Contemporary Utilization of Resuscitative Thoracotomy: Results From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Multicenter Registry

Emergency Department Thoracotomy: Time to Stop - A Trauma Video Review

INTRODUCTION

Emergency department thoracotomy (EDT) can restore spontaneous circulation in selected trauma patients as a bridge to definitive operating room repair. Compared with medical cardiopulmonary resuscitation, there is little guidance on EDT resuscitation duration in trauma. We hypothesized that prolonged EDT resuscitation efforts was not associated with durable return of spontaneous circulation (ROSC) (ROSC with survival to operating room).

METHODS

This institutional review board approved study was performed at a level 1 trauma center from January 2022 to January 2023. Trauma bay video and electronic medical data were reviewed on patients undergoing EDT. Patients with inadequate video data, known to be under the age of 18, known to be a prisoner, or known to be pregnant were excluded. Resuscitation duration was defined as EDT incision start to ROSC and/or death pronouncement.

RESULTS

Seven of 41 patients (39 gunshots, 2 blunt) achieved ROSC after EDT. Comparing patients achieving durable ROSC versus not, there was no difference in median time until incision (ROSC 3.2 min versus no ROSC 2.7 min, P = 0.85) or resuscitation duration (ROSC 8.2 min versus no ROSC 10.5 min, P = 0.62). No patients achieved durable ROSC after 20 min of resuscitation. Two of seven durable ROSC patients survived through hospital discharge-both were neurologically intact and achieved durable ROSC within 10 min.

CONCLUSIONS

In this trauma video review study, prolonged EDT resuscitation times was not associated with increased durable ROSC rates. Prolonged resuscitations should prompt critical re-evaluation for futility.

Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database

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.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be superior to resuscitative thoracotomy (RT) in patients with traumatic brain injury (TBI)

Background

The effects of aortic occlusion (AO) on brain injury are not well defined. We examined the impact of AO by resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative thoracotomy (RT) on outcomes in the setting of traumatic brain injury (TBI).

Methods

Patients sustaining TBI who underwent RT or REBOA in zone 1 (thoracic aorta) from September 2013 to December 2018 were identified. The indication for REBOA or RT was hemodynamic collapse due to hemorrhage below the diaphragm. Primary outcomes included mortality and systemic complications.

Results

282 patients underwent REBOA or RT. Of these, 76 had mild TBI (40 REBOA, 36 RT) and 206 sustained severe TBI (107 REBOA, 99 RT). Overall, the mean (±SD) age was 42±17 years, with an Injury Severity Score (ISS) of 40±17 and mean systolic blood pressure (SBP) at the time of REBOA or RT of 81±34 mm Hg. REBOA patients had a mean SBP at the time of AO of 78.39±29.45 mm Hg, whereas RT patients had a mean SBP of 83.18±37.87 mm Hg at the time of AO (p=0.24). 55% had ongoing cardiopulmonary resuscitation (CPR) at the time of AO, and the in-hospital mortality was 86%. Binomial logistic regression controlling for TBI severity, age, ISS, SBP at the time of AO, crystalloid infusion, and CPR during AO demonstrated that the odds of mortality are 3.1 times higher for RT compared with REBOA. No significant differences were found in systemic complications between RT and REBOA.

Discussion

Patients with TBI who receive REBOA may have improved survival, but no difference in systemic complications, compared with patients who receive RT for the same indication. Although some patients are receiving RT prior to arrest for extrathoracic hemorrhagic shock, these results suggest that REBOA should be considered as an alternative to RT when RT is chosen for the sole purpose of resuscitation in the setting of TBI.

Level of evidence

4.

A National Study of Emergency Thoracotomy for Trauma

Introduction:

The role of resuscitative thoracotomy in the emergency department (ED) for patients that have suffered severe thoracoabdominal trauma has been the subject of much debate. Most studies that characterize emergency thoracotomy are from urban, academic, and trauma centers. We sought to describe patient and hospital characteristics of a nationally representative sample of ED thoracotomy (EDT).

Methods:

The health-care cost and utilization project 2013 National ED Sample (NEDS) and the 2013 National Inpatient Sample (NIS) maintained by the agency for health-care research and quality were used to generate a nationally representative estimate of resuscitative thoracotomies performed in the ED. We obtained patient demographics and clinical characteristics and compared the descriptive statistics of the two datasets.

Results:

The NEDS dataset identified 124 unsuccessful EDTs, whereas the NIS dataset identified 77 admissions for thoracotomy. When weighted to create a national estimate, these represent 952 emergency thoracotomies performed in the US in 2013. Most were male (82.5% and 88.2% in NEDS and NIS, respectively). In addition, 32.9% and 36.4% in NEDS and NIS, respectively, were between the ages of 20 and 29. The majority of thoracotomies were performed at metropolitan teaching hospitals (64.2% and 75.3%, NEDS and NIS, respectively). The mean total ED charges for patients who had an unsuccessful thoracotomy were $32,664 and the mean total inpatient charges were $141,215.

Conclusion:

Nearly 1000 thoracotomies are performed annually on the day of presentation to U. S. hospitals. Although emergency thoracotomy for trauma is an infrequently performed procedure, it almost always occurs at an urban, high volume, and level I or level II trauma centers.

Structured and Systematic Team and Procedure Training in Severe Trauma: Going from 'Zero to Hero' for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods

Background

Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome.

Methods

An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time.

Results

Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time.

Conclusion

The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

Supplementary Information

The online version contains supplementary material available at (doi:10.1007/s00268-021-05980-1).

Validation of a Novel Clinical Criteria to Predict Candidacy for Aortic Occlusion: An Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Study

For trauma patients with noncompressible truncal hemorrhage (NCTH), aortic occlusion (AO) is attempted with either resuscitative thoracotomy (RT) or the resuscitative endovascular balloon occlusion of the aorta (REBOA). However, it is often challenging to identify the group of patients who would benefit from AO procedures. We hypothesized that patients who met simple clinical criteria would have better outcomes following AO procedures. This is a retrospective cohort study using the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database (November 2013-August 2019) which included patients who arrived with signs of life and underwent AO procedures (RT or zone 1 REBOA). Outcomes were compared between patients who met the criteria (admission vital signs: Glasgow Coma Scale (GCS) ≥9 and systolic blood pressure <90 mm Hg) and those who did not. Subgroup analyses were then conducted on patients who had a REBOA placed and those who underwent RT. A total of 998 patients met our inclusion criteria. Of those, a REBOA was placed in 364 patients (37%), while 634 (64%) underwent RT. The overall mortality rate in the criteria (+) group was significantly lower than that in the criteria (-) group (62 vs. 79%, P < .001). In patients who survived beyond the emergency department following AO procedures, those who met the criteria underwent hemorrhage control procedures more frequently (83% vs. 57%, P < .001). Our data suggest that simple clinical criteria could guide the provider for proceeding with AO in patients with suspected NCTH.

Does Clamshell Thoracotomy Better Facilitate Thoracic Life-Saving Procedures Without Increased Complication Compared with an Anterolateral Approach to Resuscitative Thoracotomy? Results from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry

BACKGROUND

Resuscitative thoracotomy (RT) is life-saving in select patients and can be accomplished through a left anterolateral (AT) or clamshell thoracotomy (CT). CT may provide additional exposure, facilitating certain operative procedures, but the added blood and heat loss and time to perform it may increase complications. No prospective multicenter comparison of techniques has yet been reported.

STUDY DESIGN

The observational AAST Aortic Occlusion for Resuscitation in Trauma and Acute care surgery (AORTA) registry was used to compare AT and CT in RT.

RESULTS

AORTA recorded 1,218 RTs at 46 trauma centers from June 2014 to January 2020. Overall survival after RT was 6.0% (AT 6.6%; [59 of 900]; CT 4.2% [13 of 296], p = 0.132). Among all RTs, 11.1% (142 of 1,278) surviving at least 24 hours were used tocompare AT (112) and CT (30). There was no difference between the 2 groups withregard to age, sex, Injury Severity Score, or mechanism of injury (Table 1). CT was significantly more likely to be used in patients needing resection of the lung or cardiac repair. CT was not associated with increased local thoracic/systemic complications, higher transfusion requirement, or greater ventilator, ICU, or hospital days compared with AT.

CONCLUSIONS

Clamshell thoracotomy facilitates thoracic life-saving procedures withoutincreased systemic or thoracic complications compared with AT in patients undergoing RT.

Are We Out of the Woods Yet? The Aftermath of Resuscitative Thoracotomy

BACKGROUND

After traumatic arrest, resuscitative thoracotomy is lifesaving in appropriately selected patients, yet data are limited regarding hospital course after intensive care unit (ICU) admission. The objective of this study was to describe the natural history of resuscitative thoracotomy survivors admitted to the ICU.

MATERIALS AND METHODS

We conducted a retrospective review (January 1, 2012-June 30, 2017) of all adult trauma patients who underwent resuscitative thoracotomy after traumatic arrest at two adult level 1 trauma centers. Data evaluated include demographics, injury characteristics, hospital course, and outcome.

RESULTS

Over 66 mo, there were 52,624 trauma activations. Two hundred ninety-eight patients underwent resuscitative thoracotomy and 96 (32%) survived to ICU admission. At ICU admission, mean age was 35.8 ± 14.5 y, 79 (82%) were male, 36 (38%) sustained blunt trauma, and the mean injury severity score was 32.3 ± 13.7. Eight blunt and 20 penetrating patients (22% and 34% of ICU admissions, respectively) survived to discharge. 67% of deaths in the ICU occurred within the first 24 h, whereas 90% of those alive at day 21 survived to discharge. For the 28 survivors, mean ICU length of stay was 24.1 ± 17.9 d and mean hospital length of stay was 43.9 ± 32.1 d. Survivors averaged 1.9 ± 1.5 complications. Twenty-four patients (86% of hospital survivors) went home or to a rehabilitation center.

CONCLUSIONS

After resuscitative thoracotomy and subsequent ICU admission, 29% of patients survived to hospital discharge. Complications and a long hospital stay should be expected, but the functional outcome for survivors is not as bleak as previously reported.

Thoracic trauma in military settings: a review of current practices and recommendations

PURPOSE OF REVIEW

To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population.

RECENT FINDINGS

Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters.

SUMMARY

The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.