Emergency thoracotomy in trauma: rationale, risks, and realities

Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries

PURPOSE

To develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees' performance for emergent and urgent thoracic surgeries.

METHODS

With a homemade machine, animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage, urgent sternotomy, and emergent thoracotomy. Coefficient of variation of abbreviated injury scale and blood loss was calculated to judge the reproducibility of animal models. Five operation teams from basic-level hospitals (group A) and five operation teams from level III hospitals (group B) were included to be trained and tested. Testing standards for the operations were established after thorough literature review, and expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards. Tests were carried out after the training. Pre- and post-training performances were compared. Post-training survey using 7-point Likert scale was taken to evaluate the feelings of the trainees to these training approaches.

RESULTS

Animal models of the three kinds of penetrating chest injuries were successfully established and the coefficient of variation of abbreviated injury scale and blood loss were all less than 25%. After literature review, testing standards were established, and expert questionnaire results showed that the scientific score was 7.30 ± 1.49, and the feasibility score was 7.50 ± 0.89. Post-training performance was significantly higher in both group A and group B than pre-training performance. Post-training survey showed that all the trainees felt confident in applying the operations and were generally agreed that the training procedure were very helpful in improving operation skills for thoracic penetrating injury.

CONCLUSIONS

Animal model-based simulation training established in the current study could improve the trainees' performance for emergent and urgent thoracic surgeries, especially of the surgical teams from basic-level hospitals.

A comparison of mortality and indicators of treatment success of resuscitative endovascular balloon occlusion of aorta (REBOA): a systematic review and meta-analysis

Background

Emergency resuscitative thoracotomy (RT) is a recognised method of controlling non-compressible torso haemorrhage (NCTH) often in adjunct to emergency surgery. Recently, there is much debate regarding resuscitative endovascular balloon occlusion of aorta (REBOA) on its role in civilian trauma cases in controlling NCTH. This study aims to provide an updated review on in-hospital mortality rates in patients who underwent REBOA versus RT and standard care without REBOA (non-REBOA) and to identify the potential indicators of REBOA survival.

Methods

Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to perform the study. All adult trauma cases were included, while pre-hospital, military and non-English studies were excluded. A literature search was done on studies from 01 January 2005 to 30 June 2020 using EMBASE, MEDLINE and COCHRANE databases. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. Meta-analysis was conducted using a random effects model and the DerSimonian and Laird estimation method. A significance level of p < 0.05 was used.

Results

Twenty-five studies were included in this study. The odds of in-hospital mortality of patients who underwent REBOA compared to RT was 0.18 (p < 0.01, 0.12-0.26). The odds of in-hospital survival of patients who underwent REBOA compared to non-REBOA was 1.28 (p = 0.62, 0.46-3.53). There was a significant difference found between survivors and non-survivors in terms of their pre-REBOA systolic blood pressure (SBP) (19.26 mmHg, p < 0.01), post-REBOA SBP (20.73 mmHg, p < 0.01), duration of aortic occlusion (- 40.57 min, p < 0.01) and injury severity score (- 8.50, p < 0.01).

Conclusions

REBOA has a potential for wider application in civilian settings, with our study demonstrating lower in-hospital mortality compared to RT. Prospective multi-centre studies are needed for further evaluation of the indications and feasibility of REBOA.Level of Evidence + Study Type: Level IV. Systematic review with meta-analysis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-022-01413-3.

Successful management of a combined cardiopulmonary penetrating injury: a case report

Background

Penetrating thoracic injury is a type of critical illness with a high mortality rate, which often involves the heart, large blood vessels, and lungs. Penetrating cardiac injury is a very serious condition, and most patients die rapidly within minutes due to hemorrhagic shock and acute cardiac tamponade. Due to the critical condition and rapid development of this type of injury, most patients die before reaching the hospital. It is rare in clinical practice and difficult to treat.

Case Description

Our hospital recently admitted a case of penetrating cardiac injury. In this case, a 50-year-old male was admitted to the hospital following “a fall from a height [that] caused steel bar[s] to penetrate the chest cavity for 7 hours before he arrived at the hospital”. The patient fell from a height of 3meters at a construction site, which caused 2 steel bars to penetrate his chest. The patient presented with symptoms such as chest pain, dyspnea, and apathy. Chest computed tomography suggested combined cardiopulmonary penetrating injury. Echocardiography suggested penetrating cardiac injury, and moderate pericardial effusion. After the patient was sent to the Emergency Department of our hospital, the relevant laboratory examinations and an emergency surgery were performed. The rescue team consisting of cardiac surgery, thoracic surgery, anesthesiology, emergency department, and imaging department specified the treatment plan. Under general anesthesia, cardiopulmonary bypass was performed via right femoral arteriovenous cannulation. The steel bars were removed, the left atrial posterior wall and ventricular septal perforation were repaired, and the great cardiac vein was sutured. Coronary artery bypass surgery was performed at the same time, and the anterolateral lung tissue of the left lower lobe was resected. Postoperative treatment was given to prevent against infection and improve cardiopulmonary function. The patient recovered well, and he was discharged from the hospital. The results of the follow-up 1 year after surgery were normal.

Conclusions

Timely treatment and a reasonable operation mode is essential in treating this kind of trauma. A joint diagnosis and treatment by a multidisciplinary team can enable a comprehensive assessment of the condition to be made quickly and an optimal treatment plan to be formulated.

A Life Saving Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with Open Groin Technique

A 53-year-old male pedestrian was hit by a car and arrived at our hospital with a blunt abdominal injury and hemorrhagic shock. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was performed in a timely fashion using the open groin technique in the emergency room. The procedure resulted in rapid improvement of hemodynamic status while the bleeding source was controlled. Recently, REBOA is a proper adjunctive procedure in major non-compressible torso hemorrhage patients. The procedure requires a portable X-ray or fluoroscopic machine in the ER to confirm the balloon’s position. This method has likely limited the use of REBOA in developing countries. The procedure with open groin technique, using anatomical landmarks and physiologic change to confirm the position of the balloon, has been developed to address these concerns. Here we report on the treatment’s success with this technique and believe that it can benefit trauma patient care.

Surgical management of traumatic diaphragmatic hernia: a single institutional experience of more than two decades

Background

We present here our experience with surgical management of traumatic diaphragmatic hernia, trying to find out the era impact of different periods on the outcome and risk factors of mortality.

Methods

A series of 63 patients with traumatic diaphragmatic hernia were referred to us and operated on during March, 1990-August, 2017. The patient records were reviewed and statistically analyzed to demonstrate injury characteristics and to find out optimal treatment strategy, risk factors of death as well as the difference between two periods (1990–2005, 2005–2017) divided by introduction of computed tomography at our institution.

Results

The overall mean age was 31.2 ± 16.3 years old with a female to male ratio of 11/52. The mechanism was penetrating trauma in 19 cases (30.2%), and blunt trauma in 44 cases (69.9%). Two thirds of the patients in the second group (2005–2017) yet none in the first group (1990–2005) underwent computed tomography. Ten patients (15.9%), of which 8 in the first and the other 2 in the second group (p = .042), had late diagnoses. The most commonly used incision was a thoracotomy (n = 43, 89.6%). There was no statistical difference in etiology or mortality between the two periods. Univariate analysis showed survivors were younger, and had lesser injury severity scores (ISS) and lower American Association for the Surgery of Trauma (AAST) grade than non-survivors. By multivariate logistic regression analysis, increased age (odds ratio, 1.275; p = .013) and greater ISS (OR, 1.174; p = .028) were risk factors of death in all patients.

Conclusions

High-definition computed tomography has significantly improved the preoperative diagnosis rate. The transthoracic approach could be used in selected cases with traumatic diaphragmatic hernia with good outcomes. Patients with greater ISS and advanced ages are at a higher risk of death.

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).

Surviving traumatic cardiac arrest: Identification of factors associated with survival

INTRODUCTION

The endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary arrest varies across institutions and even among providers. The purpose of this study was to examine survival characteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED).

METHODS

The National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hospitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed.

RESULTS

A total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mechanism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99).

CONCLUSION

Over a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physicians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review

BACKGROUND

Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries.

METHODS

Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints.

RESULTS

A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT.

CONCLUSIONS

EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

Performance and outcome evaluation of emergency resuscitative thoracotomy in a Norwegian trauma centre: a population-based consecutive series with survival benefits

BACKGROUND

Emergency resuscitative thoracotomy (ERT) is a lifesaving procedure for select indications in severely injured patients. The main body of the literature stem from regions with a high prevalence of penetrating injuries, while data from European institutions remain scarce. We aimed to evaluate a decade of ERT in a Norwegian trauma centre.

METHODS

A prospectively collected series from the institutional trauma registry of all consecutive trauma patients who had an ERT at Stavanger University Hospital (SUH) from 2006 to 2018. Data were extracted using both registry and electronic patient record (EPR) data, including injury profile, demographics and outcomes. Comparison of groups were done by descriptive statistics.

RESULTS

A total of 26 ERTs were performed during the study period, of which 20 were men (75%) and 6 women (25%). Five patients (19%) survived to hospital discharge, of which 3 men and 2 women with a median age of 46 years (range 24-68). All survivors had thoracic injury as location of major injury (LOMI.). Of the five survivors, four suffered blunt injury and one patient penetrating injury. At one-year of follow-up of the survivors, three patients scored 8/8 on Glasgow outcome scale-extended, 1 patient scored 7/8 and one patient 5/8.

CONCLUSION

In this study, ERT conferred good outcome with survival in one of every five procedures. Performing ERT in severely injured patients presenting in extremis appears to be justified even in low-volume centres and in blunt trauma.

Is Emergency Department Thoracotomy Effective in Trauma Resuscitation? The Retrospective Study of the Emergency Department Thoracotomy in Trauma Patients at Thammasat University Hospital, Thailand

Introduction:

The survival rate after the emergency department thoracotomy (EDT) in trauma patients varies from the previous study as 1.6% in blunt injury and 11.2% in penetrating injury. Most of the data came from Europe, the US, South Africa, and Japan. This study aims to identify the success of EDT of trauma patients at Thammasat University Hospital, Thailand, and to evaluate the effectiveness of EDT. This study may be representative data for Southeast Asia.

Materials and Methods:

This retrospective review of 21 consecutive EDT cases which performed by our staffs and chief of general surgery residents between June 2009 and July 2016. Age, gender, injury mechanisms, injury sites, patient transport methods, initial vital signs, fluids and blood component requirements, resuscitation times, laboratory results, and injury severity scores were all analyzed.

Results:

Of the 21 EDT cases, one patient was excluded due to being a nontraumatic case. The remaining twenty patients were primarily young (mean 36.5 years), male (85%), suffering from blunt injuries (75%), of which 45% were predominantly thoracic injuries. Most of the patients presented without any sign of life (75%), and the total time for resuscitation was 43.5 ± 19.6 min. Seven patients (35%) had the return of spontaneous circulation (ROSC) and were successful in being brought to the operating room. Unfortunately, all patients passed away within 24 h of the operation.

Conclusions:

The ROSC rate of EDT in this study was 35%, but with no survival benefit. Therefore, we cannot guarantee that EDT serves as an effective life-saving procedure. However, EDT may play a significant role in treating extremis injured patients.

Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU®

AIM OF THE STUDY

Emergency department thoracotomy (EDT) may be the last chance for survival in some severe thoracic trauma. This study investigates a representative collective with the aim to compare the findings in Europe to the international experience. Moreover, the influence of different levels of trauma care is investigated.

METHODS

All emergency thoracotomies in patients with an ISS ≥ 9 from TR-DGU (2009-2014) within the first 60 min after arrival were identified. EDTs were identified separately, and mini thoracotomies and drainage systems were excluded.

RESULTS

99,013 patients with sufficient data were observed. 1736 (1.8%) received thoracotomy during their hospital stay. 887 patients had a thoracotomy within the first hour in the emergency department (ED). 52.5% were treated in supraregional trauma centers (STC), 36.4% in regional (RTC) and 11.0% in local trauma centers (LTC). The mortality rates were 39.4% (STC), 20.9% (RTC) and 20.8% (LTC). The overall mortality rate showed no significant differences for blunt (28.2%) and penetrating trauma (31.3%). In case of cardiac arrest in the ED, a survival rate of 4.8% for blunt trauma and 20.7% for penetrating trauma was determined if EDT was carried out. Those patients showed a higher rate in severe thoracic organ injuries due to penetrating trauma but less extrathoracic injuries.

CONCLUSION

Just over half of EDTs were performed in STC. Emergency room resuscitation followed by EDT had survival rates of 4.8% and 20.7% for blunt and penetrating trauma patients, respectively.

The epidemiology of emergency department thoracotomy in a statewide trauma system: Does center volume matter?

BACKGROUND

The relationship between high volume and improved outcomes has been described for a host of elective high-impact, low-frequency procedures, but there are little data to support such a relationship in high-impact low-frequency procedures in trauma. Using emergency department thoracotomy (EDT) as a model, we hypothesized that patients presenting to centers with higher institutional volumes of EDT would have improved survival referent to those presenting to lower volume institutions.

METHODS

We queried the Pennsylvania Trauma Outcomes Study registry from 2007 to 2015 for all EDTs performed at Level I and II centers identified by ICD-9 procedure codes and a location stamp indicating the emergency department. We examined patient-level risk factors for survival in univariate regression and multivariable regression models. Centers were divided into tertiles of mean annual EDT volume, and the association between mean annual EDT volume and patient survival was examined using logistic regression after controlling for patient factors.

RESULTS

1,399 EDTs were performed at 28 centers. Overall survival was 6.8%. After controlling for patient age, mechanism of injury, signs of life, and injury severity, patients presenting to centers in the highest tertile of volume had significantly higher odds of survival compared with patients presenting to centers in the lowest tertile of volume (OR 4.56, 95% CI 1.43-14.50).

CONCLUSIONS

Patients presenting to centers with higher mean annual volume of EDTs have improved survival compared with those presenting to institutions with lower mean annual EDT volume. Efforts to understand the etiology of this finding may lead to interventions to improve outcomes at lower-volume centers.

LEVEL OF EVIDENCE

Prognostic/Epidemiological, level III; Therapeutic, level IV.

Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in exsanguinating torso hemorrhage, but causes ischemic injury to distal organs. The aim was to investigate whether blood pressure targeting by partial REBOA (pREBOA) is possible in porcine severe hemorrhagic shock and to compare pREBOA and total REBOA (tREBOA) regarding hemodynamic, metabolic and inflammatory effects.

METHODS

Eighteen anesthetized pigs were exposed to induced controlled hemorrhage to a systolic blood pressure (SBP) of 50 mmHg and randomized into three groups of thoracic REBOA: 30 min of pREBOA (target SBP 80-100 mmHg), tREBOA, and control. They were then resuscitated by autologous transfusion and monitored for 3 h. Hemodynamics, blood gases, mesenteric blood flow, intraperitoneal metabolites, organ damage markers, histopathology from the small bowel, and inflammatory markers were analyzed.

RESULTS

Severe hemorrhagic shock was induced in all groups. In pREBOA the targeted blood pressure was reached. The mesenteric blood flow was sustained in pREBOA, while it was completely obstructed in tREBOA. Arterial pH was lower, and lactate and troponin levels were significantly higher in tREBOA than in pREBOA and controls during the reperfusion period. Intraperitoneal metabolites, the cytokine response and histological analyses from the small bowel were most affected in the tREBOA compared to the pREBOA and control groups.

CONCLUSION

Partial REBOA allows blood pressure titration while maintaining perfusion to distal organs, and reduces the ischemic burden in a state of severe hemorrhagic shock. Partial REBOA may lower the risks of post-resuscitation metabolic and inflammatory impacts, and organ dysfunction.

Critical analysis of thoracotomies performed in the emergency room in 10 years

OBJECTIVE

To conduct a critical analysis of thoracotomies performed in the emergency rooms.

METHODS

We analyzed mortality rates and survival as outcome variables, mechanism of injury, site of injury and anatomic injury as clinical variables, and gender and age as demographic variables of patients undergoing thoracotomy in the emergency room after traumatic injury.

RESULTS

Of the 105 patients, 89.5% were male. The average age was 29.2 years. Penetrating trauma accounted for 81% of cases. The most common mechanism of trauma was wound by a firearm projectile (gunshot), in 64.7% of cases. Patients with stab wounds (SW) accounted for 16.2% of cases. Overall survival was 4.7%. Survival by gunshot was 1.4%, and by SW, 23.5%. The ERT following blunt trauma showed a 100%mortality.

CONCLUSION

The results obtained in the Emergency Hospital of Porto Alegre POA-HPS are similar to those reported in the world literature.

The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh

‘The pre-hospital management of chest injury: a consensus statement’ was originally published by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in 2007. To update the pre-existing guideline, a consensus meeting of stakeholders was held by the Faculty of Pre-hospital Care in Coventry in November 2013. This paper provides a guideline for the pre-hospital management of patients with the life-threatening chest injuries of tension pneumothorax, open pneumothorax, massive haemothorax, flail chest (including multiple rib fractures), and cardiac tamponade.

Comparison of risk-adjusted survival in two Scandinavian Level-I trauma centres

BACKGROUND

Assessment of trauma-system performance is important for improving the care of injured patients. The aim of the study was to compare risk-adjusted survival in two Scandinavian Level-I trauma centres.

METHODS

This was an observational, retrospective study of prospectively-collected trauma registry data for patients >14 years from Karolinska University Hospital - Solna (KUH), Sweden, and Oslo University Hospital - Ullevål (OUH), Norway, from 2009-2011. Probability of survival (Ps) was calculated according to the Trauma and Injury Severity Score (TRISS) method. Risk-adjusted survival per patient was calculated by assigning every patient a value corresponding to gained or lost fractional life: Each survivor contributed a reward of 1-Ps and each death a penalty of -Ps. The sum of penalties and rewards, corresponding to the difference between expected and actual mortality, was compared between the centres. We present the data as excess survivors per 100 trauma patients.

RESULTS

There were 4485 admissions at KUH and 3591 at OUH. The proportion of severely injured patients was higher at OUH compared with KUH (Injury Severity Score [ISS] >15: 33.9 % vs. 21.1 %, p <0.001). OUH had a larger proportion of patients >65 years (16.0 % vs. 13.4 %, p <0.001) and greater comorbidity (ASA-PS ≥3: 14.6 % vs. 6.9 %, p <0.001) compared with KUH. The frequency of helicopter transport and presence of prehospital physicians was higher at OUH compared with KUH (27.6 % vs. 15.5 % and 30.5 % vs. 3.7 %, both p <0.001). Secondary admissions were 5.2-fold more common at OUH compared with KUH (p <0.001). There were no differences in 30-day mortality for severely injured patients (ISS >15). Risk-adjusted survival rate was higher at OUH than at KUH for primary (0.59 vs. 0.51) but lower for secondary (1.41 vs. 2.85) admissions (both p <0.001).

CONCLUSION

Adjustments for age as a continuous variable and comorbidity should be made when comparing risk-adjusted survival between hospitals, but this is not possible with the TRISS model. A survival prediction model that takes this into account may be a better choice for Scandinavian trauma populations. The current study could not rule out the influence of the system differences between the centres on risk-adjusted survival.

Aorta Balloon Occlusion in Trauma: Three Cases Demonstrating Multidisciplinary Approach Already on Patient's Arrival to the Emergency Room

PURPOSE

To describe the usage of aortic balloon occlusion (ABO), based on a multidisciplinary approach in severe trauma patients, emphasizing the role of the interventional radiologist in primary trauma care.

METHODS

We briefly discuss the relevant literature, the technical aspects of ABO in trauma, and a multidisciplinary approach to the bleeding trauma patient. We describe three severely injured trauma patients for whom ABO was part of initial trauma management.

RESULTS

Three severely injured multi-trauma patients were treated by ABO as a bridge to surgery and embolization. The procedures were performed by an interventional radiologist in the early stages of trauma management.

CONCLUSIONS

The interventional radiologist and the multidisciplinary team approach can be activated already on severe trauma patient arrival. ABO usage and other endovascular methods are becoming more widely spread, and can be used early in trauma management, without delay, thus justifying the early activation of this multidisciplinary approach.

Emergency resuscitative thoracotomy performed in European civilian trauma patients with blunt or penetrating injuries: a systematic review

PURPOSE

Emergency resuscitative thoracotomy (ERT) is a lifesaving procedure in selected patients. Indications are still being debated, but outcome in blunt trauma is believed to be poor. Recent reports from European populations, where blunt trauma predominates, have suggested favorable outcome also in blunt trauma. Our aim was to identify all European studies reported over the last decade and compare reported outcomes to existing knowledge.

METHODS

We performed a systematic literature search according to PRISMA guidelines (January 1st, 2004 to December 31st, 2014). The "grey literature" was included by searching Google Scholar. Qualitative comparison of studies and outcomes was done.

RESULTS

A total of 8 articles from Europe were included originating from Croatia, Norway (n = 2), Denmark, Iceland, the Netherlands, Scotland, and Switzerland. Of 376 resuscitative thoracotomies, 193 (51.3 %) were for blunt trauma. Male:female distribution was 3.5:1. The collectively reported overall survival was 42.8 % (n = 161), with 25.4 % (49 of 193) blunt trauma and 61.2 % (112 of 183) penetrating injuries. When strictly including those ERTs designated as done in the emergency department for blunt mechanism (n = 139) only, a total of 18 patients survived (12.9 %). Survival after EDTs for penetrating trauma was 41.6 % (37 of 89). Neurological outcome (reported in 5 of 8 studies) reported favorable neurological long-term outcome in the majority of survivors, even after blunt trauma. None referred to Glasgow Outcome Score. Heterogeneity in the studies prevented outcome analyses by formal quantitative meta-analysis.

CONCLUSION

The reported outcome after ERT in European civilian trauma populations is favorable, with one in every four ERTs in the ED surviving. Notably, outcome is at variance with previously reported collective data, in particular for blunt trauma. Multicenter, prospective, observational data are needed to validate the modern role of ERT in blunt trauma.

[Successful preclinical thoracotomy in a 17-year-old man]

We report the case of a 17-year-old man who sustained multiple stab wounds after a knife attack. After arrival of the emergency medical team the patient suffered a cardiac arrest caused by cardiac tamponade. After emergency thoracotomy and open heart massage the patient developed ROSC and could be discharged 13 days later without neurological deficits. Prehospital thoracotomy is rarely performed in Austria but is the only realistic chance for survival in cases of hematopericardium and tamponade. Better training of emergency physicians in Austria concerning surgical resuscitation could increase survival rates especially after penetrating thoracic trauma.

Current management of penetrating torso trauma: nontherapeutic is not good enough anymore

A highly organized approach to the evaluation and treatment of penetrating torso injuries based on regional anatomy provides rapid diagnostic and therapeutic consistency. It also minimizes delays in diagnosis, missed injuries and nontherapeutic laparotomies. This review discusses an optimal sequence of structured rapid assessments that allow the clinician to rapidly proceed to gold standard therapies with a minimal risk of associated morbidity.

A Patient With Blunt Trauma and Cardiac Arrest Arriving Pulseless at the Emergency Department; is that Enough Reason to Stop Resuscitation? Review of Literature and Case Report

The decision to stop or continue resuscitation in a patient with blunt trauma and cardiac arrest arriving pulseless to the hospital has always been controversial. While many authors still believe that it is a futile effort, with no chance of success for complete neurological recovery, some recent reports have challenged the idea. Here we report complete recovery of a severely injured patient following a motor vehicle accident who lost vital signs completely before arrival at our trauma center. No cardiac motion was detected on ultrasound examination on arrival. Emergency department thoracotomy, open cardiac massage, massive blood transfusion, damage control laparotomy with abdominal and pelvic packing, followed by angio-embolization of pelvic bleeding, and staged abdominal exploration were performed. This case is an example showing that resuscitation of patients with blunt trauma and cardiac arrest arriving pulseless to the hospital is not always futile.

Emergency thoracotomies: Two center study

Introduction and Aim:

Emergency thoracotomy is performed either immediately at the scene of injury, in the emergency department or in the operating room. It aims to evacuate the pericardial tamponade, control the haemorrhage, to ease the open cardiac massage and to cross-clamp the descending thoracic aorta to redistribute blood flow and maybe to limit sub-diaphragmatic haemorrhage, bleeding and iatrogenic injury are the common risk factors. We aimed to review our experience in the field of emergency thoracotomies, identify the predictors of death, analyze the early results, detect the risk factors and asses the mortalities and their risk factors.

Patients and Methods:

Our hospital records of 197 patients who underwent emergency thoracotomy were reviewed. We retrospectively analyzed a piece of the extensive experience of the Mansoura University Hospitals and Mansoura Emergency Hospital; Egypt and Saudi German Hospitals; Jeddah in the last 12 years in the management of trauma cases for whom emergency thoracotomy. The aim was to analyse the early results of such cases and to detect the risk factors of dismal prognosis.

Results:

Our series included 197 cases of emergency thoractomies in Mansoura; Egypt and SGH; Jeddah; KSA in the last 12 years. The mean age of the victims was 28 years and ranged between 5 and 62 years. Of the 197 patients with emergency thoracotomy, the indications were both penetrating and blunt chest trauma, iatrogenic and postoperative hemodynamito a surgical cause. The commonest indication was stab heart followed by traumatic diaphragmatic ruptures.

Conclusion:

The results of emergency thoracotomy in our series were cooping with the results of other reports, mainly due to our aggressive measures to achieve rapid stabilization of the hemodynamic condition. We emphasize the importance of emergency medicine education programs on rapid diagnosis of traumatic injuries with early intervention, and adequate hemodynamic and respiratory support. Emergency thoracotomy has an important role in emergency big volume hospitals and can save a lot of lives. Outcome can be improved by increasing the learning curve and the integrated cooperation of the emergency and surgical teams.

Penetrating cardiac trauma: 20-y experience from a university teaching hospital

BACKGROUND

Penetrating traumas, including gunshot and stab wounds, are the major causes of cardiac trauma. Our aim was to describe and compare the variables between patients with penetrating cardiac trauma in the past 20 y in a university hospital, identifying risk factors for morbidity and death.

METHODS

Review of trauma registry data followed by descriptive statistical analysis comparing the periods 1990-1999 (group 1, 54 cases) and 2000-2009 (group 2, 39 cases). Clinical data at hospital admission, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS) were recorded.

RESULTS

The incidences of penetrating cardiac injuries were steady within the period of study in the chosen metropolitan area. The two groups were similar regarding age, mechanism of trauma (gunshot × stab), and ISS. Group 1 showed lower systolic blood pressure at admission (mean 87 versus 109 mm Hg), lower GCS (12.9 versus 14.1), lower RTS (6.4 versus 7.3), higher incidence of grade IV-V cardiac lesions (74% versus 48.7%), and were less likely to survive (0.83 versus 0.93). The major risk factor for death was gunshot wound (13 times higher than stab wound), systolic blood pressure < 90 mm Hg, GCS < 8, RTS < 7.84, associated injuries, grade IV-V injury, and ISS > 25. We observed a tendency in mortality reduction from 20.3% to 10.3% within the period of observation.

CONCLUSIONS

Several associated factors for mortality and morbidity were identified. In the last decade, patients were admitted in better physiological condition, perhaps reflecting an improvement on prehospital treatment. We observed a trend toward a lower mortality rate.

Immediate thoracotomy for penetrating injuries: ten years' experience at a Dutch level I trauma center

BACKGROUND

An emergency department thoracotomy (EDT) or an emergency thoracotomy (ET) in the operating theater are both beneficial in selected patients following thoracic penetrating injuries. Since outcome-descriptive European studies are lacking, the aim of this retrospective study was to evaluate ten years of experience at a Dutch level I trauma center.

METHOD

Data on patients who underwent an immediate thoracotomy after sustaining a penetrating thoracic injury between October 2000 and January 2011 were collected from the trauma registry and hospital files. Descriptive and univariate analyses were performed.

RESULTS

Among 56 patients, 12 underwent an EDT and 44 an ET. Forty-six patients sustained one or multiple stab wounds, versus ten with one or multiple gunshot wounds. Patients who had undergone an EDT had a lower GCS (p < 0.001), lower pre-hospital RTS and hospital triage RTS (p < 0.001 and p = 0.009, respectively), and a lower SBP (p = 0.038). A witnessed loss of signs of life generally occurred in EDT patients and was accompanied by 100 % mortality. Survival following EDT was 25 %, which was significantly lower than in the ET group (75 %; p = 0.002). Survivors had lower ISS (p = 0.011), lower rates of pre-hospital (p = 0.031) and hospital (p = 0.003) hemodynamic instability, and a lower prevalence of concomitant abdominal injury (p = 0.002).

CONCLUSION

The overall survival rate in our study was 64 %. The outcome of immediate thoracotomy performed in this level I trauma center was similar to those obtained in high-incidence regions like the US and South Africa. This suggests that trauma units where immediate thoracotomies are not part of the daily routine can achieve similar results, if properly trained.

Resuscitative emergency thoracotomy in a Swiss trauma centre

BACKGROUND

Resuscitative emergency thoracotomy (ET) is performed as a salvage manoeuvre for selected patients with trauma. However, reports from European trauma centres are scarce.

METHODS

A retrospective analysis was undertaken of injured patients who underwent resuscitative ET in the emergency department (ED) or operating room (OR) between January 1996 and September 2008. Survival in the ED and to hospital discharge was analysed using logistic regression.

RESULTS

During the study interval 121 patients required a resuscitative thoracotomy, of which 49 (40·5 per cent) were performed in the ED and 72 (59·5 per cent) in the OR. Patients in the OR had higher blood pressure on arrival (median 110 versus 60 mmHg; P < 0·001), were less often in severe haemorrhagic shock (63 versus 94 per cent; P < 0·001), had fewer serious head injuries (Abbreviated Injury Score of 3 or above in 33 versus 53 per cent; P = 0·031) and more often had a penetrating stab wound as the dominating mechanism (25 versus 10 per cent; P = 0·042) compared with those in the ED. Ten patients (20 per cent) survived to hospital discharge after ED thoracotomy, compared with 53 (74 per cent) of those treated in the OR. Penetrating injury and Glasgow Coma Scale score above 8 were independent predictors of hospital survival following ED thoracotomy. No patient with a blunt injury and no detectable signs of life on admission survived. Three of 26 patients with blunt trauma and signs of life on admission survived to hospital discharge.

CONCLUSION

Resuscitative ET may be life-saving in selected patients. Location of the procedure is dictated by injury severity and vital parameters. Outcome is best when signs of life are present on admission, even for blunt injuries.

Emergency thoracotomies in the largest trauma center in Denmark: 10 years' experience

AIM

The aim of our study was to investigate the outcome in terms of 30-day survival and to determine whether preoperative factors could predict the outcome.

METHODS

All patients who underwent an emergency thoracotomy (ET) during the period 2000 to 2009 were included. The patients were divided into two groups: emergency department thoracotomy and operating room thoracotomy. Data on demographics, mechanism of injury, intraoperative data, Injury Severity Scores (ISS), probability of survival, signs of life, transportation time, indications, and outcome were collected.

RESULTS

Forty-four ETs were performed. The mechanisms of injury were penetrating in 28 (64%) and blunt in 16 (36%) cases. In the emergency department thoracotomy group, the survival was 45 versus 20% for penetrating and blunt trauma, respectively. The total survival was 33%. In the operating room thoracotomy group, the survival was 83%. The survivors had a significantly lower ISS and a higher calculated probability of survival. The calculated mean probability of survival was 44 and 84% in the emergency department thoracotomy and operating room thoracotomy groups, respectively. The actual survival was similar, with 33% in the emergency department thoracotomy group and 83% in the operating room thoracotomy group.

CONCLUSIONS

The probability of survival and ISS are good predictors of survival in these patients and should be included in the future in order to make upcoming studies easier to compare. Patients with very high ISS or low probability of survival survived, justifying the procedure in our center.

Changes in the patterns, presentation and management of penetrating chest trauma patients at a level II trauma centre in southern Pakistan over the last two decades

Penetrating chest trauma can be used as an indicator of violence in the country. We aimed to look at the changes in its incidence and management at a major trauma centre in the country. We also wanted to look at any effect of prehospital time on surgical intervention and outcome of the victim. In this retrospective descriptive study, we observed the presentation and management of 191 penetrating chest injury patients at a level II trauma hospital in Pakistan in the last 20 years. The study sample was divided into two groups: Group 1, 1988-1998 and Group 2, 1999-2009. No significant change in incidence of trauma was observed between the two groups. The delay in the time between event and arrival showed an increase in the number of surgical procedures performed. Also the number of thoracotomies performed went up significantly in the second decade from 5.7 to 16.5% with a P<0.05. Six (3.1%) mortality cases were observed in 20 years. It was seen that the greater the prehospital time, the greater the chances of surgery. Also seen was the increase in mortality as critical cases could make it to the hospital alive in recent times due to improved transportation services.

The Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG

BACKGROUND

In 1999, an Utstein Template for Uniform Reporting of Data following Major Trauma was published. Few papers have since been published based on that template, reflecting a lack of international consensus on its feasibility and use. The aim of the present revision was to further develop the Utstein Template, particularly with a major reduction in the number of core data variables and the addition of more precise definitions of data variables. In addition, we wanted to define a set of inclusion and exclusion criteria that will facilitate uniform comparison of trauma cases.

METHODS

Over a ten-month period, selected experts from major European trauma registries and organisations carried out an Utstein consensus process based on a modified nominal group technique.

RESULTS

The expert panel concluded that a New Injury Severity Score > 15 should be used as a single inclusion criterion, and five exclusion criteria were also selected. Thirty-five precisely defined core data variables were agreed upon, with further division into core data for Predictive models, System Characteristic Descriptors and for Process Mapping.

CONCLUSION

Through a structured consensus process, the Utstein Template for Uniform Reporting of Data following Major Trauma has been revised. This revision will enhance national and international comparisons of trauma systems, and will form the basis for improved prediction models in trauma care.