9931
SJS103210.1177/1457496914529931R. RabinoviciSixty-Seven Consecutive Resuscitative Thoracotomies by A Single Surgeon
OriginaL Article
Scandinavian Journal of Surgery 103: 156–160, 2014
Sixty-Seven Consecutive Resuscitative Thoracotomies by A Single Surgeon R. Rabinovici Division of Trauma and Acute Care Surgery, Tufts Medical Center, Boston, MA, USA
Abstract
Background: 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. Methods: 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. Results: 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. Conclusion: This single-surgeon series supports that resuscitative thoracotomy can be lifesaving in selected penetrating trauma patients in extremis. A switch to a selective
Correspondence: Reuven Rabinovici, M.D., F.A.C.S. Division of Trauma and Acute Care Surgery Tufts Medical Center 800 Washington Street, #4488 Boston, MA 02111 USA Email: [email protected]
157
Resuscitative thoracotomy by a single surgeon
evidence-based protocol increased overall and penetrating resuscitative thoracotomy survival and limited resuscitative thoracotomy performance to patients arriving with signs of life. Key words: Resuscitative thoracotomy; blunt injury; penetrating injury; asystole; pulselessness
Introduction Resuscitative thoracotomy (RT) is a bold procedure, which may present the only hope for some moribund trauma patients (1). Since its introduction about five decades ago, the approach to performing RT has repeatedly alternated between enthusiasm and skepticism and between liberalism and conservatism. This pendulous reality has been fueled by studies with ambiguous nomenclature, poor designs, and variable sizes, as well as ethical and logistical difficulties in performing prospective controlled studies. Consequently, in spite of significant efforts to identify the group(s) of patients who may benefit from RT, no consensus guidelines are available to assist the surgeon in caring for the trauma patient in extremis. For example, some of the American College of Surgeons Committee on Trauma (ACS-COT) guidelines published in 2001 in an attempt to clarify the confusion surrounding RT (2), including the approach to the pre-hospital pulseless patient and to the patient with abdominal vascular injury, have been recently challenged by several large retrospective studies (3,4). Regardless of the differences among the various studies, they all reported the experience of groups of surgeons in a single or multiple institutions. This study aimed to provide more consistent information regarding RT by describing the practice and results of a single trauma surgeon during more than two decades. Also, given this long time perspective, the study aimed to describe the evolution of the approach to the trauma patient in extremis. Specifically, the study compared management and outcomes before and after the implementation of a selective resuscitative thoracotomy protocol (SRTP). Methods A retrospective analysis of a prospectively maintained database was performed on 67 patients in extremis who underwent consecutive RT by the author between January 1990 and December 2012. Extracted data included demographics, mechanism of injury, signs of life (SOL), defined as the presence of organized cardiac electrical activity with or without a palpable pulse on admission, injuries, and outcomes. Comparisons were made between penetrating and blunt trauma patients and between pre- and postintroduction of the SRTP in February 2001 (Fig. 1). This SRTP replaced a protocol indicating RT on all trauma patients with less than 10 min pre-hospital loss of SOL and on those who arrested or acutely deteriorated in the trauma room. Statistical evaluation was done using a one-tail chi-square analysis (GraphPad
RT: When to perform? Penetrating, prehospital pulse loss Blunt, Prehospital pulse loss PEA
Asystole FAST+
RT
RT
FASTACLS*
Penetrating, In-hospital pulse loss PEA or Asystole
RT +/+/- relates to pericardial effusion * Including bilateral chest tubes
Asystole
PEA FAST+ RT
FASTACLS* Pronounce
Blunt, In-hospital pulse loss PEA or Asystole
FAST+ RT
FASTACLS*
Fig. 1. An evidence-based protocol for a selective approach to the performance of RT. RT: resuscitative thoracotomy; PEA: pulseless electrical activity; FAST: focal abdominal sonography for trauma; ACLS: advanced cardiac life support.
Software, La Jolla, CA, USA) with significance determined at
SJS103210.1177/1457496914529931R. RabinoviciSixty-Seven Consecutive Resuscitative Thoracotomies by A Single Surgeon
OriginaL Article
Scandinavian Journal of Surgery 103: 156–160, 2014
Sixty-Seven Consecutive Resuscitative Thoracotomies by A Single Surgeon R. Rabinovici Division of Trauma and Acute Care Surgery, Tufts Medical Center, Boston, MA, USA
Abstract
Background: 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. Methods: 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. Results: 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. Conclusion: This single-surgeon series supports that resuscitative thoracotomy can be lifesaving in selected penetrating trauma patients in extremis. A switch to a selective
Correspondence: Reuven Rabinovici, M.D., F.A.C.S. Division of Trauma and Acute Care Surgery Tufts Medical Center 800 Washington Street, #4488 Boston, MA 02111 USA Email: [email protected]
157
Resuscitative thoracotomy by a single surgeon
evidence-based protocol increased overall and penetrating resuscitative thoracotomy survival and limited resuscitative thoracotomy performance to patients arriving with signs of life. Key words: Resuscitative thoracotomy; blunt injury; penetrating injury; asystole; pulselessness
Introduction Resuscitative thoracotomy (RT) is a bold procedure, which may present the only hope for some moribund trauma patients (1). Since its introduction about five decades ago, the approach to performing RT has repeatedly alternated between enthusiasm and skepticism and between liberalism and conservatism. This pendulous reality has been fueled by studies with ambiguous nomenclature, poor designs, and variable sizes, as well as ethical and logistical difficulties in performing prospective controlled studies. Consequently, in spite of significant efforts to identify the group(s) of patients who may benefit from RT, no consensus guidelines are available to assist the surgeon in caring for the trauma patient in extremis. For example, some of the American College of Surgeons Committee on Trauma (ACS-COT) guidelines published in 2001 in an attempt to clarify the confusion surrounding RT (2), including the approach to the pre-hospital pulseless patient and to the patient with abdominal vascular injury, have been recently challenged by several large retrospective studies (3,4). Regardless of the differences among the various studies, they all reported the experience of groups of surgeons in a single or multiple institutions. This study aimed to provide more consistent information regarding RT by describing the practice and results of a single trauma surgeon during more than two decades. Also, given this long time perspective, the study aimed to describe the evolution of the approach to the trauma patient in extremis. Specifically, the study compared management and outcomes before and after the implementation of a selective resuscitative thoracotomy protocol (SRTP). Methods A retrospective analysis of a prospectively maintained database was performed on 67 patients in extremis who underwent consecutive RT by the author between January 1990 and December 2012. Extracted data included demographics, mechanism of injury, signs of life (SOL), defined as the presence of organized cardiac electrical activity with or without a palpable pulse on admission, injuries, and outcomes. Comparisons were made between penetrating and blunt trauma patients and between pre- and postintroduction of the SRTP in February 2001 (Fig. 1). This SRTP replaced a protocol indicating RT on all trauma patients with less than 10 min pre-hospital loss of SOL and on those who arrested or acutely deteriorated in the trauma room. Statistical evaluation was done using a one-tail chi-square analysis (GraphPad
RT: When to perform? Penetrating, prehospital pulse loss Blunt, Prehospital pulse loss PEA
Asystole FAST+
RT
RT
FASTACLS*
Penetrating, In-hospital pulse loss PEA or Asystole
RT +/+/- relates to pericardial effusion * Including bilateral chest tubes
Asystole
PEA FAST+ RT
FASTACLS* Pronounce
Blunt, In-hospital pulse loss PEA or Asystole
FAST+ RT
FASTACLS*
Fig. 1. An evidence-based protocol for a selective approach to the performance of RT. RT: resuscitative thoracotomy; PEA: pulseless electrical activity; FAST: focal abdominal sonography for trauma; ACLS: advanced cardiac life support.
Software, La Jolla, CA, USA) with significance determined at
