic out-of-hospital cardiac arrest.

METHODS

We conducted this review in accordance with the PRISMA and CHARMS guidelines. We searched Medline, Pubmed, Embase, Scopus, Web of Science and the Cochrane Database of Systematic Reviews from inception through December 1st, 2019. We included English language studies evaluating pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA. Risk of bias was assessed using the QUIPS tool. We pooled unadjusted odds ratios using random-effects models and presented adjusted odds ratios with 95% confidence intervals. We used the GRADE method to describe certainty.

RESULTS

We included 53 studies involving 37,528 patients. The most important predictors of survival were presence of cardiac motion on ultrasound (odds ratio 33.91, 1.87-613.42, low certainty) or a shockable initial cardiac rhythm (odds ratio 7.29, 5.09-10.44, moderate certainty), based on pooled unadjusted analyses. Importantly, mechanism of injury was not associated with either ROSC (odds ratio 0.97, 0.51-1.85, very low certainty) or survival (odds ratio 1.40, 0.79-2.48, very low certainty).

CONCLUSION

This review provides very low to moderate certainty evidence that pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA predict ROSC and survival. This evidence is primarily based on unadjusted data. Further well-designed studies with larger cohorts are warranted to test the adjusted prognostic ability of pre- and intra-arrest factors and guide therapeutic decision-making.

Emergency department resuscitative thoracotomy at an adult major trauma centre: Outcomes following a training programme with standardised indications

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.

Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?

BACKGROUND

Generally considered a sign of life, PEA is the most common arrhythmia encountered following pre-hospital traumatic cardiac arrest. Some recommend cardiac ultrasound (CUS) to determine cardiac wall motion (CWM) prior to terminating resuscitation efforts. This purpose of this study was to evaluate the outcomes of patients with traumatic cardiac arrest presenting with PEA, with and without CWM.

METHODS

Trauma patients who underwent pre-hospital CPR were identified from the registries of two level-1 trauma centers. Pre-hospital management by emergency medical transport services was guided by advanced life support protocols. The on-duty trauma surgeon directed the resuscitations and performed or supervised CUS and determined CWM.

RESULTS

Among 277 patients who underwent pre-hospital CPR, 110 patients had PEA on arrival to ED. 69 (62.7%) were injured by blunt mechanisms. Median CPR duration was 20.0 and 8.0 min for pre-hospital and ED, respectively. Sixty-three patients (22.7%) underwent resuscitative thoracotomy. One hundred seventy-two patients (62.1%) received CUS and of these 32 (18.6%) had CWM. CWM was significantly associated with survival to hospital admission (21.9% vs. 1.4%; P < 0.001); however, no patient with CUS survived to hospital discharge. Overall, only one patient with PEA on arrival survived to discharge.

CONCLUSION

Following pre-hospital traumatic cardiac arrest, PEA on arrival portends death. Although CWM is associated with survival to admission, it is not associated with meaningful survival. Heroic resuscitative measures may be unwarranted for PEA following pre-hospital traumatic arrest, regardless of CWM.

Improving survival after an emergency resuscitative thoracotomy: a 5-year review of the Trauma Quality Improvement Program

BACKGROUND

Advancement in trauma care has led to the evolution of emergency resuscitative thoracotomy (ERT) for the revival of trauma patients. We now have more precise understanding of selecting suitable patients for achieving optimal outcomes. The aim of our study was to analyze the utilization and survival trends during the past 5 years, as well as factors that influence survival after ERT.

METHODS

A 5-year (2010-2014) analysis of all trauma patients ≥18 years who underwent ERT in the American College of Surgeons Trauma Quality Improvement Program. Outcome measures were utilization rates and survival trends after ERT during the 5-year period. Regression analysis was performed.

RESULTS

2229 patients underwent ERT, mean age was 37±17 years, 81% were male. Overall 56% patients had penetrating mechanism, location of major injury was thorax in 48, and 71% had signs of life (SOL) on arrival. The overall survival rate was 9.6%. From 2010-2014 ERT utilization has decreased from 331/100 000 to 243/100 000 trauma admissions (p=0.002) and the survival rate has improved from 7.9% to 11.3% (p<0.001). On regression, the independent predictors of survival were penetrating mechanism, age<60 years, SOL on arrival, no prehospital CPR and ISS. No patient aged >60 years with a blunt mechanism of injury (MOI) survived, and there were no survivors above the age of 70 years, regardless of injury mechanism.

DISCUSSION

Utilization of ERT has been decreased during the study period along with improved survival rates. The results of our study demonstrate that performing ERT on patients aged >60 years with a blunt MOI or on any patient aged ≥70 years, regardless of MOI, is futile and should be avoided.

LEVEL OF EVIDENCE

Level III, prognostic studies.

ABCDE of prehospital ultrasonography: a narrative review

Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.

Emergency clamshell thoracotomy in blunt trauma resuscitation: Shelling the paradigm-2 cases and review of the literature

Clamshell thoracotomy (CST) may be indicated and life-saving in carefully selected cases of blunt trauma. As such, the current clinical stance of general contraindication of CST in blunt trauma should be reviewed and criteria developed to accommodate select cases, considering the diversity of injuries resulting from blunt trauma.

Point-of-Care Ultrasound in Trauma

The use of point-of-care ultrasound in trauma is widespread. Focused Assessment with Sonography for Trauma examination is a prototypical bedside examination used by the treating provider to quickly determine need for intervention and appropriate patient disposition. The role of bedside ultrasound in trauma, however, has expanded beyond the Focused Assessment with Sonography for Trauma examination. Advancements in diagnostics include contrast-enhanced ultrasound, thoracic, and musculoskeletal applications. Ultrasound is also an important tool for trauma providers for procedural guidance including vascular access and regional anesthesia. Its portability, affordability, and versatility have made ultrasound an invaluable tool in trauma management in resource-limited settings. In this review, we discuss these applications and the supporting evidence for point-of-care ultrasound in trauma.

Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma?

PURPOSE

The indications for pre-hospital resuscitative thoracotomy (PHRT) remain undefined. The aim of this paper is to explore the variation in practice for PHRT in the UK, and review the published literature.

METHODS

MEDLINE and PUBMED search engines were used to identify all relevant articles and 22 UK Air Ambulance Services were sent an electronic questionnaire to assess their PHRT practice.

RESULTS

Four European publications report PHRT survival rates of 9.7, 18.3, 10.3 and 3.0% in 31, 71, 39 and 33 patients, respectively. All patients sustained penetrating chest injury. Six case reports also detail survivors of PHRT, again all had sustained penetrating thoracic injury. One Japanese paper presents 34 cases of PHRT following blunt trauma, of which 26.4% survived to the intensive therapy unit but none survived to discharge. A UK population reports a single survivor of PHRT following blunt trauma but the case details remain unpublished. Ten (45%) air ambulance services responded, each service reported different indications for PHRT. All perform PHRT for penetrating chest trauma, however, length of allowed pre-procedure down time varied, ranging from 10 to 20 min. Seventy percent perform PHRT for blunt traumatic cardiac arrest, a procedure which is likely to require aggressive concurrent circulatory support, despite this only 5/10 services carry pre-hospital blood products.

CONCLUSIONS

Current indications for PHRT vary amongst different geographical locations, across the UK, and worldwide. Survivors are likely to have sustained penetrating chest injury with short down time. There is only one published survivor of PHRT following blunt trauma, despite this, PHRT is still being performed in the UK for this indication.

Critical Decisions in the Management of Thoracic Trauma

Traumatic injuries to the thorax are common after both blunt and penetrating trauma. Emergency medicine physicians must be able to manage the initial resuscitation and diagnostic workup of these patients. This involves familiarity with a range of radiologic investigations and invasive bedside procedures, including resuscitative thoracotomy. This knowledge is critical to allow for rapid decision making when life-threatening injuries are encountered. This article explores the initial resuscitation and assessment of patients after thoracic trauma, discusses available imaging modalities, reviews frequently performed procedures, and provides an overview of the indications for operative intervention, while emphasizing the critical decision making throughout.

Reanimating Patients After Traumatic Cardiac Arrest: A Practical Approach Informed by Best Evidence

Resuscitation of traumatic cardiac arrest is typically considered futile. Recent evidence suggests that traumatic cardiac arrest is survivable. In this article key principles in managing traumatic cardiac arrest are discussed, including the importance of rapidly seeking prognostic information, such as signs of life and point-of-care ultrasonography evidence of cardiac contractility, to inform the decision to proceed with resuscitative efforts. In addition, a rationale for deprioritizing chest compressions, steps to quickly reverse dysfunctional ventilation, techniques for temporary control of hemorrhage, and the importance of blood resuscitation are discussed. The best available evidence and the authors' collective experience inform this article.

Retrospective study of thoracotomy performed in a French level 1-trauma center

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.

ALiEM Blog and Podcast Watch: Procedures in Emergency Medicine

Introduction

The WestJEM Blog and Podcast Watch presents high-quality, open-access educational blogs and podcasts in emergency medicine (EM) based on the ongoing Academic Life in EM (ALiEM) Approved Instructional Resources (AIR) and AIR-Professional series. Both series critically appraise resources using an objective scoring rubric. This installment of the Blog and Podcast Watch highlights the topic of procedure emergencies from the AIR Series.

Methods

The AIR Series is a continuously building curriculum that follows the Council of Emergency Medicine Residency Directors’ (CORD) annual testing schedule. For each module, relevant content is collected from the top 50 Social Media Index sites published within the previous 12 months, and scored by eight AIR board members using five equally weighted measurement outcomes: Best Evidence in Emergency Medicine (BEEM) score, accuracy, educational utility, evidence based, and references. Resources scoring ≥30 out of 35 available points receive an AIR label. Resources scoring 27–29 receive an “honorable mention” label if the executive board agrees that the post is accurate and educationally valuable.

Results

A total of 85 blog posts and podcasts were evaluated in June 2016. This report summarizes key educational pearls from the three AIR posts and the 10 Honorable Mentions.

Conclusion

The WestJEM Blog and Podcast Watch series is based on the AIR and AIR-Pro series, which attempts to identify high-quality educational content on open-access blogs and podcasts. This series provides an expert-based, post-publication curation of educational social media content for EM clinicians, with this installment focusing on procedure emergencies within the AIR series.

Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma

INTRODUCTION

Emergency department thoracotomy is an established procedure for cardiac arrest in patients suffering from penetrating thoracic trauma and yields relatively high survival rates (up to 21%) in patients with cardiac tamponade. To minimize the delay between arrest and thoracotomy, some have advocated thoracotomy on the accident scene. The aim of this study was to determine the proportion of patients with return of spontaneous circulation and subsequent survival after out of hospital thoracotomy in the Netherlands.

METHODS

A retrospective analysis of data collected on all out of hospital thoracotomies performed in the Netherlands after penetrating trauma between April 1st, 2011 and September 30th, 2016 was performed. Data on patient characteristics, trauma mechanism and outcome were collected and analyzed. Primary outcome measure was return of spontaneous circulation after the intervention. Survival to hospital discharge was the secondary outcome variable.

RESULTS

Thirty-three prehospital emergency thoracotomies were performed. Ten patients (30%) had gunshot wounds and 23 patients (70%) had stab wounds. Nine patients (27%) had return of spontaneous circulation and were presented to the hospital. Of these, one patient survived until discharge without neurological damage. Five died in the emergency department or operating room and three died in ICU.

CONCLUSION

Return of spontaneous circulation after out of hospital thoracotomy for cardiac arrest due to penetrating thoracic injury is achievable, but a substantial number of patients die during the in hospital resuscitation phase. However, neurologic intact survival can be achieved.

Focused Real-Time Ultrasonography for Nephrologists

We propose that renal consults are enhanced by incorporating a nephrology-focused ultrasound protocol including ultrasound evaluation of cardiac contractility, the presence or absence of pericardial effusion, inferior vena cava size and collapsibility to guide volume management, bladder volume to assess for obstruction or retention, and kidney size and structure to potentially gauge chronicity of renal disease or identify other structural abnormalities. The benefits of immediate and ongoing assessment of cardiac function and intravascular volume status (prerenal), possible urinary obstruction or retention (postrenal), and potential etiologies of acute kidney injury or chronic kidney disease far outweigh the limitations of bedside ultrasonography performed by nephrologists. The alternative is reliance on formal ultrasonography, which creates a disconnect between those who order, perform, and interpret studies, creates delays between when clinical questions are asked and answered, and may increase expense. Ultrasound-enhanced physical examination provides immediate information about our patients, which frequently alters our assessments and management plans.

Resuscitative thoracotomy

Resuscitative thoracotomy is often performed on trauma patients with thoracoabdominal penetrating or blunt injuries arriving in cardiac arrest. The goal of this procedure is to immediately restore cardiac output and to control major hemorrhage within the thorax and abdominal cavity. Only surgeons with experience in the management of cardiac and thoracic injuries should perform this procedure.