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Kanlerd A, Sapsamarn N, Auksornchart K. Is Emergency Department Thoracotomy Effective in Trauma Resuscitation? The Retrospective Study of the Emergency Department Thoracotomy in Trauma Patients at Thammasat University Hospital, Thailand. J Emerg Trauma Shock 2019; 12:254-259. [PMID: 31798238 PMCID: PMC6883499 DOI: 10.4103/jets.jets_36_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/17/2019] [Accepted: 09/20/2019] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Amonpon Kanlerd
- Department of Surgery, Division of Trauma and Surgical Critical Care, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Nattida Sapsamarn
- Department of Surgery, Division of Trauma and Surgical Critical Care, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Karikarn Auksornchart
- Department of Surgery, Division of Trauma and Surgical Critical Care, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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2
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Matsushima K, Conti B, Chauhan R, Inaba K, Dutton RP. Novel Methods for Hemorrhage Control: Resuscitative Endovascular Balloon Occlusion of the Aorta and Emergency Preservation and Resuscitation. Anesthesiol Clin 2019; 37:171-182. [PMID: 30711230 DOI: 10.1016/j.anclin.2018.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemorrhage is the leading cause of preventable death after trauma. Junctional and extremity hemorrhage can be temporized with direct pressure and tourniquet application, but noncompressible torso hemorrhage has traditionally required operative or angiographic intervention. Retrograde endovascular balloon occlusion of the aorta (REBOA) can temporize patients with hemorrhage below the diaphragm long enough to enable definitive surgery. REBOA is increasingly available in US trauma centers but prospective, randomized demonstration of efficacy is not yet available. Emergency perfusion and resuscitation is an investigational therapy, limited to use in patients with cardiac arrest due to hemorrhage.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, LAC+USC Medical Center, 2051 Marengo Street, IPT C5L100, Los Angeles, CA 90033, USA
| | - Bianca Conti
- Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Ravi Chauhan
- Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, 2051 Marengo Street, IPT C5L100, Los Angeles, CA 90033, USA
| | - Richard P Dutton
- Department of Anesthesiology, Texas A&M School of Medicine, US Anesthesia Partners, 12222 Merit Drive, Dallas, TX 75251, USA.
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Segalini E, Di Donato L, Birindelli A, Piccinini A, Casati A, Coniglio C, Di Saverio S, Tugnoli G. Outcomes and indications for emergency thoracotomy after adoption of a more liberal policy in a western European level 1 trauma centre: 8-year experience. Updates Surg 2018; 71:121-127. [PMID: 30588565 PMCID: PMC6450838 DOI: 10.1007/s13304-018-0607-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 11/11/2018] [Indexed: 12/03/2022]
Abstract
The role of emergency thoracotomy (ET) in blunt trauma is still a matter of debate and in Europe only a small number of studies have been published. We report our experience about ET both in penetrating and blunt trauma, discussing indications, outcomes and proposing an algorithm for patient selection. We retrospectively analysed patients who underwent ET at Maggiore Hospital Trauma Center over two periods: from January 1st, 2010 to December 31st, 2012, and from January 1st, 2013 to May 31st, 2017. Demographic and clinical data, mechanism of injury, Injury Severity Score, site of injury, time of witnessed cardiac arrest, presence/absence of signs of life, length of stay were considered, as well as survival rate and neurological outcome. 27 ETs were performed: 21 after blunt trauma and 6 after penetrating trauma. Motor vehicle accident was the main mechanism of injury, followed by fall from height. The mean age was 40.5 years and the median Injury Severity Score was of 40. The most frequent injury was cardiac tamponade. The overall survival rate was 10% during the first period and 23.5% during the second period, after the adoption of a more liberal policy. No long-term neurological sequelae were reported. The outcomes of ET in trauma patient, either after penetrating or blunt trauma, are poor but not negligible. To date, only small series of ET from European trauma centres have been published, although larger series are available from USA and South Africa. However, in selected patients, all efforts must be made for the patient’s survival; the possibility of organ donation should be taken into consideration as well.
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Affiliation(s)
- Edoardo Segalini
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Luca Di Donato
- General and Emergency Surgery, Arcispedale S. Maria Nuova Hospital, Reggio Emilia, Italy
| | - Arianna Birindelli
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Alice Piccinini
- Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Alberto Casati
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Carlo Coniglio
- Trauma Intensive Care Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Salomone Di Saverio
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy.
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Gregorio Tugnoli
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
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Ito K, Nakazawa K, Nagao T, Chiba H, Miyake Y, Sakamoto T, Fujita T. Performing Trauma Surgery in the Emergency Room Impacts the Timeliness of Surgery. J Surg Res 2018; 232:510-516. [PMID: 30463766 DOI: 10.1016/j.jss.2018.07.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/19/2018] [Accepted: 07/11/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our institution has emergency rooms (ERs) with an operating room (OR) setup, which enables surgeons to perform thoracotomy and/or laparotomy for trauma patients without transferring patients to the OR. We hypothesized that the ERs with an OR setup improve the timeliness of surgery for trauma patients. MATERIALS AND METHODS Data were reviewed from trauma patients who underwent emergency surgeries performed by our acute care surgery group from April 2013 to June 2017. Patients' demographics, diagnoses, location of the operation (ER versus regular OR), type of operation, time from admission to operation, and perioperative outcomes including in-hospital mortality were analyzed. These data were compared between patients who underwent surgery in the ER versus the OR. RESULTS There were 105 trauma patients who met the inclusion criteria. Of these 105 patients, 50 underwent surgery in the ER (47.6%, ER group), whereas 55 underwent surgery in the OR (52.4%, OR group). Compared with the OR group, the ER group had a shorter time from admission to operation (median 43 min [range 3-105 min] versus 109 min [range 15-1340 min], P < 0.04), and higher in-hospital mortality rate (38.2% versus 0%, P < 0.01). CONCLUSIONS An ER with an OR setup can enable surgery to be started sooner. Compared with the OR group, patients who underwent surgery performed in the ER tended to be in a more serious condition, and were thus likely to have a higher mortality rate. Further study is warranted to determine which patients would benefit best from this approach.
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Affiliation(s)
- Kaori Ito
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine, Tokyo, Japan.
| | - Kahoko Nakazawa
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine, Tokyo, Japan
| | - Tsuyoshi Nagao
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine, Tokyo, Japan
| | - Hirohito Chiba
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasufumi Miyake
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine, Tokyo, Japan
| | - Takashi Fujita
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine, Tokyo, Japan
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Nevins EJ, Bird NTE, Malik HZ, Mercer SJ, Shahzad K, Lunevicius R, Taylor JV, Misra N. A systematic review of 3251 emergency department thoracotomies: is it time for a national database? Eur J Trauma Emerg Surg 2018; 45:231-243. [PMID: 30008075 DOI: 10.1007/s00068-018-0982-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/10/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world. METHODS Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications. RESULTS Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012). CONCLUSIONS Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.
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Affiliation(s)
- Edward John Nevins
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.
| | - Nicholas Thomas Edward Bird
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Hassan Zakria Malik
- Liverpool Medical School, University of Liverpool, Liverpool, UK.,North West Hepatobiliary Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Simon Jude Mercer
- Liverpool Medical School, University of Liverpool, Liverpool, UK.,Department of Anaesthesia, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Khalid Shahzad
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - Raimundas Lunevicius
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - John Vincent Taylor
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - Nikhil Misra
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
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6
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Moskowitz EE, Burlew CC, Kulungowski AM, Bensard DD. Survival after emergency department thoracotomy in the pediatric trauma population: a review of published data. Pediatr Surg Int 2018; 34:857-860. [PMID: 29876644 DOI: 10.1007/s00383-018-4290-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND/PURPOSE The utility of EDT in the adult trauma population, using well-defined guidelines, is well established, especially for penetrating injuries. Since the introduction of these guidelines, reports on the use of EDT for pediatric trauma have been published, and these series reveal a dismal, almost universally fatal, outcome for EDT following blunt trauma in the child. This report reviews the clinical outcomes of EDT in the pediatric population. MATERIALS/METHODS We performed a review of EDT in the pediatric population using the published data from 1980 to 2017. Variables extracted included mechanism of injury and mortality. To minimize bias, single case reports were not included in the review. RESULTS Upon review of four decades of published literature on the use of emergency department thoracotomy (EDT) in the pediatric population, mortality rates are comparable between adults and pediatric patients for penetrating thoracic trauma. In contrast, in pediatric patients sustaining blunt trauma, no patient under the age of 15 has survived. CONCLUSION In patients between 0 and 14 years of age presenting with no signs of life following blunt trauma, withholding EDT should be considered. Patients between the ages of 15 and 18 should be treated in accordance with adult ATLS principles for the management of thoracic trauma. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Eliza E Moskowitz
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO, USA
- Department of Surgery, University of Colorado, 12631 E. 17th Ave., C302, Aurora, CO, 80045, USA
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO, USA
- Department of Surgery, University of Colorado, 12631 E. 17th Ave., C302, Aurora, CO, 80045, USA
| | - Ann M Kulungowski
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO, USA
- Department of Surgery, University of Colorado, 12631 E. 17th Ave., C302, Aurora, CO, 80045, USA
| | - Denis D Bensard
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO, USA.
- Department of Surgery, University of Colorado, 12631 E. 17th Ave., C302, Aurora, CO, 80045, USA.
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7
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Yamamoto R, Suzuki M, Nakama R, Kase K, Sekine K, Kurihara T, Sasaki J. Impact of cardiopulmonary resuscitation time on the effectiveness of emergency department thoracotomy after blunt trauma. Eur J Trauma Emerg Surg 2018; 45:697-704. [PMID: 29855670 DOI: 10.1007/s00068-018-0967-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/28/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Debate remains about the threshold cardiopulmonary resuscitation (CPR) duration associated with futile emergency department thoracotomy (EDT). To validate the CPR duration associated with favorable outcomes, we investigated the relationship between CPR duration and return of spontaneous circulation (ROSC) after EDT in blunt trauma. METHODS A retrospective observational study was conducted at three tertiary centers over the last 7 years. We included bluntly injured adults who were pulseless and required EDT at presentation, but excluded those with devastating head injuries. After multivariate logistic regression identified the CRP duration as an independent predictor of ROSC, receiver operating characteristic curves were used to determine the threshold CPR duration. Patient data were divided into short- and long-duration CPR groups based on this threshold, and we developed a propensity score to estimate assignment to the short-duration CPR group. The ROSC rates were compared between groups after matching. RESULTS Forty patients were eligible for this study and ROSC was obtained in 12. The CPR duration was independently associated with the achievement of ROSC [odds ratio 1.18; 95% confidence interval (CI) 1.01-1.37, P = 0.04], and the threshold CPR duration was 17 min. Among the 14 patients with a short CPR duration, 13 matched with the patients with a long CPR duration, and a short CPR duration was significantly associated with higher rates of ROSC (odds ratio 8.80; 95% CI 1.35-57.43, P = 0.02). CONCLUSIONS A CPR duration < 17 min is independently associated with higher ROSC rates in patients suffering blunt trauma.
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Affiliation(s)
- Ryo Yamamoto
- Trauma Service, Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Masaru Suzuki
- Department of Emergency Medicine, Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan
| | - Rakuhei Nakama
- Department of Emergency Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Kenichi Kase
- Department of Emergency Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Tomohiro Kurihara
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
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Abstract
Thoracic injury is common in high-energy and low-energy trauma, and is associated with significant morbidity and mortality. Evaluation requires a systematic approach prioritizing airway, respiration, and circulation. Chest injuries have the potential to progress rapidly and require prompt procedural intervention. For the diagnosis of nonemergent injuries, a careful secondary survey is essential. Although medicine and trauma management have evolved throughout the decades, the basics of thoracic trauma care have remained the same.
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Affiliation(s)
- Joseph J Platz
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA.
| | - Loic Fabricant
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA
| | - Mitch Norotsky
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA
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Abstract
BACKGROUND/PURPOSE Emergency department thoracotomy (EDT) has been proposed to be futile in the pediatric patient population. This extreme procedure has survival rates of 0 to 26% in the nonadult population. When taking into consideration that the mechanism of injury is one of the strongest predictors of survival, we hypothesize that the low survival rate in pediatric patients is attributable to a higher rate of blunt trauma compared to their adolescent counterparts. METHODS Prospective data collected from our level 1 trauma center from 1974 to 2014 on all patients undergoing EDT at our institution were evaluated for age 18years or younger. Patient predictor variables included injury mechanism, injury pattern, and detected cardiac activity in the field. Outcomes included successful resuscitation (reestablish of blood pressure and taken to operating room) and overall survival. Patients were dichotomized by age into pediatric (age≤15years) and adolescent (16-18years) categories. RESULTS 1691 patients who underwent EDT were evaluated for age of 18years or less, which included 179 patents (11%). Overall survival in the adult population was 6.1%, compared to 3.4% in the nonadult population (p=0.157). Pediatric patients were more likely to sustain blunt injury than adolescents (72% vs 32%, p<0.001). This also corresponded to differences in anatomic injury patterns and more multisystem trauma (52% vs 44%, p=0.001). Adolescents had significantly higher survival rates than pediatric patients (5% vs 0%, p=0.036). CONCLUSION In nonadult patients undergoing EDT, adolescents have a higher survival rate than pediatric patients. The pediatric population had a significantly lower incidence of penetrating trauma and higher incidence of head injury. The discrepancy in survival between adolescent and pediatric patients appears to be attributable to differences in mechanism. Therefore, those pediatric patients with penetrating thoracic injuries may still benefit from EDT.
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Affiliation(s)
- Hunter B Moore
- University of Colorado, Aurora, CO, United States; Denver Health Medical Center, Denver, CO, United States.
| | - Ernest E Moore
- University of Colorado, Aurora, CO, United States; Denver Health Medical Center, Denver, CO, United States.
| | - Denis D Bensard
- University of Colorado, Aurora, CO, United States; Denver Health Medical Center, Denver, CO, United States; Children's Hospital Colorado, Aurora, CO, United States.
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de Lesquen H, Avaro JP, Gust L, Ford RM, Beranger F, Natale C, Bonnet PM, D'Journo XB. Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg 2014; 20:399-408. [PMID: 25476459 DOI: 10.1093/icvts/ivu397] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.
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Affiliation(s)
- Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Lucile Gust
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | - Fabien Beranger
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Claudia Natale
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre-Mathieu Bonnet
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Xavier-Benoît D'Journo
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
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