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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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Atkins K, Schneider A, Gallaher J, Cairns B, Charles A. Who benefits from resuscitative thoracotomies following penetrating trauma: The patient or the learner? Injury 2023; 54:111033. [PMID: 37716863 PMCID: PMC10591838 DOI: 10.1016/j.injury.2023.111033] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/23/2023] [Accepted: 09/08/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Resuscitative thoracotomy (RT) is a salvage procedure following traumatic cardiac arrest. We aim to evaluate RT trends and outcomes in adults with cardiac arrest following penetrating trauma to determine the effect on mortality in this population. Further, we aim to estimate the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality. METHODS We reviewed the National Trauma Data Bank (2017-2021) for adults (≥16 years old) with penetrating trauma and prehospital cardiac arrest, stratified by the performance of a RT. We performed multivariable logistic regressions to estimate the effect of RT on mortality and the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality. RESULTS 13,115 patients met our inclusion criteria. RT occurred in 12.7% (n = 1,664) of patients. Rates of RT trended up over the study period. Crude mortality was similar in RT and Non-RT patients (95.6% vs. 94.5%, p = 0.07). There was no statistically significant difference in the adjusted odds of mortality based on RT status (OR 0.82, 95%CI 0.56-1.21). University-teaching hospitals had an adjusted odds ratio of 1.68 (95% CI 1.31-2.17) for performing a RT than non-teaching hospitals. There was no difference in the adjusted odds of mortality in patients that underwent RT based on hospital teaching status. CONCLUSION Despite up-trending rates, a resuscitative thoracotomy may not improve mortality in adults with penetrating, traumatic cardiac arrest. University teaching hospitals are nearly twice as likely to perform a RT than non-teaching hospitals, with no subsequent improvement in mortality.
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Affiliation(s)
- Kathryn Atkins
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Andrew Schneider
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, USA.
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Sam ASY, Nawijn F, Benders KEM, Houwert RM, Leenen LPH, Hietbrink F. Outcomes of the resuscitative and emergency thoracotomy at a Dutch level-one trauma center: are there predictive factors for survival? Eur J Trauma Emerg Surg 2022; 48:4877-4887. [PMID: 35713680 DOI: 10.1007/s00068-022-02021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate the 30-day survival rate of resuscitative and emergency thoracotomies in trauma patients. Moreover, factors that positively influence 30-day survival rates were investigated. METHODS A retrospective study of patients (> 16 years), between 2008 and 2020, who underwent a resuscitative or emergency thoracotomy at a level-one trauma center in the Netherlands was conducted. RESULTS Fifty-six patients underwent a resuscitative (n = 45, 80%) or emergency (n = 11, 20%) thoracotomy. The overall 30-day survival rate was 32% (n = 18), which was 23% after blunt trauma and 72% after penetrating trauma, and which was 18% for the resuscitative thoracotomy and 91% for the emergency thoracotomy. The patients who survived had full neurologic recovery. Factors associated with survival were penetrating trauma (p < 0.001), (any) sign of life (SOL) upon presentation to the hospital (p = 0.005), Glasgow Coma Scale (GCS) of 15 (p < 0.001) and a thoracotomy in the operating room (OR) (p = 0.018). Every resuscitative thoracotomy after blunt trauma and pulseless electrical activity (PEA) or asystole in the pre-hospital phase was futile (0 survivors out of 11 patients), of those patients seven (64%) had concomitant severe neuro-trauma. CONCLUSION This study found a 30-day survival rate of 32% for resuscitative and emergency thoracotomies, all with good neurological recovery. Factors associated with survival were related to the trauma mechanism, the thoracotomy indication and response to resuscitation prior to thoracotomy (for instance, if resuscitation enables enough time for safe transport to the operating room, survival chances increase). Resuscitative thoracotomies after blunt trauma in combination with loss of SOL before arrival at the emergency room were in all cases futile, interestingly in nearly all cases due to concomitant neuro-trauma.
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Affiliation(s)
- A S Y Sam
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - K E M Benders
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R M Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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4
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Kristiansen S, Storm B, Dahle D, Domaas Josefsen T, Dybwik K, Nilsen BA, Waage-Nielsen E. Intraosseous fluid resuscitation causes systemic fat emboli in a porcine hemorrhagic shock model. Scand J Trauma Resusc Emerg Med 2021; 29:172. [PMID: 34930433 PMCID: PMC8686379 DOI: 10.1186/s13049-021-00986-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Intraosseous cannulation can be life-saving when intravenous access cannot be readily achieved. However, it has been shown that the procedure may cause fat emboli to the lungs and brain. Fat embolization may cause serious respiratory failure and fat embolism syndrome. We investigated whether intraosseous fluid resuscitation in pigs in hemorrhagic shock caused pulmonary or systemic embolization to the heart, brain, or kidneys and if this was enhanced by open chest conditions. METHODS We induced hemorrhagic shock in anesthetized pigs followed by fluid-resuscitation through bilaterally placed tibial (hind leg) intraosseous cannulas. The fluid-resuscitation was limited to intraosseous or i.v. fluid therapy, and did not involve cardiopulmonary resuscitation or other interventions. A subgroup underwent median sternotomy with pericardiectomy and pleurotomy before hemorrhagic shock was induced. We used invasive hemodynamic and respiratory monitoring including Swan Ganz pulmonary artery catheter and transesophageal echocardiography and obtained biopsies from the lungs, heart, brain, and left kidney postmortem. RESULTS All pigs exposed to intraosseous infusion had pulmonary fat emboli in postmortem biopsies. Additionally, seven of twenty-one pigs had coronary fat emboli. None of the pigs with open chest had fat emboli in postmortem lung, heart, or kidney biopsies. During intraosseous fluid-resuscitation, three pigs developed significant ST-elevations on ECG; all of these animals had coronary fat emboli on postmortem biopsies. CONCLUSIONS Systemic fat embolism occurred in the form of coronary fat emboli in a third of the animals who underwent intraosseous fluid resuscitation. Open chest conditions did not increase the incidence of systemic fat embolization.
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Affiliation(s)
- Steinar Kristiansen
- Surgery and Intensive Care Unit, University Hospital of Northern Norway, Tromsø, Norway.
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway.
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway.
| | - Benjamin Storm
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway
- Research Laboratory, Nordland Hospital Trust, Bodø, Norway
| | - Dalia Dahle
- Faculty of Biosciences and Aquaculture, Nord University, Bodø, Norway
| | | | - Knut Dybwik
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | | | - Erik Waage-Nielsen
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway
- Research Laboratory, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
- Department of Immunology, Oslo University Hospital, University of Oslo, Oslo, Norway
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5
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Panossian VS, Nederpelt CJ, El Hechi MW, Chang DC, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA. Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility. J Surg Res 2020; 255:486-494. [PMID: 32622163 DOI: 10.1016/j.jss.2020.05.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/18/2020] [Accepted: 05/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.
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Affiliation(s)
- Vahe S Panossian
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Charlie J Nederpelt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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6
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Dimitrakakis G, Podila SR, Stefanadi E, Dimitrakaki IA, Kornaszewska M. Pre-hospital clamshell thoracotomy for blunt cardiac trauma. Injury 2020; 51:1934-1935. [PMID: 32540178 DOI: 10.1016/j.injury.2020.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Georgios Dimitrakakis
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom.
| | - Sitaramarao Rao Podila
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Ellie Stefanadi
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
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7
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Schulz-Drost S, Merschin D, Gümbel D, Matthes G, Hennig FF, Ekkernkamp A, Lefering R, Krinner S. Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU ®. Eur J Trauma Emerg Surg 2019; 46:473-485. [PMID: 31520155 DOI: 10.1007/s00068-019-01212-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 08/16/2019] [Indexed: 12/13/2022]
Abstract
AIM OF THE STUDY Emergency department thoracotomy (EDT) may be the last chance for survival in some severe thoracic trauma. This study investigates a representative collective with the aim to compare the findings in Europe to the international experience. Moreover, the influence of different levels of trauma care is investigated. METHODS All emergency thoracotomies in patients with an ISS ≥ 9 from TR-DGU (2009-2014) within the first 60 min after arrival were identified. EDTs were identified separately, and mini thoracotomies and drainage systems were excluded. RESULTS 99,013 patients with sufficient data were observed. 1736 (1.8%) received thoracotomy during their hospital stay. 887 patients had a thoracotomy within the first hour in the emergency department (ED). 52.5% were treated in supraregional trauma centers (STC), 36.4% in regional (RTC) and 11.0% in local trauma centers (LTC). The mortality rates were 39.4% (STC), 20.9% (RTC) and 20.8% (LTC). The overall mortality rate showed no significant differences for blunt (28.2%) and penetrating trauma (31.3%). In case of cardiac arrest in the ED, a survival rate of 4.8% for blunt trauma and 20.7% for penetrating trauma was determined if EDT was carried out. Those patients showed a higher rate in severe thoracic organ injuries due to penetrating trauma but less extrathoracic injuries. CONCLUSION Just over half of EDTs were performed in STC. Emergency room resuscitation followed by EDT had survival rates of 4.8% and 20.7% for blunt and penetrating trauma patients, respectively.
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Affiliation(s)
- Stefan Schulz-Drost
- Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany. .,Department of Orthopaedic and Trauma Surgery, Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
| | - David Merschin
- Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany
| | - Denis Gümbel
- Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.,Centre of Orthopaedics, Trauma Surgery and Rehabilitative Medicine, Ferdinand-Sauerbruch-Straße, Universitätsmedizin Greifswald, 17475, Greifswald, Germany
| | - Gerrit Matthes
- Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.,Centre of Orthopaedics, Trauma Surgery and Rehabilitative Medicine, Ferdinand-Sauerbruch-Straße, Universitätsmedizin Greifswald, 17475, Greifswald, Germany
| | - Friedrich Frank Hennig
- Department of Orthopaedic and Trauma Surgery, Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Axel Ekkernkamp
- Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.,Centre of Orthopaedics, Trauma Surgery and Rehabilitative Medicine, Ferdinand-Sauerbruch-Straße, Universitätsmedizin Greifswald, 17475, Greifswald, Germany
| | - Rolf Lefering
- Faculty of Health, Department of Medicine, Institute for Research in Operative Medicine (IFOM), University Witten-Herdecke, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Sebastian Krinner
- Department of Orthopaedic and Trauma Surgery, Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
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Shi J, Wang Y, Geng W. Thoracoscope and thoracotomy in the treatment of thoracic trauma. Pak J Med Sci 2019; 35:1238-1242. [PMID: 31488985 PMCID: PMC6717472 DOI: 10.12669/pjms.35.5.514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare clinical effects of thoracoscopic surgery and thoracotomy in the treatment of thoracic trauma. Methods: Two hundred and fourteen patients with thoracic trauma were randomly divided into a control group and an observation group, 107 in each group. The control group was treated with conventional thoracotomy, while the observation group was treated with thoracoscopic surgery. The operation-related indications, hospitalization, postoperative complications and inflammatory factor level were observed and compared between the two groups. The study was conducted from April 2016 to February 2018. Results: The duration of operation of the observation group was shorter than that of the control group, the amount of bleeding during operation of the observation group was less than that of the control group, and the postoperative visual analogue score (VAS) of the observation group was lower than that of the control group; the difference were statistically significant (P<0.05). The hospitalization time, time of off-bed activity and time of resuming daily life of the observation group were shorter than those of the control group, and the amount of drainage fluid of the observation group within 24 hours after operation was less than that of the control group; the differences had statistical significance (P<0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P>0.05). The levels of C-reactive protein (CRP), tumor necrosis factor (TNF)-a and interleukin (IL)-6 in both groups after surgery were higher than those before surgery, but the indicators in the observation group were lower than those in the control group (P<0.05). Conclusion: Thoracoscopic surgery can reduce pains of patients, speed up recovery, and reduce incidence of surgical infection in the treatment of thoracic trauma. It is a safe and effective treatment method, which is worth clinical application.
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Affiliation(s)
- Juan Shi
- Juan Shi, Department of Cardiothoracic Surgery, Binzhou People's Hospital, Shandong, 256610, China
| | - Yucun Wang
- Yucun Wang, Department of Rheumatology and Immunology, Binzhou People's Hospital, Shandong, 256610, China
| | - Wenzhen Geng
- Wenzhen Geng, Department of Cardiovascular Medicine, Binzhou People's Hospital, Shandong, 256610, China
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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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Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma? Eur J Trauma Emerg Surg 2018; 44:811-818. [PMID: 29564472 DOI: 10.1007/s00068-018-0937-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/03/2018] [Indexed: 10/17/2022]
Abstract
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.
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