Abstract
Resuscitative thoracotomy (RT) may be utilized to obtain a perfusing rhythm, but identifying and treating bleeding immediately after successful RT is mandatory for survival. Trauma surgeons must be able to manage all injuries in these cases as there will likely not be enough time to obtain specialty consultation or to use endovascular management. We sought to determine common injuries in patients arriving in extremis and the injuries that require operative management. A retrospective review was conducted of all patients who underwent a RT at a high-volume Level 1 trauma center from 2010 to 2020. Those who had an autopsy report or lived to discharge were included in the study. High-grade cardiac, high-grade liver injuries, and pelvic fractures are commonly seen when trauma patients arrive in extremis and often require hemorrhage control. Trauma surgeons must be able to manage such injuries as obtaining specialty consultation or using endovascular therapy is not feasible.
Prehospital care of the trauma patient has evolved significantly over the years. Trauma system maturation has emphasized shorter scene times and quicker prehospital transport. As a result, patients that may have otherwise been pronounced deceased on the scene may now be presenting in extremis. Resuscitative thoracotomy (RT) has historically been utilized to obtain a perfusing rhythm for those patients arriving in extremis by obtaining temporary hemorrhage control while maintaining both cerebral and coronary perfusion.
While RT is an aggressive procedure, outcomes are often dismal. 1 Much of the literature examining outcomes after RT focuses on survival to discharge; however, mortality after RT can occur during the procedure, immediately after the procedure, or well into the hospital course. Given that the concept of RT is to achieve temporary hemorrhage control before more definitive measures can be taken to achieve true hemorrhage control, it becomes imperative to understand which injuries are commonly seen necessitating hemorrhage control in patients that arrive in extremis. Inability to address such injuries in a timely fashion may explain why outcomes after RT remain dismal despite advances in trauma care and resuscitation over the decades. Additionally, trauma surgeons need to be equipped with the technical skill set to address such injuries independently without reliance on specialty consultations and/or endovascular platforms, as these tools may not be readily available.
We sought to determine common injuries in patients arriving in extremis and the injuries that require operative management, and hypothesized that patients who arrive in extremis often have injuries that may require a degree of technical expertise to address.
A retrospective review was conducted of all patients who underwent RT at a high-volume, academic, urban, Level 1 trauma center from 2010 to 2020. Patients who survived to discharge or those with autopsy reports were included for analysis, whereas patients with sealed records or those who underwent a RT outside of the trauma resuscitation unit were excluded.
Data collection included patient demographics, including age and sex, and the mechanism of injury. Presence or absence of signs of life, adjunct procedures performed at the time of RT, diagnoses, and injury severity scores were gathered. Additional grading information was gathered on injury patterns that often require operative management by trauma surgeons. Data are presented as medians with interquartile ranges for continuous variables and as percentages for categorical variables. The study was approved by the Institutional Review Board.
Characteristics of Study Population.
Common injuries encountered in the penetrating cohort included lung (54.1%, median grade 3), cardiac (40.4% median grade of 4), and hepatic injuries (29.4%, median grade 4). Just under half of blunt patients (44.3%) had traumatic brain injury, 35.7% had pelvic fractures, and 34.3% hepatic injuries (median grade 3). The median injury severity score was 44 and 43 for patients belonging in the blunt and penetrating cohorts, respectively.
This study provides insight into the types of injuries that patients in extremis arrive with. If RT is a measure taken by a trauma surgeon as a form of salvage, trauma surgeons must be equipped with the technical skill set to manage complex injuries, namely to the lungs, heart, liver, and pelvis, in the setting of hemorrhage, hemodynamic instability, and hypocoagulability. These injuries may need to be managed independently if specialty consultation and/or endovascular therapy is not feasible.
Exposure to operative trauma has declined significantly over the years. Drake et al reviewed a database of operative case logs from the Accreditation Council for Graduate Medical Education (ACGME) from academic year 1989-1990 to academic year 2009-2010. Over this 20-year study, they noted significant reduction in case volume from 31 intra-abdominal trauma operations down to 17. Specifically, the average number of operative trauma liver cases decreased from 4 to 2. 2 Contributing factors for this decline include the implementation of work hour restrictions and increased utilization of non-operative management, particularly of solid organ injuries. Compared to prior graduates, newly graduating residents may not have the expertise to manage the specific injuries identified by our study.
With respect to hepatic trauma specifically, a retrospective review from England and Wales showed that trauma centers with an on-site hepatobiliary service had increased odds of survival after accounting for confounders including age, hemodynamics, and injury severity score. 3 While the data presented in this paper lacks granularity, making it difficult to postulate why this is, it is reasonable to assume that expertise in specific organ systems can improve outcomes for trauma patients.
Controversy remains if trauma surgeons are equipped to manage injuries that are often delegated to other subspecialists. A single-center retrospective review by Karam et al from 2009 to 2019 demonstrated similar outcomes for peripheral artery vascular repairs between trauma surgeons and vascular surgeons with respect to complications, vascular outcomes, and mortality. 4 The findings from this study indicate that trauma surgeons are equipped with the technical skill set to manage such injuries. Educational opportunities, such as the Advanced Surgical Skills for Exposure in Trauma course, the Advanced Trauma Operative Management course, simulation, and additional training in fellowships with high trauma operative volume, may have a role in achieving better outcomes.
Limitations of this study include its retrospective nature and selection bias, as we were limited to individuals who lived to discharge or had autopsy reports available. Autopsy reports additionally may have undercoded injuries. Regardless, the findings of this study demonstrate that trauma surgeons are obligated to know how to independently manage high-grade liver and cardiac injuries, along with pelvic fractures, in patients arriving in extremis.
Footnotes
Author’s Note
This manuscript was a quickshot presentation at the annual of the Southeastern Surgical Congress meeting in Savannah, Georgia on February 14, 2023.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.