Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center

[Open chest cardiopulmonary resuscitation: is there an interest in France?]

OBJECTIVE

To expose and clarify indications, techniques, results, complications and cost for open chest cardiopulmonary resuscitation manoeuvres (OCCRM) in traumatic or nontraumatic cardiac arrest.

DATA SOURCES

References were obtained from Pubmed data bank using the following keywords: "emergency thoracotomy", "resuscitative thoracotomy".

STUDY SELECTION

We focused on publications in English language, from 2000 to 2007.

DATA SYNTHESIS

OCCRM are useful especially in case of traumatic cardiac arrest, penetrating trauma, but also in blunt trauma. Time between cardiac arrest and realisation of the thoracotomy seems to be the most important factor for the prognosis.

CONCLUSION

According to the French "physician in ambulance" prehospital system, OCCRM might be promising in France, because this system favours the fastness of care and therefore would minimize the time factor.

Trauma

In terms of cost and years of potential lives lost, injury arguably remains the most important public health problem facing the United States. Care of traumatically injured patients depends on early surgical intervention and avoiding delays in the diagnosis of injuries that threaten life and limb. In the critical care phase, successful outcomes after injury depend almost solely on diligence, attention to detail, and surveillance for iatrogenic infections and complications.

Emergency department thoracotomy: still useful after abdominal exsanguination?

BACKGROUND

Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage.

METHODS

A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival.

RESULTS

The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days).

CONCLUSIONS

Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.

[Cardiac arrest following blunt chest injury. Emergency thoracotomy without ifs or buts?]

In German-speaking countries, most serious thoracic injuries are attributable to the impact of blunt force; they are the second most frequent result of injury after head injury in polytrauma patients with multiple injuries. Almost one in every three polytraumatized patients with significant chest injury develops acute lung failure, and one in every four, acute circulatory failure. The acute circulatory arrest following serious chest injury involves a high mortality rate, and in most cases it reflects a tension pneumothorax, cardiac tamponade, or hemorrhagic shock resulting from injury to the heart or one of the large vessels close to it. Brisk drainage of tension pneumothorax and adequate volume restoration are therefore particularly important in resuscitation of multiply traumatized patients, as are rapid resuscitative thoracotomy to allow direct heart massage, drainage of pericardial tamponade, and control of hemorrhage. However the probability of survival described in the literature is very low for patients sustaining severe chest trauma with acute cardiac arrest. The case report presented here describes a female polytrauma patient who suffered an acute cardiac arrest following cardiac tamponade after admission in the emergency department and who survived without neurological deficits after an emergency thoracotomy. Selections from the topical literature can help the treating physician in the emergency department in making decisions on whether an emergency thoracotomy is indicated after a blunt chest injury and on the procedure itself.

Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest

BACKGROUND

Resuscitation of traumatic cardiorespiratory arrest patients (TCRA) is generally associated with poor outcome, however some authors report survival rates of more than 10% in blunt trauma patients. The purpose of this investigation was to determine predictive factors for mortality in trauma patients having received external chest compressions (ECC).

PATIENTS AND METHODS

Twenty thousand eight hundred and fifteen patients from the Trauma Registry of the German Trauma Society were analysed (mean ISS=24.0). Inclusion criteria were ISS>/=16 and available information on ECC either on-scene and/or during trauma room treatment. Included into the Trauma Registry were only patients with ECC and transportation into a hospital. Patients declared dead on-scene without transportation to a hospital were not recorded in the data base. A Logistic regression was performed to find out predictive factors for mortality.

RESULTS

Ten thousand three hundred and fifty nine patients fulfilled the inclusion criteria. N=757 patients received ECC, 415 prehospital, 538 during trauma room (TR) treatment and 196 prehospital and in-hospital. Blunt trauma occurred in 93.2%, mean age was 40.3 and median ISS was 41.0. 23.2% of the patients were treated with a chest tube, 5.7% had a tension pneumothorax and 10.2% underwent emergency thoracotomy. The overall survival rate was 17.2%. 9.7% of the TCRA patients with ECC achieved good recovery or moderate disability (Glasgow outcome scale>/=4). Logistic regression showed thromboplastin time lower than 50% to be the strongest predictor for non-survival (OR 5.2, 95% CI 2.3-11.9), followed by massive blood transfusion of more than 10 units of packed red blood cells (OR 4.8, 95% CI 2.0-11.5), on-scene blood pressure of 0 (OR 4.3, 95% CI 1.6-11.3), age over 55 (OR 2.9, 95% CI 1.1-7.3), base excess lower than -8 (OR 2.7, 95% CI 1.2-5.9). The insertion of a chest tube on-scene could be detected as a factor significantly increasing the probability of survival (OR 0.3, 95% CI 0.13-0.8).

CONCLUSIONS

Prehospital chest tube insertion was found to be a strong predictor for survival. On-scene chest decompression of TCRA patients is recommended in case of the decision to start with ECC. Based on our data, resuscitation after severe trauma seems to be more justified than the current guidelines state.

Emergency department thoracotomy in Jamaica: A case controlled study

Increasing numbers of severely injured patients have been presenting to Emergency Rooms worldwide due to advances in pre-hospital trauma care. Some of these patients may be candidates for Emergency Department Thoracotomy (EDT). Large advisory bodies have identified selection criteria for EDT in Developed Countries, but there are no regional statistics to guide the selection process in Developing Caribbean Nations. This study evaluates outcomes with EDT at the University Hospital of the West Indies in Jamaica in order to determine factors that could predict survival in this setting. A retrospective study was performed over 11 years from January 1995 to January 2006 examining patients who had EDT at the University Hospital of the West Indies. There were 13 procedures performed over 11 years, with two early survivors (15%) and one patient surviving to discharge. The factors that have been found to be significant predictors of mortality include gunshot injuries, extra-thoracic injury location, inadequate pre-hospital resuscitation, prolonged transportation time and the absence of signs of life on arrival to hospital. Several health care limitations have been uncovered in this setting that must be improved if we are to expect improved outcomes. Focused preparation of the Emergency Room is an initial step that can be easily achieved. We also need to define strict management protocols using selection criteria that are tailored to our local environment in order to exclude futile procedures in unsalvageable patients.

Cost-Utility Analysis of Emergency Department Thoracotomy for Trauma Victims

BACKGROUND

Our objective was to assess the cost-effectiveness of emergency department thoracotomy (EDT) performed on both penetrating and blunt trauma victims, using both published survival and outcome data and previously unaccounted for data on the cost of occupational exposure.

METHODS

Cost-utility analysis was performed using decision-analytic models constructed for both penetrating and blunt trauma scenarios. Survival and impairment data, the rates and costs of occupational exposure, and the utilities of neurologic impairment and provider seroconversion were all based on published literature. Costs of EDT were estimated using the National Inpatient Sample (NIS) from the Health Care Utilization Project database. One-way sensitivity analyses on input parameters and probabilistic sensitivity analyses using Monte Carlo simulations were performed.

RESULTS

The incremental cost-effectiveness ratio of EDT for penetrating trauma was $16,125 per quality-adjusted life year (QALY), and less than $50,000 per QALY with a 93.4% probability. The incremental cost-effectiveness ratio for blunt trauma was $163,136 per QALY, and less than $50,000 per QALY with a 37% probability. Neither model was sensitive to provider exposure. The penetrating model was insensitive to the probability of neurologically intact survival, the utility adjustment, procedure costs, and long-term care. The blunt model was sensitive to the probabilities of survival and of neurologic impairment.

CONCLUSIONS

EDT is cost-effective for penetrating trauma, and not cost-effective for blunt trauma given current rates of survival and impairment. Occupational exposure does not significantly impact the cost-effectiveness of the procedure.

Thoracic trauma: when and how to intervene

Trauma is the leading cause of death in patients younger than 40 years of age. Thoracic injuries are common and often can be managed by tube thoracostomy. In many patients, however, the thoracic injuries must be repaired surgically in one of three time periods: immediate, urgent, or delayed thoracotomy. In this article, we describe the general approach to effectively managing thoracic trauma patients. We review common injuries and scenarios that may be encountered by the surgeon and discuss the considerations and variables that enter into the decision-making process for operative intervention.

Management of Pulseless and Apneic Trauma Patients: Are Aggressive Measures Justified?

This study prospectively examined the care of trauma patients in extremis on presentation to a tertiary medical center between January 2000 and August 31, 2002. There were 144 patients who presented without a pulse or spontaneous respiration and required cardiopulmonary resuscitation (mean age, 41.5 ± 2.3 years; male-to-female ratio, 105:39). Successfully resuscitated patients, who were either admitted to the surgical intensive care unit (SICU) or who were taken to the operating room for surgical exploration, had significantly shorter duration of cardiopulmonary resuscitation (14.55 ± 1.64 minutes vs. 33.32 ± 1.23 minutes; P < 0.001) and received less amounts of epinephrine than those who died in the emergency room ( P < 0.05). One hundred sixteen patients died in the emergency room. Nineteen admitted patients died within 24 hours of presentation. Nine patients survived beyond 24 hours and all of them were admitted directly to the SICU for the management of brain injury. Six patients were taken to the operating room for surgical exploration to control the bleeding; all of them died in the operating room or shortly thereafter in the SICU. No patient in this study survived to be discharged. The financial cost of successfully resuscitated patients was significantly higher than that of patients who died in the emergency room ( P < 0.001). Instead of insisting on aggressive measures to resuscitate trauma patients in extremis on presentation, the authors suggest we should redirect that fervor toward efforts made to promote trauma awareness and injury prevention programs.

Resuscitative emergency thoracotomy in a Scandinavian trauma hospital--is it justified?

OBJECTIVE

Resuscitative emergency thoracotomy (ET) is of value in selected (penetrating) trauma patients. Current survival-estimates and recommended guidelines are based on data from the United States. However, reports from European trauma centres are lacking. We report the current experience from a Scandinavian trauma hospital.

METHODS

Identification of all consecutive ETs performed during a 5-year period. Data on demographics, and injury severity score (ISS), mechanism and location were recorded. Physiological status on admission (revised trauma score, RTS) and probability of survival (Ps) were calculated. Signs of life (SOL) and need for closed-chest cardiopulmonary resuscitation (CC-CPR) were recorded through the post-injury phase.

RESULTS

Ten patients underwent ET with no survivors. The annual incidence of ET was 0.7 per 100,000 inhabitants during the study period, with an increasing trend during the last years (r=0.74, p=0.014). ETs were performed in 0.7% of all trauma admissions, and in 2.5% of all severely injured patients (ISS>or=16). Blunt mechanism dominated; only three had penetrating injuries. Most frequent location of major injury was "multiple" (n=4) and "thoracic" (n=4). The male to female ratio was 7:3. Median age was 51 years (range 21-77). Median ISS was 34.5 (range 26-75), indicating severely injured patients, with seriously deranged physiology (median RTS of 0.0, range 0-6.1) with poor chance of survival (median Ps of 4.4%, range 0-89.5%). Males had significantly lower RTS and Ps (p=0.007 and 0.03, respectively) than females. Eight patients had signs of life at some time post-injury, but only four in the emergency room. Six patients had both pre- and in-hospital CC-CPR. Four patients had additional surgery to ET. Two possible preventable deaths were identified (Ps) of 51 and 89%), one in a third trimester pregnancy.

CONCLUSION

Emergency thoracotomy is a rarely performed procedure in a rather busy Scandinavian trauma hospital, and outcome is dismal. Reevaluation of our decision-making process concerning the use of emergency thoracotomy is needed. How survival data and clinical experience in Europe compare to current figures from North America deserves further attention.

Toracotomia de reanimação: racionalização do uso do procedimento

OBJETIVO: Contesta-se a aplicação indiscriminada da toracotomia de reanimação (TR) no trauma. Este estudo objetiva reavaliar as indicações de TR na nossa instituição. MÉTODO: Estudo retrospectivo envolvendo 126 pacientes submetidos à TR entre janeiro de 1995 e dezembro de 2004. Definiram-se quatro grupos considerando os sinais vitais dos pacientes na admissão: morto ao chegar, fatal, agônico e choque profundo. O protocolo incluiu dados como mecanismo de trauma, sinais vitais, Escore de Trauma Revisado (Revised Trauma Score ou RTS), locais de lesão (identificados durante cirurgia ou autópsia), Índice de Gravidade da Lesão (Injury Severity Score ou ISS) e sobrevida. RESULTADOS: Setenta e dois (57,2%) pacientes apresentavam ferimento por projétil de arma de fogo, 11 (8,7%) ferimento por arma branca e 43 (34,1%) por trauma fechado. Nenhum dos sessenta pacientes (47,6%) dos grupos fatal e morto ao chegar sobreviveu, mas 13 (39,4%) dos pacientes fatais foram encaminhados ao centro cirúrgico (CC) para tratamento definitivo. Dos 66 pacientes dos grupos agônico e choque profundo, 44 (66,7%) foram submetidos a TR no prontosocorro (PS) e 31 (70,5%) destes foram transferidos até o CC. Nos 22 restantes, a parada cardiorrespiratória ocorreu já no CC, onde foi feita a TR. Dois pacientes do grupo choque profundo sobreviveram (1,6% do total) e receberam alta com função cerebral normal. O ISS médio foi 33, sendo exsangüinação a causa mais freqüente de óbito. CONCLUSÕES: Resultados ruins enfatizam a necessidade de uma abordagem mais seletiva para aplicar a TR. Um algoritmo baseado no mecanismo de trauma e nos sinais vitais na admissão é proposto para otimizar as indicações de TR.

Emergency department resuscitative thoracotomy for nontorso injuries

BACKGROUND

Resuscitative thoracotomy performed in the emergency department (EDT) continues to have clear indications in patients sustaining trauma to the torso, particularly penetrating injuries. However, adjunctive use of aortic cross-clamping during EDT for hemorrhagic shock also may be useful in the acute resuscitation of patient with nontorso injuries (NTI). We questioned the utility of EDT in patients with nontorso trauma.

METHODS

Patients undergoing EDT have been prospectively followed since 1977 at our regional level I trauma center.

RESULTS

During the 26-year study period, 959 patients underwent EDT; 27 (3%) of these patients underwent EDT for penetrating NTI. Three (11%) of these patients survived to leave the hospital, with only 1 patient sustaining mild neurologic deficit. The mechanism of injury in the survivors was stab wound to the neck (1), gunshot wound to the neck (1), and extremity vascular injury (1). All survivors of EDT for NTI underwent prehospital cardiopulmonary resuscitation and successful endotracheal intubation in the field. There were no survivors of EDT for penetrating injury to the head.

CONCLUSIONS

Resuscitative EDT with aortic cross-clamping is a potential adjunct in the acute resuscitation of NTI involving penetrating neck or extremity vascular injuries.

Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes

In the past three decades there has been a significant clinical shift in the performance of emergency department thoracotomy (EDT), from a nearly obligatory procedure before declaring any trauma patient to select patients undergoing EDT. The value of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable. Its indiscriminate use, however, renders it a low-yield and high-cost procedure. Overall analysis of the available literature indicates that the success of EDT approximates 35% in the patient arriving in shock with a penetrating cardiac wound, and 15% for all penetrating wounds. Conversely, patient outcome is relatively poor when EDT is done for blunt trauma; 2% survival in patients in shock and less than 1% survival with no vital signs. Patients undergoing CPR upon arrival to the emergency department should be stratified based upon injury and transport time to determine the utility of EDT. The optimal application of EDT requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences.

Thoracotomie transverse de réanimation

The technique of resuscitative transverse thoracotomy is for use in case of circulatory arrest in the trauma patient. This technique, performed after orotracheal intubation, is initiated by a 5th intercostal space thoracostomy in each mid-axillary line. If the circulatory arrest is not caused by a tension pneumothorax, bilateral thoracotomies in the 5th intercostal spaces with transverse transsection of the sternum is performed. Middle vertical incision of the pericardium allows the evacuation of a cardiac tamponade. This wide surgical access has proved simple to perform, even by non experienced operators. It allows digital control of a heart wound, cross-clamping of the thoracic descending aorta or of pulmonary hilum, rapid perfusion of warm fluids through the right auricle and the performance of bimanual internal cardiac massage.

Blunt trauma patients with prehospital pulseless electrical activity (PEA): poor ending assured

BACKGROUND

The paucity of information on the outcome of patients experiencing prehospital pulseless electrical activity (PEA) after blunt injury led to the present study.

METHODS

A retrospective review was performed of all blunt trauma victims with prehospital PEA from 1997 to 2001 in an urban county trauma system.

RESULTS

One hundred ten patients, 78 men and 32 women, met study criteria. Seventy-nine patients had PEA at the scene, and 31 experienced PEA en route to a trauma center. All patients were transported in advanced life support ambulances. Cardiopulmonary resuscitation was initiated when PEA was detected. Vital signs were regained en route or at the trauma center by 25 patients (23%). The incidence of pupillary reactivity at the scene was higher in patients who regained vital signs (48% vs. 16%). Only one patient, who has significant residual neurologic impairment, survived. The mean Injury Severity Score of this population was 45.1.

CONCLUSION

If these grim results are corroborated by other investigators, consideration should be given to allowing paramedics to declare blunt trauma victims with PEA dead at the scene.

Emergency Room Thoracotomy: Updated Guidelines for a Level I Trauma Center

The purpose of this study was to evaluate whether 1995 study conclusions influenced patient selection and subsequent survival and whether indications for emergency room thoracotomy (ERT) could be further limited on the basis of patient physiologic status. A retrospective review of patient demographics, physiologic status both at the scene and on arrival to the emergency room (ER), and survival was performed on those who underwent ERT from July 1995 to December 1999. Sixty-five patients underwent ERT for sustained gunshot wounds and 14 patients for stab wounds. There were no survivors from Class I or II at the scene or Class I on presentation to the ER. Although there was a significant decrease in patients of Class I at the scene (27% vs 8%) and in the ER (58.3% vs 35.4%) the overall survival rate remained the same (2.6%). ERT could be eliminated for patients of Class I or II at the scene and for those of Class I on arrival to the ER without negating survivors; survival would improve to 16.2 per cent.

Emergency Thoracotomy: Appropriate Use in the Resuscitation of Trauma Patients

The objective of this study was to evaluate the use of emergency thoracotomy in our institution in an effort to determine whether this procedure is both beneficial and cost effective in blunt and/or penetrating trauma. We conducted a retrospective review of charts and coroner's reports. Our setting was a Level I trauma center in a tertiary-care facility. We examined the cases of trauma patients presenting to the trauma center over a 2-year period. Of 2490 patients who presented to the emergency department over the study period 41 underwent early thoracotomy. Twelve of these were excluded from the study because their cases were not truly emergent. Of the remaining 29 ten were admitted for penetrating injuries and 19 for blunt injuries. The average Injury Severity Scores for penetrating and blunt injuries were 30 and 40 respectively. There were four blunt trauma patients who died in the emergency department, 15 went to the operating room, and five who survived to go to the intensive care unit. All blunt trauma patients requiring emergency thoracotomy died within 9 days of presentation. Of the ten penetrating wound patients two died in the emergency department, four died in the operating room, and four went to the intensive care unit after surgery. One of the four patients who went to the intensive care unit died approximately 6 days after injury. The other three patients survived and are now living normal productive lives. All survivors of penetrating trauma who required emergency thoracotomy had their procedure performed in the operating room. Overall survival rates for penetrating and blunt trauma were 30 and 0 per cent respectively. Pericardial tamponade was found in 50 per cent of the penetrating trauma patients (two of the three survivors) and four of 19 of the blunt trauma patients. This reinforces the importance of a prompt pericardiotomy upon opening the chest. At our institution the algorithm for emergency thoracotomy is liberal and is not cost effective for blunt trauma. We need to re-evaluate our decision-making process concerning the use of emergency thoracotomy especially in the blunt trauma patient. The review also shows the importance of pericardiotomy when performing an emergency thoracotomy.

A critical analysis of outcome for children sustaining cardiac arrest after blunt trauma

PURPOSE

Injury is the leading cause of cardiac arrest in children older than 1 year. Previous findings suggest that children who require cardiopulmonary resuscitation (CPR) administered by paramedics for any reason rarely survive to hospital discharge. The authors evaluated the outcome of children sustaining cardiac arrest after blunt trauma in a Regional Pediatric Trauma Center.

METHODS

Children (age < 16) who underwent CPR in the field or in the emergency department (ED) after blunt trauma were identified from the trauma registry of a regional pediatric trauma center over a 3-year period (1997 to 2000). Patient demographics, rate of survival to discharge, factors influencing survival, and organ donation data were obtained from the trauma registry and medical record. Probability of survival (Ps) was calculated by TRISS analysis.

RESULTS

Twenty-five children were identified with a history of cardiac arrest after blunt injury (mean age; 3.3 years; range, 0.1 to 10; mean ISS, 30.7; range, 13-75; mean RTS, 1.58). Mean calculated Ps was 22.7%. However, only 2 (8%) survived. Death in the majority (91%) of the 23 patients who died occurred secondary to brain or spinal cord injury, and only 2 (9%) occurred as the result of exsanguinating hemorrhage. CPR was first performed in the field in 10 patients (40%), en route in 6 (24%), and in the ED in 9 (36%). Of the children who survived, both had vitals in the field, and CPR was administered initially in the ED. Mean length of ED resuscitation before death was 80 minutes. Of the children who died, organ donation occurred in only 3 (13%). The 2 survivors had no head injury and were discharged within 3 weeks of injury.

CONCLUSIONS

Cardiopulmonary resuscitation after blunt injury in children rarely results in survival. The majority of deaths occur as a result of isolated intracranial injury and not exsanguinating hemorrhage. Although all children should receive aggressive resuscitation after injury, the need for CPR in the field portends a poor outcome. Furthermore, these data would suggest that prolonged or heroic efforts for children sustaining cardiac arrest in the field are not indicated.

Termination of resuscitative efforts: medical futility for the trauma patient

Despite years of research on the resuscitation of the patient with critical traumatic injuries, controversy remains surrounding the criteria to waive initiation of resuscitation in the pre-hospital setting or to terminate such efforts in the emergency department. The decision to initiate or continue resuscitation on moribund trauma patients is associated with considerable costs. Ambulance transport using lights and sirens carries potential risk. Emergency department thoracotomy, with exposure to high risk bodily fluids, involvement of numerous staff, and usage precious blood products, is a procedure that has fewer and fewer indications. This review presents guidelines to help determine when to initiate resuscitation for the critically injured trauma patient and when to cease these efforts in the emergency department. Since there are economic, societal, and ethical implications, each system should establish their own criteria, using these guidelines as a basis.

Selective aortic arch perfusion with hemoglobin-based oxygen carrier-201 for resuscitation from exsanguinating cardiac arrest in swine

OBJECTIVE

The prospects for resuscitation after blunt traumatic cardiac arrest are dismal. Selective aortic arch perfusion (SAAP) with a hemoglobin-based oxygen carrier (HBOC-201) offers a potentially effective therapy. This study evaluated the acute cardiovascular and metabolic effects of SAAP with HBOC-201 in an exsanguination model of cardiac arrest.

DESIGN

Randomized, controlled, laboratory investigation.

SETTING

University research laboratory.

SUBJECTS

Domestic swine, 25-39 kg.

INTERVENTIONS

Partial resection of four liver lobes rapidly led to profound hemorrhagic shock and subsequent cardiac arrest at 10-13 mins. At 15 mins, swine were randomized to receive either SAAP with oxygenated lactated Ringer's (LR) solution (n = 6) or SAAP with oxygenated HBOC-201 (n = 6) at a rate of 10 mL x kg(-1) x min(-1) until return of spontaneous circulation with a mean aortic pressure of 60 mm Hg (8.0 kPa) was achieved. Epinephrine (0.005 mg/kg) was given via intra-aortic route every 30 secs as needed to promote return of spontaneous circulation beginning at 18 mins after onset of liver injury (3 mins after beginning SAAP).

MEASUREMENTS AND MAIN RESULTS

Mean aortic pressure, cardiac output, total blood loss, and time of arrest were similar for both groups before SAAP therapy. In the SAAP-HBOC group, return of spontaneous circulation with a sustained mean aortic pressure of 60 mm Hg (8.0 kPa) was achieved in six of six swine at 1.9 +/- 0.3 mins of SAAP, and none of these swine required epinephrine. In the SAAP-LR group, no swine (from a total of six) achieved return of spontaneous circulation before intra-aortic epinephrine administration, and only two of six swine had brief return of spontaneous circulation with an mean aortic pressure of 60 mm Hg (8.0 kPa) after intra-aortic epinephrine that was sustained for <10 mins. One-hour survival was five of six in the SAAP-HBOC group and none of six in the SAAP-LR group (p <.05, Fisher's exact test).

CONCLUSION

SAAP with oxygenated HBOC-201 rapidly restored viable cardiovascular function after exsanguinating cardiac arrest in this swine model of liver injury with profound hemorrhagic shock.

Current opinion regarding indications for emergency department thoracotomy

BACKGROUND

Emergency department thoracotomy (EDT) is a dramatic but rarely lifesaving intervention. Clinical variability regarding indications for EDT has yet to be quantified. Members of the Eastern and American Associations for the Surgery of Trauma were questioned by mail to evaluate which clinical and demographic factors influence the decision to perform EDT and whether physicians perform EDT in accordance with current practice guidelines.

METHODS

A single mailing of an anonymous survey was sent to 1,124 surgeons to collect institutional and physician demographics as well as indications for EDT on the basis of variable mechanisms of trauma, duration of arrest, and signs of life (SOL). Statistical analysis included the Pearson and linear-by-linear association chi(2) tests, independent samples t test, and univariate and multivariate analyses of variance; p values of < 0.05 were considered significant.

RESULTS

Completed surveys were received from 358 respondents. After 54 surveys were excluded that were incomplete, late, or from noneligible respondents, 304 surveys were analyzed. There were no significant differences in EDT indications among institutions of differing caseload volume, exposure to penetrating trauma, trauma level designation, American College of Surgeons verification status, or residency program affiliation. In addition, neither the respondent's position nor whether attendings versus residents performed the majority of EDTs influenced clinical decision-making. Performance criteria for EDT were liberal in comparison with established guidelines, especially for blunt trauma. The presence or recent loss of SOL influenced responses, but respondents varied greatly in their definition of SOL.

CONCLUSION

A lack of agreement exists regarding the indications for EDT in multiple clinical scenarios as well as in defining SOL. Indications for EDT were liberal, especially for blunt trauma-related indications, and were determined by clinical parameters, not by physician or institutional factors. Our results suggest that clinical practice is at variance with Advanced Trauma Life Support guidelines. We recommend that practice guidelines for EDT be established on the basis of a consensus definition of SOL to allow for a more uniform and selective approach to EDT.

Emergency room thoracotomy for penetrating chest injury: effect of an institutional protocol

BACKGROUND

Emergency room thoracotomy (ERT) can be life saving in patients with penetrating chest injury. A protocol was established at our institution stating that ERT be performed for cases of cardiac tamponade secondary to penetrating chest trauma on patients with vital signs/mentation in the field or on arrival to the emergency room. To validate our protocol, we reevaluated patients undergoing ERT at our institution.

METHODS

In our retrospective review, there were 49 patients undergoing ERT over a 6-year period.

RESULTS

Survival in patients with vital signs was approximately 50%. Survival in those without was 0%. Compared with the preprotocol data, the number of ERTs declined from 32.2 cases per year to 8.1 cases per year. Overall survival increased from 4% to 20%. Neurologic outcome remained unchanged.

CONCLUSION

We believe that the data validate our protocol, and the establishment of a guideline has enabled us to maximize patient survival and minimize exposure risks to our staff.

Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series

OBJECTIVE

The purpose of this study is to present the rationale for an algorithm that describes the place of resuscitative thoracotomy in the prehospital management of a patient with penetrating chest injury, and to review a 6-year experience using this algorithm.

METHODS

This study was a retrospective review of all cases where a prehospital thoracotomy was performed by the medical teams of the London Helicopter Emergency Medical Service.

RESULTS

Thirty-nine prehospital thoracotomies were performed. Four (10%) patients survived, one with long-term disability. Factors associated with survival were stab wound, single cardiac wound, cardiac tamponade, and loss of pulse in the presence of an experienced prehospital doctor.

CONCLUSION

Current evidence suggests that patients who suffer a cardiac arrest more than 10 minutes away from emergency room thoracotomy are very unlikely to survive. Prehospital thoracotomy is associated with a small number of survivors. This intervention should be considered if there is an appropriately experienced, trained, and equipped doctor present, who is acting within a trauma system with ongoing training and quality assurance.

Emergency department thoracotomy: nursing implications for pediatric cases

Cardiac arrest in the pediatric patient is an infrequent event. Although an emergency department thoracotomy is a potentially lifesaving procedure, it should be used in only a small, select group of patients. A literature review was conducted to determine the indications, surgical techniques, emergency procedures, and nursing responsibilities associated with an emergency department thoracotomy.

Induced hypothermia during emergency department thoracotomy: an animal model

BACKGROUND

Induced hypothermia is used clinically to prevent ischemic injury during elective procedures. We present an animal model of asanguinous hypothermic (10 degrees C) circulatory arrest, induced through a left anterior lateral thoracotomy after exsanguinating uncontrolled hemorrhage.

METHODS

Through a left anterior thoracotomy, 26 swine (45-70 kg) sustained a laceration of the descending thoracic aorta, producing exsanguinating uncontrolled hemorrhage. After 5 minutes of severe hypotension (systolic BP <20 mm Hg), a 22 French Foley catheter was directed cephalad through the enlarged aortic wound. A solution (containing 42.5 mmol/L K+ and precooled to 1 degrees C) was infused to arrest/preserve the heart and brain. A second 24 French Foley catheter was then directed caudally through the same wound. The right atrium was opened to drain the venous system. The animal was cooled with a cardiopulmonary bypass pump (>5L/min) through the Foley catheters. Once 10 degree C was reached, a cannula was placed to the aortic root and the aortic laceration repaired. The animal was maintained at 10 degree C for a total of 90 minutes. Before the rewarming process, the circulation was rinsed with a solution containing normal levels of electrolytes followed by infusion of whole blood. Rewarming was performed by maintaining a 10-degree gradient on the heat exchanger. The first 16 animals were used in nonsurvival experiments to develop the technique and to record dural temperatures and electroencephalogram tracings. The last 10 animals were used to determine long-term survival and neurologic outcome. Group I: seven animals were kept at < 10 degrees C with flows less than 2L/min. Group II: three animals underwent 20, 30, and 40 minutes of no flow once they were cooled to 10 degrees C. After 6 weeks of survival and neurologic examinations, the brains were fixed for histologic evaluations.

RESULTS

The average time to cool the head to 18 degrees C and 10 degrees C was 6 minutes and 12 minutes, respectively. The hematocrit fell below 2% by the end of the cooling period. A total of 7 of the 10 animals from the long-term study survived. Group I: five of seven animals survived. Four of the survivors had no appreciable neurologic deficits, were fully functional at 6 weeks, and had no evidence of histologic injury. One of the five survivors in this group had moderate neurologic disability. Of the two animals that died, one died from air embolism from the i.v. line. The second death was in an animal for which maximal cooling to 2.7 degrees C was attempted. Group II: The first two animals that had "no flow" for 20 and 30 minutes were fully functional and had normal neurologic examinations. However, the second animal was found to have brain injury on histologic examination. The last animal in this group died of accidental extubation during recovery.

CONCLUSION

Induction of hypothermic arrest through the chest after exsanguination is possible. The further development of this technique may provide an extended state of "suspended animation" to allow for repairs of hemorrhaging injuries in trauma patients who require emergency department thoracotomy.

Survival after emergency department thoracotomy: review of published data from the past 25 years

BACKGROUND

Emergency department thoracotomy (EDT) has become standard therapy for patients who acutely arrest after injury. Patient selection is vitally important to achieve optimal outcomes without wasting valuable resources. The aim of this study was to determine the main factors that most influence survival after EDT.

STUDY DESIGN

Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates.

RESULTS

EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries. When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries. If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%. There was no clear single independent preoperative factor that could uniformly predict death.

CONCLUSIONS

The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department. All three factors-MOI, LOMI, and SOL-should be taken into account when deciding whether to perform EDT. Uniform reporting guidelines are needed to further elucidate the role of EDT taking into account the combination of MOI, LOMI, and SOL.