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Schellenberg M, Owattanapanich N, Ugarte C, Grigorian A, Nahmias J, Lam L, Martin MJ, Inaba K. Witnessed prehospital traumatic arrest: predictors of survival to hospital discharge. Eur J Trauma Emerg Surg 2024; 50:959-965. [PMID: 38087080 DOI: 10.1007/s00068-023-02398-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/03/2023] [Indexed: 07/16/2024]
Abstract
PURPOSE Trauma patients are rapidly transported to the hospital for definitive care. Nonetheless, some are alive upon Emergency Medical Services (EMS) arrival but arrest on-scene or during transport. The study objective was to examine EMS-witnessed traumatic arrests to define patients who survived hospital discharge. METHODS Patients sustaining EMS-witnessed traumatic arrest and entered into the National Trauma Data Bank were included (2007-2018). Mortality defined groups: survival to hospital discharge vs. in-hospital death vs. death in ED/declared dead on arrival (DOA). ANOVA/Chi-square compared cohorts. Multivariable analysis established factors associated with survival out of ED and to hospital discharge. RESULTS After exclusions, 14,177 patients met the criteria: 10% survived, 22% died in hospital, and 68% died in ED/DOA. Survivors tended to be female (33% vs. 23% vs. 23%, p < 0.001), blunt traumas (71% vs. 56% vs. 60%, p < 0.001), have higher scene GCS (15 [7-15] vs. 3 [3-11] vs. 3 [3-7], p < 0.001), and lower injury severity (ISS 13 [7-26] vs. 27 [18-41] vs. 25 [10-30], p < 0.001), particularly of the head (AIS 0 [0-2] vs. 0 [0-4] vs. 1 [0-4], p < 0.001). Survival to hospital discharge was independently associated with higher field GCS (OR 1.252, p < 0.001) and SBP (OR 1.006, p < 0.001), and Head AIS scores (OR 1.073, p < 0.001). Increasing age (OR 0.984, p < 0.001), higher ISS (OR 0.975, p < 0.001), male sex (OR 0.695, p < 0.001), and penetrating mechanism of injury (OR 0.537, p < 0.001) were associated with reduced survival to discharge. CONCLUSION After EMS-witnessed traumatic cardiac arrest, survivors were more likely to be young, female, injured by blunt trauma, and less hypotensive/comatose on-scene. These findings may have implications for ED resuscitation or declaration of care futility and should be further investigated with a prospective multicenter study.
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Affiliation(s)
- Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA.
| | - Natthida Owattanapanich
- Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Chaiss Ugarte
- Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Areg Grigorian
- Division of Acute Care Surgery, University of California Irvine, Irvine, CA, USA
| | - Jeffry Nahmias
- Division of Acute Care Surgery, University of California Irvine, Irvine, CA, USA
| | - Lydia Lam
- Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Matthew J Martin
- Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
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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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Adami EA, Poillucci G, Di Saverio S, Khan M, Fransvea P, Podda M, Rampini A, Marini P. A critical appraisal of emergency resuscitative thoracotomy in a Western European level 1 trauma centre: a 13-year experience. Updates Surg 2024; 76:677-686. [PMID: 37839047 DOI: 10.1007/s13304-023-01667-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
Emergency Resuscitative Thoracotomy (ERT) is a lifesaving procedure in selected patients. Outcome mostly in blunt trauma is believed to be poor. The primary aim of this study was to determine the predictors of postoperative mortality following ERT. We retrospectively reviewed 34 patients ≥ 18 years who underwent ERT at San Camillo-Forlanini Hospital (Rome, Italy) between January 2009 and December 2022 with traumatic arrest for blunt or penetrating injuries. Of 34 ERT, 28 (82.4%) were for blunt trauma and 6 (17.6%) were for penetrating trauma. Injury Severity Score (p-value 0.014), positive E-FAST (p-value 0.023), Systolic Blood Pressure (p-value 0.001), lactate arterial blood (p-value 0.012), pH arterial blood (p-value 0.007), and bicarbonate arterial blood (p-value < 0.001) were significantly associated with postoperative mortality in a univariate model. After adjustment, the only independent predictor of postoperative mortality was Injury Severity Score (p-value 0.048). Our experience suggests that ERT is a technique that should be utilized for patients with critical penetrating injuries and blunt trauma in patients in extremis. Our study highlights as negative prognostic factors high values of ISS and lactate arterial blood, a positive E-FAST, and low values of Systolic Blood Pressure, pH arterial blood and bicarbonate arterial blood.
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Affiliation(s)
- Ennio Alberto Adami
- General and Emergency Surgery, St. Camillo Forlanini's Hospital, Rome, Italy
| | - Gaetano Poillucci
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, San Matteo Hospital, Spoleto, Italy.
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Mansoor Khan
- University Hospitals Sussex NHSFT, Eastern Rd, Brighton, UK
| | - Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Mauro Podda
- Department of Surgical Science, Policlinico Universitario "Duilio Casula", University of Cagliari, Cagliari, Italy
| | - Alessia Rampini
- General and Emergency Surgery, St. Camillo Forlanini's Hospital, Rome, Italy
| | - Pierluigi Marini
- General and Emergency Surgery, St. Camillo Forlanini's Hospital, Rome, Italy
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Godbole M, Olafson S, Cohen RB, Ward CL, Sailes S, Sharlin M, Parsikia A, Moran BJ, Leung PSP. 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. Cureus 2024; 16:e56521. [PMID: 38646323 PMCID: PMC11026983 DOI: 10.7759/cureus.56521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/23/2024] Open
Abstract
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.
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Affiliation(s)
- Moshumi Godbole
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Samantha Olafson
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Ryan B Cohen
- General Surgery, Einstein Healthcare Network, Philadelphia, USA
| | - Candace L Ward
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Stephanie Sailes
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Mia Sharlin
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Afshin Parsikia
- General Surgery, Einstein Healthcare Network, Philadelphia, USA
| | | | - Pak Shan P Leung
- Trauma and Acute Care Surgery, Einstein Healthcare Network, Philadelphia, USA
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Saar S, Lipping E, Bahhir A, Talviste M, Lepp J, Väli M, Talving P. Outcomes of resuscitative and emergent thoracotomies following injury at the largest trauma center in Estonia. Eur J Trauma Emerg Surg 2024; 50:243-248. [PMID: 37225875 DOI: 10.1007/s00068-023-02284-y] [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: 04/05/2023] [Accepted: 05/14/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND An emergency department thoracotomy (EDT) is performed in critically injured patients after a recent or in an imminent cardiac arrest following trauma. Emergent thoracotomy (ET) or operation room thoracotomy is reserved for more stable patients. However, the number of these interventions performed in an European settings is limited. Thus, we initiated the current study to investigate outcomes and risk factors for mortality of patients required EDT or ET at the largest trauma center in Estonia. METHODS All patients admitted after trauma to the North Estonia Medical Centre between 1/1/2017 and 31/12/2021 subjected to EDT or ET were included. Primary outcome was 30-day mortality. RESULTS Overall, 39 patients were included. EDT and ET were performed in 16 and 23 patients, respectively. Median age was 45 (33-53) years and 89.7% were males. The crude 30-day mortality was 56.4% being 87.5% and 34.8% in the EDT and ET group, respectively. None of the patients with pre-hospital CPR requirement, severe head injury (AIS head ≥ 3) or severe abdominal injury (AIS abdomen ≥ 3) survived. All the patients in the survival group had signs of life in the emergency department. The rate of stab wounds was significantly higher in the survival group (p = 0.007). Patients with CGS < 9 had significantly lower possibility for survival (p < 0.001). CONCLUSIONS EDT and ET outcomes in Estonian trauma system are comparable to similar advanced trauma systems in Europe. Patients with GCS > 8, signs of life in the ED and with isolated penetrating chest injury had the most favorable outcomes.
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Affiliation(s)
- Sten Saar
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia.
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Edgar Lipping
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Artjom Bahhir
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Maarja Talviste
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Jaak Lepp
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Marika Väli
- Department of Pathological Anatomy and Forensic Medicine, University of Tartu, Tartu, Estonia
| | - Peep Talving
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Radulovic N, Hillier M, Nisenbaum R, Turner L, Nolan B. The Impact of Out-of-Hospital Time and Prehospital Intubation on Return of Spontaneous Circulation following Resuscitative Thoracotomy in Traumatic Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:580-588. [PMID: 38015060 DOI: 10.1080/10903127.2023.2285390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
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.
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Affiliation(s)
- Nada Radulovic
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
| | - Morgan Hillier
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
- Department of Emergency Medicine, Sunnybrook Health Sciences Center, Toronto, Canada
| | - Rosane Nisenbaum
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Linda Turner
- Sunnybrook Center for Prehospital Medicine, Sunnybrook Health Sciences Center, Toronto, Canada
| | - Brodie Nolan
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Emergency Medicine, St. Michael's Hospital, Toronto, Canada
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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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Hornor M, Khan U, Cripps MW, Cook Chapman A, Knight-Davis J, Puzio TJ, Joseph B. Futility in acute care surgery: first do no harm. Trauma Surg Acute Care Open 2023; 8:e001167. [PMID: 37780455 PMCID: PMC10533797 DOI: 10.1136/tsaco-2023-001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/25/2023] [Indexed: 10/03/2023] Open
Abstract
The consequences of the delivery of futile or potentially ineffective medical care and interventions are devastating on the healthcare system, our patients and their families, and healthcare providers. In emergency situations in particular, determining if escalating invasive interventions will benefit a frail and/or severely critically ill patient can be exceedingly difficult. In this review, our objective is to define the problem of potentially ineffective care within the specialty of acute care surgery and describe strategies for improving the care of our patients in these difficult situations.
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Affiliation(s)
- Melissa Hornor
- Surgery, Loyola University Chicago, Maywood, Illinois, USA
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
| | - Uzer Khan
- Surgery, Texas Christian University, Fort Worth, Texas, USA
| | - Michael W Cripps
- Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Allyson Cook Chapman
- Medicine and Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Knight-Davis
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
- Surgery, The Ohio State University College of Medicine and Public Health, Columbus, Ohio, USA
| | - Thaddeus J Puzio
- General Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Bellal Joseph
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
- Surgery, University of Arizona Medical Center—University Campus, Tucson, Arizona, USA
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Radulovic N, Wu R, Nolan B. Predictors of survival in trauma patients requiring resuscitative thoracotomy: A scoping review. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086231156265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
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.
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Affiliation(s)
- Nada Radulovic
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard Wu
- Department of Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Brodie Nolan
- Department of Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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Ali A, Simpson JT, Tatum D, Sedhom JA, Broome J, McGrew PR, Duchesne J, Taghavi S. Traumatic Injury in Pregnancy: A Propensity Score-Matched Analysis. J Surg Res 2023; 283:1018-1025. [PMID: 36914991 DOI: 10.1016/j.jss.2022.10.087] [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: 07/14/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Trauma represents the leading cause of nonobstetrical maternal death. How in-hospital outcomes of acutely injured pregnant patients (PP) compares to that of similarly aged nonpregnant control groups (CGs) has not been described. We hypothesized that PPs suffering acute traumatic injuries would have worse outcomes compared to a matched CG. MATERIALS AND METHODS The American College of Surgeons Trauma Quality Improvement Program (TQIP) was used to identify traumatically injured females between 2017 and 2019. Propensity score matching on age, race, injury severity score , and type of trauma (blunt, penetrating, or other) was used to compare PPs and the CG. Primary outcomes were mortality, disposition, length of stay (LOS), and complications. RESULTS A total of 1078 traumatically injured pregnant females were identified. Propensity score matching resulted in 990 patients in the PP and CG cohorts. After matching, PPs were more likely to be assault victims (11% versus 6%, P < 0.001), had longer length of stay (LOS) (5 versus 3 d, P < 0.001), and were more likely to require mechanical ventilation (26% versus 16%, P < 0.001) or intensive care unit (ICU) admission (44% versus 32%, P < 0.001). PPs were more likely to proceed directly to the operating room (OR)(34% versus 15%, P < 0.001) and less likely to be discharged home from the emergency department (ED) (1% versus 12%, P < 0.001). Complications and mortality rates were similar among PPs. CONCLUSIONS After acute trauma, PPs did not have increased mortality or complications when compared to matched controls, although they were more likely to be victims of assault, directly proceed to the OR, require mechanical ventilation or ICU admission, and have longer LOSs.
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Affiliation(s)
- Ayman Ali
- Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana
| | - John T Simpson
- Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana
| | - Danielle Tatum
- Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana
| | - Jessica A Sedhom
- Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana
| | - Jacob Broome
- Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana
| | - Patrick R McGrew
- Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana
| | - Juan Duchesne
- Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana
| | - Sharven Taghavi
- Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana.
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Blank JJ, Seamon MJ. Emergency Department Thoracotomy in Trauma. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00347-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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12
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Elkbuli A, Fanfan D, Newsome K, Sutherland M, Liu H, McKenney M, Ang D. A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias? Surgery 2022; 172:410-420. [PMID: 34972592 DOI: 10.1016/j.surg.2021.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias. METHOD A nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016-2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05. RESULTS A total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001). CONCLUSION Surgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL.
| | - Dino Fanfan
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Kevin Newsome
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Huazhi Liu
- Department of Surgery, Ocala Regional Medical Center, FL
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL; Department of Surgery, University of South Florida, Tampa, FL
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, FL; Department of Surgery, University of Central Florida, Ocala, FL
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13
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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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14
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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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15
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Abstract
As care of the injured patient continues to evolve, new surgical technologies and new resuscitative therapies can change the algorithms that drive trauma care. In particular, the advent of resuscitative endovascular balloon occlusion of the aorta has changed the way trauma surgeons treat patients in extremis. The science of resuscitation continues to evolve, leading to controversy about the optimal administration of fluid and blood products. Laparoscopy has given additional tools to the trauma surgeon to potentially avoid exploratory laparotomy, and rib fracture fixation can be beneficial in the proper patient.
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Affiliation(s)
- Stephanie Bonne
- Department of Surgery, Division of Trauma and Surgical Critical Care, Rutgers, New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Fariha Sheikh
- Department of Surgery, Division of Trauma and Surgical Critical Care, Rutgers, New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA
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16
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Stolberg-Stolberg J, Katthagen JC, Hillemeyer T, Wiebe K, Koeppe J, Raschke MJ. Blunt Chest Trauma in Polytraumatized Patients: Predictive Factors for Urgent Thoracotomy. J Clin Med 2021; 10:jcm10173843. [PMID: 34501292 PMCID: PMC8432076 DOI: 10.3390/jcm10173843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/22/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Current guidelines on urgent thoracotomy of polytraumatized patients are based on data from perforating chest injuries. We aimed to identify predictive factors for urgent thoracotomy after chest-tube placement for blunt chest trauma in a civilian setting. Methods: Polytraumatized patients (Injury Severity Score ≥16) with blunt chest trauma, submitted to a level I trauma centre during a period of 12 years that received at least one chest tube were included. Trauma mechanism, chest-tube output, haemoglobin values, need for cellular blood products, coagulopathies, rib fracture pattern, thoracotomy, and mortality were retrospectively analysed. Results: 235 polytraumatized patients were included. Patients that received urgent thoracotomy (UT, n = 10) showed a higher mean chest-tube output within 24 h with a median (Mdn) of 3865 (IQR 2423–5156) mL compared to the group with no additional thoracic surgery (NT, n = 225) with Mdn 185 (IQR 50–463) mL (p < 0.001). The cut-off 24-h chest-tube output value for recommended thoracotomy was 1270 mL (ROC-Curve). UT showed an initial haemoglobin of Mdn 11.7 (IQR 9.2–14.3) g/dL and an INR value of Mdn 1.27 (IQR 1.11–1.69) as opposed to Mdn 12.3 (IQR 10–13.9) g/dL and Mdn 1.13 (IQR 1.05–1.34) in NT (haemoglobin: p = 0.786; INR: p = 0.215). There was an average number of 7.1(±3.4) rib fractures in UT and 6.7(±4.8) in NT (p = 0.649). Conclusions: Chest-tube output remains the single most important predictive factor for urgent thoracotomy also after blunt chest trauma. Patients with a chest-tube output of more than 1300 mL within 24 h after trauma should be considered for transfer to a level I trauma centre with standby thoracic surgery.
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Affiliation(s)
- Josef Stolberg-Stolberg
- Department of Trauma-, Hand- and Reconstructive Surgery, Albert-Schweitzer-Campus 1, University Hospital Muenster, Building W1, 48149 Muenster, Germany; (J.C.K.); (M.J.R.)
- Correspondence: ; Tel.: +49-251-83-59231
| | - Jan Christoph Katthagen
- Department of Trauma-, Hand- and Reconstructive Surgery, Albert-Schweitzer-Campus 1, University Hospital Muenster, Building W1, 48149 Muenster, Germany; (J.C.K.); (M.J.R.)
| | - Thomas Hillemeyer
- Department of Anesthesiology, Intensive Care, and Pain Medicine, Albert-Schweitzer-Campus 1, University Hospital Muenster, Building A1, 48149 Muenster, Germany;
| | - Karsten Wiebe
- Section of Thoracic Surgery and Lung Transplantation, Department of Cardiothoracic Surgery, Albert-Schweitzer-Campus 1, University Hospital Muenster, Building A1, 48149 Muenster, Germany;
| | - Jeanette Koeppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany;
| | - Michael J. Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, Albert-Schweitzer-Campus 1, University Hospital Muenster, Building W1, 48149 Muenster, Germany; (J.C.K.); (M.J.R.)
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Abstract
Changing demographic trends have led to an increase in the overall geriatric trauma patient volume. Furthermore, the intersection of aging and injury can be problematic because geriatric patients have multiple comorbidities, geriatric-specific syndromes, and reduced physiological reserve. Despite mounting evidence that frail geriatric patients have inferior outcomes following trauma, very few studies have examined the effect of aging on the biological response to injury. In the present article, we review the current literature and explore the pathophysiological rationale underlying observed data, available evidence, and future directions on this topic.
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18
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Owattanapanich N, Inaba K, Allen B, Lewis M, Henry R, Clark D, Matsushima K, Strumwasser A. Extracorporeal Membrane Oxygenation May Improve Outcomes After Resuscitative Thoracotomy: A National Trauma Data Bank Analysis. Am Surg 2021; 87:1565-1568. [PMID: 34132618 DOI: 10.1177/00031348211024234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Albeit low survival rates, resuscitative thoracotomy (RT) is considered standard for selected trauma patients. Because it has potential for rapid cardiopulmonary rescue, extracorporeal membrane oxygenation (ECMO) may augment RT. The aim of this study was to identify the impact of ECMO on trauma patients that recently underwent RT after injury. STUDY DESIGN All patients who underwent RT were identified from the National Trauma Data Bank (2007-2017). Patients were excluded if they died within 60 minutes, underwent delayed ECMO, and/or had missing data. Delayed ECMO group was defined as those patients undergoing ECMO after 1 hour following RT. RESULTS Out of 8 694 272 injured patients, 10 106 (.1%) underwent RT. Median age was 31 years [23-45], 86% male. Penetrating injury was the dominant mechanism (62%). Of these, .6% (23) underwent immediate ECMO. Extracorporeal membrane oxygenation patients were significantly younger (23[17-33] vs. 31[23-46], p .003) and had significantly higher chest abbreviated injury scale scores (5[4-5] vs. 3[3-4], P < .001). Extracorporeal membrane oxygenation patients achieved significantly higher rate of return of spontaneous circulation (96% vs. 70%, p .007) and had nonsignificant trend of improved mortality (52% vs. 63%, p .260). CONCLUSION Immediate ECMO may be a useful therapeutic modality after RT. It achieves higher ROSC rates with opportunity for improved survival. Future prospective study is warranted.
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Affiliation(s)
- Natthida Owattanapanich
- Division of Trauma and Surgical Critical Care LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Brad Allen
- Division of Trauma and Surgical Critical Care LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Meghan Lewis
- Division of Trauma and Surgical Critical Care LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Reynold Henry
- Division of Trauma and Surgical Critical Care LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Damon Clark
- Division of Trauma and Surgical Critical Care LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Trauma and Surgical Critical Care LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Aaron Strumwasser
- Division of Trauma and Surgical Critical Care LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
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19
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Levin JH, Estroff JM, Zebley J, Butano V, Pierce A, Panahi A, Amdur R, Sarani B. Age Does Not Predict Failure to Rescue Following Resuscitative Thoracotomy in Penetrating Trauma. J Emerg Med 2021; 61:12-18. [PMID: 33618932 DOI: 10.1016/j.jemermed.2021.01.021] [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: 09/24/2020] [Revised: 01/07/2021] [Accepted: 01/17/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The limitations of resuscitative thoracotomy (RT) after penetrating trauma have been well documented, but there is a paucity of data on the effect age has on mortality. This begs the question as to the utility of RT in an aging patient population. We investigate the significance of age as a predictor for failure to rescue after RT in penetrating trauma. OBJECTIVE We sought to identify whether chronologic age has a measurable effect on rates of failure to rescue after RT. METHODS We performed a retrospective cohort analysis using the Trauma Quality Improvement Program from 2011 to 2015 including all pulseless patients undergoing RT after penetrating injury. Our primary outcome was failure to rescue defined as death in the emergency department after RT. Multivariate analyses were performed to identify the relationship between age and morality controlling for injury severity. RESULTS One thousand one hundred twelve RTs were performed during the study period with an overall failure to rescue rate of 61.8% (n = 687) within the emergency department and an in-hospital mortality rate of 96.9%, which is in line with national data. On univariate analysis, there was no significant association between age and mortality (p = 0.44). On multivariate analysis examining the interaction between age and mortality adjusting for injury severity, we found that chronologic age was not an independent predictor of death after RT. CONCLUSIONS Age does not appear to be an independent predictor of failure to rescue after RT in penetrating trauma and should not be a sole determinant in procedural decision making.
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Affiliation(s)
- Jeremy H Levin
- Department of Surgery, Division of Trauma and Critical Care, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jordan M Estroff
- Department of Surgery, Division of Trauma and Critical Care, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James Zebley
- Department of Surgery, Division of Trauma and Critical Care, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Vince Butano
- Department of Surgery, Division of Trauma and Critical Care, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Ayal Pierce
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Armon Panahi
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Rich Amdur
- Department of Surgery, Division of Trauma and Critical Care, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Babak Sarani
- Department of Surgery, Division of Trauma and Critical Care, George Washington University School of Medicine and Health Sciences, Washington, DC
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20
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Nationwide analysis of resuscitative thoracotomy in pediatric trauma: Time to differentiate from adult guidelines? J Trauma Acute Care Surg 2020; 89:686-690. [PMID: 33017132 DOI: 10.1097/ta.0000000000002869] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency department thoracotomy (EDT) for pediatric patients is uncommon, and practice patterns have not been evaluated. We examined the indications and outcomes for EDT by trauma center designation using a nationwide database. METHODS Patients 16 years or younger who underwent EDT within 30 minutes of arrival from 2013 to 2016 were identified in the American College of Surgeons National Trauma Data Bank. Patient demographic information, indications for EDT, and outcomes were analyzed. Outcomes were compared between centers with and without pediatric trauma center designation. RESULTS A total of 114 patients were identified for analysis with a mean ± SD age of 10.3 ± 4.7 years. Patients were predominantly male (69%) with a median Injury Severity Score of 26 (interquartile range, 18-42). Penetrating trauma occurred in 56%. Overall, mortality was 90% and was similar in penetrating and blunt trauma (88% vs. 94%; p = 0.34). There were no survivors among the 53 patients (46%) who arrived with no signs of life. Among the 11 patients (10%) who survived, median length of stay was 26 days (interquartile range, 6-28 days). Overall, 8% of EDT was performed at free-standing pediatric trauma centers, 45% at adult centers, and 47% at combined trauma centers. Mortality rates and indications were similar among trauma centers regardless of designation status. CONCLUSION In a national population-based data set, the mortality after pediatric EDT is high, and many of these procedures are performed at nonpediatric trauma centers. Regardless of injury mechanism, EDT is not appropriate in children without signs of life on arrival. Pediatric guidelines are needed to increase awareness of the poor outcomes and limited indications for EDT. LEVEL OF EVIDENCE Therapeutic, level IV.
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21
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Vreeswijk SJM, Mommers LPW, Bergmans DCJJ, van Wageningen B. Clamshell in a Heartbeat. Air Med J 2020; 39:509-511. [PMID: 33228905 DOI: 10.1016/j.amj.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/24/2020] [Accepted: 08/02/2020] [Indexed: 06/11/2023]
Abstract
There is a restrained attitude toward the implementation and performance of resuscitative thoracotomy as a last resort procedure in patients with cardiac arrest after penetrating thoracic trauma. We present a case with a remarkable recovery and hope to boost morality in the use of this procedure in the prehospital setting. A disoriented 25-year-old woman stabbed multiple times was found next to the highway. Her clinical situation deteriorated swiftly upon arrival of the helicopter emergency medical services. They were able to perform a clamshell thoracotomy and fly the patient out to the nearest trauma center. She awoke with good neurologic function. Her hospital admission was complicated by mediastinitis. A routine cardiac ultrasound showed mitral valve insufficiency due to combined perforation of the anterior leaflet and ventricular septum. Both lesions were in the trajectory of the primary stab wound. Successful outcome in our case was due to the following: little delay between clinical deterioration and the arrival of the helicopter emergency medical services physician (signs of life on arrival of paramedics are an independent predictor of survival), young age and penetrating injury are associated with a good neurologic outcome in case of traumatic cardiac arrest, and extensive follow-up cardiac ultrasound as part of tertiary survey after resuscitative emergency thoracotomy is advised.
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Affiliation(s)
- Sebastiaan J M Vreeswijk
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Lars P W Mommers
- Department of Anesthesiology, Maastricht University Medical Centre+, Maastricht, The Netherlands; Helicopter Emergency Medical Service, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Bas van Wageningen
- Helicopter Emergency Medical Service, Radboud University Medical Center, Nijmegen, The Netherlands
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22
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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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23
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Endo A, Kojima M, Hong ZJ, Otomo Y, Coimbra R. Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients with signs of life upon hospital arrival: a retrospective multicenter study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:541. [PMID: 32873326 PMCID: PMC7465718 DOI: 10.1186/s13054-020-03259-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/23/2020] [Indexed: 11/15/2022]
Abstract
Background The effectiveness and indications of open-chest cardiopulmonary resuscitation (OCCPR) have been still debatable. Although current guidelines state that the presence of signs of life (SOL) is an indication for OCCPR, scientific evidence corroborating this recommendation has been scarce. This study aimed to compare the effectiveness of OCCPR to closed-chest cardiopulmonary resuscitation (CCCPR) in severe trauma patients with SOL upon arrival at the emergency department (ED). Methods A retrospective cohort study analyzing data from the Trauma Quality Improvement Program (TQIP) database, a nationwide trauma registry in the USA, between 2010 and 2016 was conducted. Severe trauma patients who had SOL upon arrival at the hospital and received cardiopulmonary resuscitation within the first 6 h of ED admission were identified. Survival to hospital discharge was evaluated using logistic regression analysis, instrumental variable analysis, and propensity score matching analysis adjusting for potential confounders. Results A total of 2682 patients (OCCPR 1032; CCCPR 1650) were evaluated; of those 157 patients (15.2%) in the OCCPR group and 193 patients (11.7%) in the CCCPR group survived. OCCPR was significantly associated with higher survival to hospital discharge in both the logistic regression analysis (adjusted odds ratio [95% confidence interval] = 1.99 [1.42–2.79], p < 0.001) and the instrumental variable analysis (adjusted odds ratio [95% confidence interval] = 1.16 [1.02–1.31], p = 0.021). In the propensity score matching analysis, 531 matched pairs were generated, and the OCCPR group still showed significantly higher survival at hospital discharge (89 patients [16.8%] in the OCCPR group vs 58 patients [10.9%] in the CCCPR group; odds ratio [95% confidence interval] = 1.66 [1.13–2.42], p = 0.009). Conclusions Compared to CCCPR, OCCPR was associated with significantly higher survival at hospital discharge in severe trauma patients with SOL upon ED arrival. Further studies to confirm these results and to assess long-term neurologic outcomes are needed.
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Affiliation(s)
- Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Mitsuaki Kojima
- Emergency and Critical Care Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, Japan
| | - Zhi-Jie Hong
- Riverside University Health System, Comparative Effectiveness and Clinical Outcomes Research Center, 26520 Cactus Avenue, CPC Suite 102-5, Moreno Valley, CA, 92555, USA.,Division of Traumatology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Raul Coimbra
- Riverside University Health System, Comparative Effectiveness and Clinical Outcomes Research Center, 26520 Cactus Avenue, CPC Suite 102-5, Moreno Valley, CA, 92555, USA.
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24
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Elhajj A, Dakessian A, Bachir R, El Sayed M. Factors Associated with Survival After Emergency Department Thoracotomy for Adult Trauma Patients in the United States. J Emerg Med 2020; 59:169-177. [PMID: 32591301 DOI: 10.1016/j.jemermed.2020.05.005] [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: 02/06/2020] [Revised: 04/11/2020] [Accepted: 05/04/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency department thoracotomy (EDT) is done to control life threatening hemorrhage and injuries. Literature examining this topic is limited to relatively small studies from single trauma centers. OBJECTIVE This study identifies factors associated with survival to hospital discharge of patients undergoing EDT using the largest U.S. national trauma database. METHODS This retrospective cohort study used the U.S. National Trauma Data Bank 2015. We conducted univariate and bivariate analyses followed by a multivariate analysis that adjusted for confounders to identify factors associated with survival. RESULTS Two thousand four hundred eighty-six patients who underwent EDT were included. Most patients were 16 to 64 years of age (92.3%) with a male predominance (84.9%) and without any previous comorbidities (62.8%). Penetrating injury was most common (60.2%), mainly as a result of assault (51.0%) by firearm (45.1%). Overall survival to hospital discharge was 38.2%. After adjusting for confounders, factors associated with increased survival were cut/piece injuries, presenting with signs of life, Glasgow Coma Scale score ≥8, systolic blood pressure >90 mm Hg, and transportation to the ED through helicopter/fixed-wing ambulance or public/private vehicle (reference, ground ambulance). CONCLUSIONS Factors associated with survival in patients undergoing EDT were identified. The clinical indication of presence of appropriate resources to continue and repair EDT was validated, along with the contraindications of lack of signs of life and presence of major nonsurvivable injuries. Future studies should focus on validation of all criteria of EDT, namely hemodynamic instability despite appropriate fluid resuscitation, duration of time of cardiopulmonary resuscitation and pulselessness, cardiac rhythm on arrival, and the presence of pericardial tamponade.
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Affiliation(s)
- Ali Elhajj
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Alik Dakessian
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Bachir
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mazen El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Emergency Medical Services and Prehospital Care Program, American University of Beirut Medical Center, Beirut, Lebanon
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25
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Affiliation(s)
- S Paulich
- North Bristol NHS Trust, Bristol, UK
| | - D Lockey
- North Bristol NHS Trust, Bristol, UK
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26
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Dumas RP, Vella MA, Chreiman KC, Smith BP, Subramanian M, Maher Z, Seamon MJ, Holena DN. Team Assessment and Decision Making Is Associated With Outcomes: A Trauma Video Review Analysis. J Surg Res 2019; 246:544-549. [PMID: 31635832 DOI: 10.1016/j.jss.2019.09.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/24/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Teamwork is a critical element of trauma resuscitation. Assessment tools such as T-NOTECHS (Trauma NOn-TECHnical Skills) exist, but correlation with patient outcomes is unclear. Using emergency department thoracotomy (EDT), we sought to describe T-NOTECHS scores during resuscitations. We hypothesized that patients undergoing EDT whose resuscitations had better scores would be more likely to have return of spontaneous circulation (ROSC). METHODS Continuously recording video was used to review all captured EDTs over a 24-mo period. We used a modification of the validated T-NOTECHS instrument to measure five domains on a 3-point scale (1 = best, 2 = average, 3 = worst). A total T-NOTECHS score was calculated by one of three reviewers. The primary outcome was ROSC. ROSC was defined as an organized rhythm no longer requiring internal cardiac compressions. Associations between variables and ROSC were examined using univariate regression. RESULTS Sixty-one EDTs were captured. Nineteen patients had ROSC (31%) and 42 (69%) did not. The median T-NOTECHS score for all resuscitations was 8 [IQR 6-10]. As demographic and injury data (age, gender, mechanism, signs of life) were not associated with ROSC in univariate analysis, they were not considered for inclusion in a multivariable regression model. The association between overall T-NOTECHS score and ROSC did not reach statistical significance, but examination of the individual components of the T-NOTECHS score demonstrated that, compared to resuscitations that had "average" (2) or "worst" (3) scores on "Assessment and Decision Making," resuscitations with a "best" score were 5 times more likely to lead to ROSC. CONCLUSIONS Although the association between overall T-NOTECHS scores and ROSC did not reach statistical significance, better scores in the domain of assessment and decision making are associated with improved rates of ROSC in patients arriving in cardiac arrest who undergo EDT. LEVEL OF EVIDENCE Level IV Therapeutic/Care Management.
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Affiliation(s)
- Ryan P Dumas
- Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Michael A Vella
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristen C Chreiman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian P Smith
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Madhu Subramanian
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zoe Maher
- Division of Trauma and Surgical Critical Care, Temple University, Philadelphia, Pennsylvania
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
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27
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Hoareau GL, Tibbits EM, Beyer CA, Simon MA, DeSoucy ES, Faulconer ER, Neff LP, Grayson JK, Stewart IJ, Williams TK, Johnson MA. Resuscitative Endovascular Balloon Occlusion of the Aorta: Review of the Literature and Applications to Veterinary Emergency and Critical Care. Front Vet Sci 2019; 6:197. [PMID: 31275952 PMCID: PMC6594359 DOI: 10.3389/fvets.2019.00197] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 06/03/2019] [Indexed: 11/13/2022] Open
Abstract
While hemorrhagic shock might be the result of various conditions, hemorrhage control and resuscitation are the corner stone of patient management. Hemorrhage control can prove challenging in both the acute care and surgical settings, especially in the abdomen, where no direct pressure can be applied onto the source of bleeding. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a promising replacement to resuscitative thoracotomy (RT) for the management of non-compressible torso hemorrhage in human trauma patients. By inflating a balloon at specific levels (or zones) of the aorta to interrupt blood flow, hemorrhage below the level of the balloon can be controlled. While REBOA allows for hemorrhage control and augmentation of blood pressure cranial to the balloon, it also exposes caudal tissue beds to ischemia and the whole body to reperfusion injury. We aim to introduce the advantages of REBOA while reviewing known limitations. This review outlines a step-by-step approach to REBOA implementation, and discusses common challenges observed both in human patients and during translational large animal studies. Currently accepted and debated indications for REBOA in humans are discussed. Finally, we review possible applications for veterinary patients and how REBOA has the potential to be translated into clinical veterinary practice.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States
| | - Emily M Tibbits
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Meryl A Simon
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Erik S DeSoucy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | | | - Lucas P Neff
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, United States
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