Emergency department resuscitative thoracotomy at an adult major trauma centre: Outcomes following a training programme with standardised indications

Abstract

ObjectiveThe objective of this study was to report the procedural incidence and patient outcomes after the 2009 introduction of an institutional resuscitative thoracotomy (RT) programme. Emergency physicians, general surgeons and emergency nursing trauma team members were trained to perform RT on thoracic trauma patients with an unresponsive systolic blood pressure (SBP) <70 mmHg within 30 min of arrival, prior to cardiothoracic team back‐up.MethodsA retrospective cohort study was conducted on patients who underwent RT from 2009 to 2017. The primary outcome measures were the incidence of the procedure and patients' survival to hospital discharge. Variables associated with survival were assessed using univariable logistic regression analyses.ResultsThere were 12 399 major trauma patients, including 7657 with major thoracic trauma and 315 presenting with SBP <70 mmHg. There were 32 RTs performed (incidence of 0.4%; 95% confidence interval [CI] 0.3–0.6) among patients with major thoracic trauma and 10.2% (99% CI 7.3–13.4) among patients with major thoracic trauma and SBP <70 mmHg. There were eight (25%; 95% CI 13.2–42.1) survivors to hospital discharge and no late mortality (mean follow‐up 2.8 years). Survival was significantly associated with the procedure performed within 30 min of arrival (odds ratio 0.09; 95% CI 0.01–0.67) while mortality was associated with the procedure being performed in the setting of traumatic cardiac arrest (odds ratio 18.3; 95% CI 2.4–140.4).ConclusionsA formal training and credentialing programme was associated with a low incidence of the procedure, yet achieved a survival rate of 25%, which is comparable to other reported literature.

Right atrial appendage rupture and cardiac tamponade secondary to blunt trauma

“…“Few surgical emergencies present so great a diagnostic challenge or provide as great a therapeutic reward,” wrote Driscoll in 1973, whilst discussing cardiac chamber rupture in blunt trauma. Whilst Beck's triad is present in only one third of trauma cases of pericardial tamponade [6] , the bedside ultrasound has ameliorated previous diagnostic challenges [2] , [3] . Ultrasound sensitivity and specificity for pericardial effusion have been reported as 96% and 98% respectively when performed by emergency physicians [8] .…”

“…Cardiac chamber rupture is associated with a high mortality rate - mostly attributed to the resultant cardiac tamponade [1] . Successful management of acute cardiac tamponade requires a high degree of clinical suspicion with early diagnosis facilitated by ultrasonography linked to timely operative intervention [2] , [3] .…”

Resuscitative Thoracotomy and Aortic Cross-Clamp and Resuscitative Endovascular Balloon Occlusion of the Aorta

“…It is often performed in resuscitative thoracotomy and can be performed simultaneously to relieve cardiac tamponade, hemostasis for cardiac, great vessel, pulmonary, chest wall injuries, prevention of air embolism, and direct cardiac massage [1,15,16]. Non-surgeons with good training and experience can perform it [17]; however, thoracotomy is a highly invasive procedure because it creates a new injury of Abbreviated Injury Scale (AIS) score of 3 points or more. There is a risk of postoperative bleeding, hypothermia, vascular injuries, intercostal arteriovenous injury, and spinal artery injury.…”

Resuscitative thoracotomy

“…3 Identify patients with the highest likelihood of benefitting from the procedure by assessing for cardiac tamponade with ultrasound. Local data from the Alfred Hospital Trauma Registry reveal that carefully selected blunt trauma patients who undergo an ED RT have a survival as high as 26% 4 and a recent European systematic review found an overall survival rate of 12.9% for ED RT performed for blunt trauma. 5 Shouldn't the thoracotomy be done in theatre?…”