1
|
Cornillon A, Balbo J, Coffinet J, Floch T, Bard M, Giordano-Orsini G, Malinovsky JM, Kanagaratnam L, Michelet D, Legros V. The ROX index as a predictor of standard oxygen therapy outcomes in thoracic trauma. Scand J Trauma Resusc Emerg Med 2021; 29:81. [PMID: 34154631 PMCID: PMC8215800 DOI: 10.1186/s13049-021-00876-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thoracic trauma is commonplace and accounts for 50-70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation. METHODS Patient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma. RESULTS One hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80-0.94], 81.63sensitivity, 95%CI [0.69-0.91] and 88.52 specificity, 95%CI [0.82-0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma. CONCLUSION We have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.
Collapse
Affiliation(s)
- Adrien Cornillon
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Juliette Balbo
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Julien Coffinet
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Thierry Floch
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France
| | - Mathieu Bard
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France.,University of Reims Champagne Ardennes, Reims, France
| | - Guillaume Giordano-Orsini
- University of Reims Champagne Ardennes, Reims, France.,Department of Emergency Medicine, Reims University Hospital, Reims, France
| | - Jean-Marc Malinovsky
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France.,University of Reims Champagne Ardennes, Reims, France
| | - Lukshe Kanagaratnam
- University of Reims Champagne Ardennes, Reims, France.,Clinical Research Unit, Reims University Hospital, Reims, France
| | - Daphne Michelet
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Vincent Legros
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France.
| |
Collapse
|
2
|
Monchal T, Martin MJ, Antevil JL, Bennett DR, DeVries WC, Zakaluzny S, Ricca RL, Tien H, Mullenix PS, Stockinger ZT. Emergency Resuscitative Thoracotomy in the Combat or Operational Environment. Mil Med 2019; 183:92-97. [PMID: 30189054 DOI: 10.1093/milmed/usy117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Indexed: 11/15/2022] Open
Abstract
Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest.
Collapse
Affiliation(s)
- Tristan Monchal
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew J Martin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jared L Antevil
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Donald R Bennett
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - William C DeVries
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Scott Zakaluzny
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Robert L Ricca
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Homer Tien
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX.,Canadian Forces Health Services
| | - Philip S Mullenix
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt T Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| |
Collapse
|
3
|
Smith JE, Le Clerc S, Hunt PAF. Challenging the dogma of traumatic cardiac arrest management: a military perspective. Emerg Med J 2015; 32:955-60. [PMID: 26493124 DOI: 10.1136/emermed-2015-204684] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 09/28/2015] [Indexed: 11/04/2022]
Abstract
Attempts to resuscitate patients in traumatic cardiac arrest (TCA) have, in the past, been viewed as futile. However, reported outcomes from TCA in the past five years, particularly from military series, are improving. The pathophysiology of TCA is different to medical causes of cardiac arrest, and therefore, treatment priorities may also need to be different. This article reviews recent literature describing the pathophysiology of TCA and describes how the military has challenged the assumption that outcome is universally poor in these patients.
Collapse
Affiliation(s)
- J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, Derriford Hospital, Plymouth, UK
| | - S Le Clerc
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, James Cook University Hospital, Middlesbrough, UK
| | - P A F Hunt
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
4
|
|
5
|
Puchwein P, Sommerauer F, Clement HG, Matzi V, Tesch NP, Hallmann B, Harris T, Rigaud M. Clamshell thoracotomy and open heart massage--A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study. Injury 2015; 46:1738-42. [PMID: 26068645 DOI: 10.1016/j.injury.2015.05.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/29/2015] [Accepted: 05/19/2015] [Indexed: 02/02/2023]
Abstract
AIMS Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. METHODS We adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. RESULTS The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. CONCLUSION Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment.
Collapse
Affiliation(s)
- Paul Puchwein
- Medical University of Graz, Department for Traumatology, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - Florian Sommerauer
- Medical University of Graz, Department for Traumatology, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Hans G Clement
- Unfallkrankenhaus Graz, Göstinger Straße 24 8020 Graz, Austria
| | - Veronika Matzi
- Unfallkrankenhaus Graz, Göstinger Straße 24 8020 Graz, Austria
| | - Norbert P Tesch
- Medical University of Graz, Institute of Anatomy, Harrachgasse 21, 8010 Graz, Austria
| | - Barbara Hallmann
- Medical University of Graz, Department for Anaesthesiology and Intensive Care, Auenbruggerplatz 29, 8036 Graz, Austria
| | - Tim Harris
- Queen Mary University of London and Barts Health NHS Trust, Whitechapel, London, UK
| | - Marcel Rigaud
- Medical University of Graz, Department for Anaesthesiology and Intensive Care, Auenbruggerplatz 29, 8036 Graz, Austria
| |
Collapse
|
6
|
Abstract
BACKGROUND Resuscitative thoracotomy is a heroic procedure that may offer the only survival hope for trauma patients in extremis. However, this operation has been the subject of much debate and its use, feasibility, outcomes, and cost are being continuously re-evaluated. METHODS This is a review of the most current (after 2000) literature on resuscitative thoracotomy, based on computer database searches for studies on resuscitative thoracotomy, emergency department thoracotomy, and emergency thoracotomy. Studies were selected for inclusion in this review based on their relevance and contribution to our understanding of resuscitative thoracotomy. RESULTS A total of 37 studies were included, and the following resuscitative thoracotomy-related topics were critically discussed: indications, biochemical profile, long-term outcome, organ donation, pre-hospital use, military use, international aspects, intra-aortic balloon occlusion, suspended animation, and cost and occupational exposure. CONCLUSIONS This review demonstrates that the indications for resuscitative thoracotomy become clearer and that new information is available regarding its use in the pre-hospital urban environment and military settings. Furthermore, it points to new strategies to supplement resuscitative thoracotomy including intra-aortic balloon occlusion and suspended animation. Finally, it sheds light on the long-term outcomes, organ donation, and cost and occupational exposure following resuscitative thoracotomy.
Collapse
Affiliation(s)
- R Rabinovici
- Division of Trauma and Acute Care Surgery, Tufts Medical Center, Boston, MA, USA
| | - N Bugaev
- Division of Trauma and Acute Care Surgery, Tufts Medical Center, Boston, MA, USA
| |
Collapse
|
7
|
Harrison OJ, Lockey D. Should resuscitative thoracotomy be performed in the pre-hospital phase of care? TRAUMA-ENGLAND 2013. [DOI: 10.1177/1460408613488481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Penetrating thoracic trauma is increasing in the UK and elsewhere and immediate transfer to a Major Trauma Centre with cardio-thoracic expertise is usually optimal management. Pre-hospital traumatic cardiac arrest has an extremely poor prognosis. Performing thoracotomy before arrival in hospital has produced neurologically intact survivors in several case series. The technique described involves rapid clamshell thoracotomy and release of pericardial tamponade. Favourable outcomes appear to be associated with a single stab wound to the heart causing cardiac tamponade. Pre-hospital thoracotomy is described in the current European Resuscitation Guidelines and courses for non-surgeons are now taught at the Royal College of Surgeons of England and at the Surgical Skills Training Centre at Newcastle Freeman Hospital. It is likely that further survivors will be reported as the technique becomes more widely used. Alternatives to pre-hospital thoracotomy in the future for patients with hypovolaemic cardiac arrest may include resuscitative endovascular balloon occlusion of the aorta and pre-hospital extended preservation and resuscitation.
Collapse
Affiliation(s)
| | - David Lockey
- North Bristol NHS Trust, Bristol, UK
- Barts Health NHS Trust, UK
- School of Clinical Sciences, University of Bristol, UK
| |
Collapse
|