Futility indications in resuscitative thoracotomy: A retrospective observational study evaluating practice guidelines.

Resuscitative thoracotomy

The use of Zone 1 REBOA for life-threatening trauma has increased dramatically. The Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database was queried for blunt and penetrating trauma between 2013 and 2021. Outcomes were examined both for mechanisms of injury combined and separately and for combinations of abdominal injury with and without traumatic brain injury and chest injuries (Abbreviated Injury Scale [AIS] score >2). A total of 531 patients underwent REBOA (408 with blunt injury and 123 with penetrating injury) and 1,603 (595 with blunt injury and 1,008 with penetrating injury) underwent resuscitative thoracotomy (RT). Mean age was 38.5 ± 16 years and mean injury severity score was 34.5 ± 21; 57.7% had chest AIS score of more than 2, 21.8% had head AIS score of more than 2, and 37.3% had abdominal AIS score of more than 2. Admission Glasgow Coma Scale was 4.9 + 4, and systolic blood pressure at aortic occlusion (AO) was 22 + 40 mmHg. No differences in outcomes in REBOA or RT patients were identified between institutions (p > 0.5). After inverse probability weighting, Glasgow Coma Scale, age, injury severity score, systolic blood pressure at AO, CPR at AO, and blood product transfusion, REBOA was superior to RT in both blunt (odds ratio [OR] 4.7, 95% CI 1.9 to 11.7) and penetrating (OR 4.9, 95% CI 1.7 to 14) injuries, across all spectrums of injury (p < 0.01). Overall mortality was significantly higher for AO more than 90 minutes compared with less than 30 minutes in blunt (OR 4.6, 95% CI 1.5 to 15) and penetrating (OR 5.4, 95% CI 1.1 to 25) injuries. Duration of AO more than 60 minutes was significantly associated with mortality after penetrating abdominal injury (OR 5.1, 95% CI 1.1 to 22) and abdomen and head (OR 5.3, 95% CI 1.6 to 18). In-hospital survival is higher for patients undergoing REBOA than RT for all injury patterns. Complete AO by REBOA or RT should be limited to less than 30 minutes. Neither hospital and procedure volume nor trauma verification level impacts outcomes for REBOA or RT.

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

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.

Resuscitative thoracotomy is a dramatic operation performed in otherwise unsalvageable trauma patients. Analysis of its efficacy is based mostly on institutional series compiling the experience of multiple surgeons. This study aimed to report more consistent information by describing the resuscitative thoracotomy practice of a single surgeon and its evolution during more than two decades. A retrospective review of consecutive patients who underwent resuscitative thoracotomy in July 1990 to December 2012. Demographics, mechanism of injury, signs of life, injuries, and outcomes were analyzed. Comparisons were made between penetrating and blunt trauma patients and between pre- and post-introduction of a selective resuscitative thoracotomy protocol. Sixty-seven resuscitative thoracotomies were performed. Most patients were males (84%), and mean age was 38 years. Mechanism of injury was stab wounds (54%, 36), blunt force (25%, 17), and gunshot wounds (21%, 14). Survival was 22% (8/36), 0% (0/17), and 7% (1/14), respectively. All nine survivors had signs of life upon admission, and survival in patients with signs of life on admission was 25% (8/32) in the stab wounds group and 8% (1/12) in the gunshot wounds group. Seven of the nine survivors (78%) were discharged neurologically intact. The most common injury in survivors was cardiac laceration with tamponade (6/9) and lung injury (3/9). Three survivors had a cardiac and lung injury, one had a lung hilum injury, and one had an abdominal inferior vena cava laceration. The switch to resuscitative thoracotomy protocol (2002) improved overall (31 vs 8%, p < 0.05) and penetrating trauma (45 vs 10%, p < 0.05) survival, eliminated resuscitative thoracotomy in patients presenting with no signs of life, and tended to reduce resuscitative thoracotomy utilization in blunt trauma patients. This single-surgeon series supports that resuscitative thoracotomy can be lifesaving in selected penetrating trauma patients in extremis. A switch to a selective evidence-based protocol increased overall and penetrating resuscitative thoracotomy survival and limited resuscitative thoracotomy performance to patients arriving with signs of life.

REBOA or resuscitative thoracotomy, different tools for different patients. A real-life analysis from the AORTA registry.

Increasing sub-specialization has reduced the number of general surgeons involved in the care of trauma patients in German-speaking countries (Germany, Austria and Switzerland) over the past decades. Thus, the aim of this study was to assess, to what extent level 1 trauma centers are still prepared to provide immediate emergency surgery in patients with thoracic or abdominal trauma. Web-based and paper questionnaires were sent to all level 1 trauma centers participating in the TraumaRegister DGU® (TR-DGU) in Germany, Austria, and Switzerland from Feb 2017 to Sep 2017. The centers were asked about the presence or availability of surgeons who were able to perform an emergency laparotomy or thoracotomy. Of all 117 level 1 trauma centers participating in the TR-DGU in Germany, Austria, and Switzerland, 97 (83%) gave a response. A board-certified surgeon who is able to perform an emergency laparotomy is present 24h/7days a week in 72% of the centers (emergency thoracotomy: 57%). In centers where no such surgeon was present the whole time, the mean maximum time of arrival of the surgeon on call was 18.9min (SD 7.0, range 10-40min) regarding the ability to perform an emergency laparotomy and 19.9min (SD 7.0, range 10-40min) regarding the emergency thoracotomy. The majority of level 1 trauma centers in Germany, Switzerland, and Austria in the TR-DGU seem to be well prepared to treat severe injuries of the abdominal and thoracic cavities. In some centers, however, a surgeon able to perform an emergency laparotomy or thoracotomy is not available within 30min.

To reassess the use of emergency thoracotomy in resuscitating victims of abdominal or thoracic trauma. Retrospective review of records and autopsy reports of patients who underwent an emergency thoracotomy between 1983 and 1989. Washington Hospital Center's Level I trauma center. Two hundred eighty-four hemodynamically unstable trauma patients (212 [75%] with penetrating injuries and 72 [25%] with blunt injuries). Emergency thoracotomy performed in the trauma operating room or in one of the trauma bays. MAIN OUTCOME MEASURES AND KEY FINDINGS: In which subset of trauma patients is emergency thoracotomy a useful therapeutic modality? Performance of an emergency thoracotomy for blunt trauma resulted in an overall survival rate of 6% compared with 27% for penetrating trauma. The survival rate for patients with penetrating cardiac trauma was 32% (44% for stab wounds and 21% for gunshot wounds). Tamponade is a major factor associated with survival in this subset of patients and may act as a pathophysiologic filter. Emergency thoracotomy is a useful therapeutic modality for victims of penetrating trauma who have vital signs on admission to the hospital, and it should be considered in blunt trauma patients who present with any evidence of life. This modality is largely ineffective, however, in resuscitating victims of penetrating and blunt trauma who present to the hospital without vital signs.

PurposeTo investigate the 30-day survival rate of resuscitative and emergency thoracotomies in trauma patients. Moreover, factors that positively influence 30-day survival rates were investigated.MethodsA retrospective study of patients (> 16 years), between 2008 and 2020, who underwent a resuscitative or emergency thoracotomy at a level-one trauma center in the Netherlands was conducted.ResultsFifty-six patients underwent a resuscitative (n = 45, 80%) or emergency (n = 11, 20%) thoracotomy. The overall 30-day survival rate was 32% (n = 18), which was 23% after blunt trauma and 72% after penetrating trauma, and which was 18% for the resuscitative thoracotomy and 91% for the emergency thoracotomy. The patients who survived had full neurologic recovery. Factors associated with survival were penetrating trauma (p < 0.001), (any) sign of life (SOL) upon presentation to the hospital (p = 0.005), Glasgow Coma Scale (GCS) of 15 (p < 0.001) and a thoracotomy in the operating room (OR) (p = 0.018). Every resuscitative thoracotomy after blunt trauma and pulseless electrical activity (PEA) or asystole in the pre-hospital phase was futile (0 survivors out of 11 patients), of those patients seven (64%) had concomitant severe neuro-trauma.ConclusionThis study found a 30-day survival rate of 32% for resuscitative and emergency thoracotomies, all with good neurological recovery. Factors associated with survival were related to the trauma mechanism, the thoracotomy indication and response to resuscitation prior to thoracotomy (for instance, if resuscitation enables enough time for safe transport to the operating room, survival chances increase). Resuscitative thoracotomies after blunt trauma in combination with loss of SOL before arrival at the emergency room were in all cases futile, interestingly in nearly all cases due to concomitant neuro-trauma.

In the past three decades, there has been a significant clinical shift in the performance of resuscitative thoracotomy (RT), from a nearly obligatory procedure before declaring any trauma patient deceased to a more selective application of RT. We have sought to formulate an evidence-based guideline for the current indications for RT after injury in the patient. The Western Trauma Association Critical Decisions Committee queried the literature for studies defining the appropriate role of RT in the trauma patient. When good data were not available, the Committee relied on expert opinion. There are no published PRCT and it is not likely that there will be; recommendations are based on published prospective observational and retrospective studies, as well as expert opinion of Western Trauma Association members. Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be stratified based on injury and transport time. Indications for RT include the following: blunt trauma patients with less than 10 minutes of prehospital CPR, penetrating torso trauma patients with less than 15 minutes of CPR, patients with penetrating trauma to the neck or extremity with less than 5 minutes of prehospital CPR, and patients in profound refractory shock. After RT, the patient's intrinsic cardiac activity is evaluated; patients in asystole without cardiac tamponade are declared dead. Patients with a cardiac wound, tamponade, and associated asystole are aggressively treated. Patients with an intrinsic rhythm following RT should be treated according to underlying primary pathology. Following several minutes of such treatment as well as generalized resuscitation, salvageability is reassessed; we define this as the patient's ability to generate a systolic blood pressure of greater than 70 mm Hg with an aortic cross-clamp if necessary. The success of RT approximates 35% for the patient arriving in shock with a penetrating cardiac wound and 15% for all patients with penetrating wounds. Conversely, patient outcome is relatively poor when RT is performed for blunt trauma, 2% survival for patients in shock and less than 1% survival for patients with no vital signs. Patients undergoing CPR on arrival to the hospital should be stratified based on injury and transport time to determine the utility of RT. This algorithm represents a rational approach that could be followed at trauma centers with the appropriate resources; it may not be applicable at all hospitals caring for the injured. There will be patient, personnel, institutional, and situational factors that may warrant deviation from the recommended guideline. The annotated algorithm is intended to serve as a quick bedside reference for clinicians.

Clinical determinants for survival following emergency thoracotomy in trauma patients: An 8-year experience from a level 1 trauma center.

Training non-surgeons to perform resuscitative thoracotomy

Objective:The purpose of this study was to evaluate for differences in the baseline mortality rates of patients injured by different mechanisms, in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial, and compare their responses to 2 resuscitation paradigms. Our hypothesis was there are differences between the blunt and penetrating trauma patients, with regard to baseline and effect size.Background:Previous research including clinical trials and basic science research suggests differences in mortality among patients injured by blunt or penetrating mechanisms, although differences between these 2 mechanisms—both baseline and effect size—are rarely considered explicitly. The objective of this analysis was to compare mortality and other clinical outcomes of trauma patients stratified specifically by injury mechanism and resuscitation strategy.Methods:We performed a retrospective review of the PROPPR trial to assess for differences in mortality outcomes in patients with blunt or penetrating injuries who received a 1:1:1 or 1:1:2 resuscitation strategy. Our primary outcome was 24-hour mortality with additional endpoints at proximate (ie, 1 hour, 3 hours, and 6 hours) times post-arrival. A logistic regression model utilizing general estimating equations and adjusted for age, Injury Severity Score (ISS), and first documented pulse and Glasgow Coma Scale (GCS) score were used to assess the interaction of mortality outcomes by resuscitation type and injury mechanism. Secondary outcomes evaluated include acute kidney injury, ventilator-associated pneumonia, cardiac arrest, symptomatic and asymptomatic pulmonary embolism, deep vein thrombosis, acute respiratory distress syndrome, and stroke. Additional nonmortality outcomes of interest included total hospital and ventilator- and ICU-free days, time to hemostasis, time to exsanguination, and time to death.Results:The original trial enrolled 680 patients, 338 (49.7%) received 1:1:1 and 342 (50.3%) 1:1:2 resuscitation. 8 patients had combined blunt and penetrating injuries and were excluded from this analysis, leaving 672 patients with blunt (350, 52.1%) and penetrating (322, 47.9%) injuries. Compared to penetrating injuries, patients with blunt injuries were older, more likely to be white, had a higher rate of air transfers, longer transport time and longer time to hemostasis, lower GCS Score, and higher ISS and R time on thromboelastography (P < 0.001). Overall mortality between blunt and penetrating injuries was similar at 1 hour (2.6% vs 4.0%, P = 0.286) and 3 hours (7.4% and 8.1%, P = 0.754). However, mortality in both groups steadily increased overtime, and more markedly at 24 hours for patients with blunt compared to penetrating injuries (16.9% and 11.8%, P = 0.063). When comparing resuscitation strategies, receipt of a 1:1:1 resuscitation significantly decreased the odds of mortality among blunt-injured patients who received a 1:1:1 transfusion (relative to blunt-injured patients receiving a 1:1:2 transfusion) at 3 hours (odds ratio [OR]: 0.26, 95% confidence interval [CI]: 0.10–0.66, P = 0.005) and 6 hours (OR: 0.38, 95% CI: 0.19–0.77, P = 0.0007). We observed no statistically significant differences in patients with penetrating injuries or at any time other points.Conclusions:We found a significant difference in adjusted mortality at 3 hours in patients with blunt injuries when comparing resuscitation strategies, which was consistent with previous studies. Responses to resuscitation may differ depending on the mechanism of injury, and some interventions may be more beneficial depending on injury type.

Background: Emergency thoracotomy is a potentially life-saving maneuver for trauma patients in extremis. Since trauma scenarios, in rural locations, usually occur with a high incidence of a severe injury that leads to hemorrhagic shock or cardiopulmonary arrest. The objective of this study was to analyze the experience in emergency thoracotomy performed by a general surgeon in a rural area in Thailand. Methods: This retrospective study was conducted by analyzing the patient records including demographics, mechanisms of injuries, specific organ injury, surgical approach, life-saving surgical procedure, and postoperative outcome for all patients who underwent emergency thoracotomy in the Department of Surgery, Srinakharinwirot University hospital between January 2010 and December 2020. Results: Twelve patients underwent emergency thoracotomy within 1 hour after arrival and were equally divided between blunt and penetrating injuries with 6 (50%). A mean patient age of 34.8 ± 15.2 years (range 16–55), mean systolic blood pressure on arrival was 65.8 ± 35.2 mmHg (range 0–100 mmHg), and the mean injury severity score (ISS) was 54.6 ± 25.2 (range 26–75). Profound hemorrhagic shock is a major indication for emergency thoracotomy. The overall survival rate was 41.7% (5/12 patients) without survivors from cardiac injuries. Four patients (66.7%) in the penetrating and 1 patient (16.7%) in the blunt intrathoracic injury group were survived and discharged from the hospital. Conclusion: Emergency thoracotomy offers a chance for survival at 41.7% for trauma patients who present with extremes in this study. Rapid decision-making, good operative technique, and adequate patient selection are crucial for reasonable outcomes.

BackgroundOutcomes following aortic occlusion for trauma and hemorrhagic shock are poor, leading some to question the clinical utility of aortic occlusion in this setting. This study evaluates neurologically intact survival following resuscitative endovascular balloon occlusion of the aorta (REBOA) versus resuscitative thoracotomy at a center with a dedicated trauma hybrid operating room with angiographic capabilities.MethodsThis retrospective cohort analysis compared patients who underwent zone 1 aortic occlusion via resuscitative thoracotomy (n = 13) versus REBOA (n = 13) for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock (systolic blood pressure less than 90 mmHg despite volume resuscitation) at a level 1 trauma center with a dedicated trauma hybrid operating room. The primary outcome was survival to hospital discharge. The secondary outcome was neurologic status at hospital discharge, assessed by Glasgow Coma Scale (GCS) scores.ResultsOverall median age was 40 years, 27% had penetrating injuries, and 23% had pre-hospital closed-chest cardiopulmonary resuscitation. In both cohorts, median injury severity scores and head-abbreviated injury scores were 26 and 2, respectively. The resuscitative thoracotomy cohort had lower systolic blood pressure on arrival (0 [0–75] vs. 76 [65–99], p = 0.009). Hemorrhage control (systolic blood pressure 100 mmHg without ongoing vasopressor or transfusion requirements) was obtained in 77% of all REBOA cases and 8% of all resuscitative thoracotomy cases (p = 0.001). Survival to hospital discharge was greater in the REBOA cohort (54% vs. 8%, p = 0.030), as was discharge with GCS 15 (46% vs. 0%, p = 0.015).ConclusionsAmong patients undergoing aortic occlusion for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock at a center with a dedicated, trauma hybrid operating room, nearly half of all patients managed with REBOA had neurologically intact survival. The high death rate in resuscitative thoracotomy and differences in patient cohorts limit direct comparison.