Abstract
Background:
Resuscitative thoracotomy (RT) is a salvage procedure following traumatic cardiac arrest. We aim to evaluate RT trends and outcomes in adults with cardiac arrest following penetrating trauma to determine the effect on mortality in this population. Further, we aim to estimate the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality.
Methods:
We reviewed the National Trauma Data Bank (2017–2021) for adults (≥16 years old) with penetrating trauma and prehospital cardiac arrest, stratified by the performance of a RT. We performed multivariable logistic regressions to estimate the effect of RT on mortality and the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality.
Results:
13,115 patients met our inclusion criteria. RT occurred in 12.7% (n=1,664) of patients. Rates of RT trended up over the study period. Crude mortality was similar in RT and Non-RT patients (95.6% vs. 94.5%, p=0.07). There was no statistically significant difference in the adjusted odds of mortality based on RT status (OR 0.82, 95%CI 0.56–1.21). University-teaching hospitals had an adjusted odds ratio of 1.68 (95% CI 1.31–2.17) for performing a RT than non-teaching hospitals. There was no difference in the adjusted odds of mortality in patients that underwent RT based on hospital teaching status.
Conclusion:
Despite up-trending rates, a resuscitative thoracotomy may not improve mortality in adults with penetrating, traumatic cardiac arrest. University teaching hospitals are nearly twice as likely to perform a RT than non-teaching hospitals, with no subsequent improvement in mortality.
Keywords: Resuscitative thoracotomy, penetrating trauma, hospital teaching status, traumatic cardiac arrest
Introduction
Traumatic injury remains the leading cause of death under the age of forty-five in the United States, with penetrating trauma accounting for approximately 15% of all injuries[1–6]. Traumatic cardiac arrest is associated with high mortality and poor neurological outcomes. Over a third of patients with traumatic cardiac arrest die in the pre-hospital period [2,7]. Resuscitative thoracotomy (RT) is a salvage procedure in moribund patients. It provides the ability to evaluate and correct multiple life-threatening injuries simultaneously. A RT can relieve cardiac tamponade or tension pneumothorax, provide access for open bimanual cardiac compressions or defibrillation, control intrathoracic hemorrhage, or cross-clamp the descending aorta or the pulmonary hilum [2,7–15].
First formally described by Beall et al. in 1967, resuscitative thoracotomy following traumatic cardiac arrest has been evaluated in depth over the past four decades and remains a highly contested procedure [2,8,9,13,14,16–19]. Reported survival rates following a resuscitative thoracotomy range widely from 0% to 66% [2,6–14,16,20–23]. In 2000, Rhee et al. performed a meta-analysis of 24 studies over 25 years, evaluating in-hospital survival rates following RT in blunt and penetrating trauma. They reported an overall survival rate of 7.4%, with an 8.8% survival for penetrating injuries and 1.4% for blunt injuries [9]. In 2016, Dayama et al. reported an overall survival rate of 8.0% (0 – 33%) after reviewing 37 studies from 2000 to 2014. The survival rate in penetrating trauma was 9.8% (0 – 45.5%) and 5.2% (0 – 12.2%) in patients with blunt trauma [13]. Seamon et al. performed a comprehensive analysis of 10,238 patients who underwent a RT across 72 studies, reporting an 8.5% overall survival rate (Penetrating: 10.6%; Blunt: 2.3%) [22]. These reviews and encompassed studies demonstrate patient survival after thoracotomy is impacted by prehospital signs of life, mechanism of injury, anatomic location of the injury, and duration of prehospital cardiac arrest [2,6,9,11–13,21–23].
The American College of Surgeons-Committee on Trauma, the Eastern Association for the Surgery of Trauma (EAST), and the Western Trauma Association (WTA) each developed guidelines for selecting trauma patients that may benefit from a resuscitative thoracotomy [14,17,22]. These guidelines incorporate signs of life, mechanism of injury, duration of cardiopulmonary resuscitation (CPR), and patient vital signs to determine if a thoracotomy is indicated [12,14,17,18,20,22].
However, resuscitative thoracotomies are not without risk. Given the emergent nature of the procedure, exposure of healthcare personnel to bloodborne pathogens is a major risk [2,8,10–13,17,20,22–24]. Further, emergent thoracotomies results in ischemic damage to distal organs secondary to aortic cross-clamping and direct iatrogenic injury to the heart, esophagus, phrenic nerve, and intrathoracic blood vessels [2,8,10–13].
As guidelines have tightened regarding indication for resuscitative thoracotomies, trends in the rate of resuscitative thoracotomies and outcomes over the past decade are unclear. Further, there is a paucity of data on teaching hospital status on the performance and outcomes of resuscitative thoracotomies. We aim to evaluate resuscitative thoracotomy trends and outcomes in adults with cardiac arrest following penetrating trauma to determine the effect on mortality in this population. Additionally, we aim to estimate the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality in this population.
Methods
We reviewed the National Trauma Data Bank (NTDB) from 2017 to 2021. Over 900 trauma centers in the United States participate in the NTDB, making it the most extensive national trauma dataset. The data bank includes demographics, diagnoses, procedures, and outcomes. Participating trauma centers are permitted access by the American College of Surgeons (ACS) to the repository for quality and research purposes [25].
Our study focused on adult trauma patients (≥16 years old) who sustained penetrating traumatic injuries with documented prehospital cardiac arrest. Utilizing the International Classification of Diseases (ICD), 9th and 10th revisions, we identified patients who underwent exploratory thoracotomy (ICD-9: 34.02; ICD-10: 0WJB0ZZ, 0WJ90ZZ). Patients with any documented head trauma (Abbreviated injury scale (AIS) ≥1) were excluded from our study (Figure 1). Patients were stratified by the performance of a resuscitative thoracotomy, defined as undergoing an exploratory thoracotomy following prehospital cardiac arrest. In a subset analysis, patients that underwent a resuscitative thoracotomy were stratified by hospital teaching status (non-teaching, community-teaching, and university-teaching; Figure 1).
Figure 1.
PRISMA Flow Diagram of Study Selection Process
*Excluded 38 patients missing hospital teaching status from subset analysis
Patient variables collected included the year of traumatic injury, age, sex, race, ethnicity, mechanism of penetrating injury, level of the trauma center, and hospital teaching status. Clinical variables collected included vital signs (systolic blood pressure (SBP), pulse rate, respiratory rate (RR), and pulse oximetry (%O2) recorded upon patient arrival to the Emergency Department (ED), total GCS recorded by Emergency medical services (EMS), total GCS on arrival, Injury severity score (ISS), presence of AIS system injury (Face, Neck, Thorax, Abdomen, Spine, Upper Extremity and Lower Extremity), and the total number of AIS systems injured. A modified Charlson comorbidity index (CCI) was calculated using previously described methods for each patient [26].
The primary outcome of our study was in-hospital mortality, defined as all deaths in the ED and before hospital discharge. Secondary outcomes, such as survival to the operating room, were evaluated. We defined statistical significance for all hypotheses tested at p <0.05. We performed bivariate analysis using Chi2 and analysis of variance for categorical variables and Kruskal-Wallis and Student’s t-test for continuous variables. We performed a multivariable logistic regression to estimate the effect of a resuscitative thoracotomy on mortality in patients with penetrating trauma and prehospital cardiac arrest. Significant potential confounding covariates (age, sex, arrival SBP, pulse rate, modified CCI, total GCS on arrival, ISS, mechanism of penetrating injury, trauma center level, and hospital teaching status) were controlled for in the model. We performed additional multivariable logistic regression models, controlling for the same covariates, to estimate the effect of hospital teaching status on the performance of a RT and mortality in RT patients. Missingness was evaluated for all variables (Table 1).
Table 1.
Baseline characteristics of all adults with penetrating traumatic injuries with prehospital cardiac arrest, stratified by resuscitative thoracotomy status
| No Thoracotomy N=11,451 (87.3%) | Resuscitative Thoracotomy N=1,664 (12.7%) | Total N=13,115 | p-value | Total Missing Values | |
|---|---|---|---|---|---|
| Age (years) | 30 (24 – 41) | 29 (23 – 39) | 30 (24 – 41) | <0.001 | 229 (1.7%) |
| Sex (male) | 10,077 (88.4%) | 1,490 (90.0%) | 11,567 (88.6%) | 0.05 | 60 (0.5%) |
| Race/Ethnicity | <0.001 | 0 (0%) | |||
| White Non-Hispanic | 2,587 (22.6%) | 263 (15.8%) | 2,850 (21.7%) | ||
| White Hispanic | 751 (6.6%) | 110 (6.6%) | 861 (6.6%) | ||
| Black | 6,221 (54.3%) | 999 (60.0%) | 7,220 (55.1%) | ||
| Asian | 208 (1.8%) | 13 (0.8%) | 221 (1.7%) | ||
| Other | 1,684 (14.7%) | 279 (16.8%) | 1,963 (15.0%) | ||
| Modified Charlson Comorbidity Index | 0.0 (0.3) | 0.0 (0.2) | 0.0 (0.3) | 0.12 | 1,606 (12.2%) |
| Mechanism of Penetrating Injury | 0.04 | 359 (2.7%) | |||
| Stabbing | 1,654 (14.9%) | 215 (13.0%) | 1,869 (14.7%) | ||
| Firearm | 9,446 (85.1%) | 1,441 (87.0%) | 10,887 (85.3%) | ||
| Arrival Vital Signs | |||||
| SBP (mmHg) | 13.4 (38.6) | 13.0 (37.0) | 13.4 (38.4) | 0. 65 | 1,599 (12.2%) |
| Pulse Rate (bpm) | 13.1 (36.1) | 13.4 (36.3) | 13.1 (36.2) | 0.78 | 1,471 (11.2%) |
| RR (bpm*) | 6.1 (9.7) | 7.2 (9.7) | 6.2 (9.7) | <0.001 | 4,451 (33.9%) |
| Pulse Oximetry (%O2) | 28.9 (43.0) | 31.9 (43.8) | 29.3 (43.1) | 0.06 | 6,117 (46.6%) |
| Total GCS – EMS | 4.2 (3.2) | 4.8 (3.8) | 4.3 (3.3) | <0.001 | 5,351 (40.8%) |
| Total GCS – Arrival | 3.4 (2.0) | 3.2 (1.2) | 3.4 (1.9) | <0.001 | 609 (4.6%) |
| ISS | 25 (11 – 33) | 26 (17 – 35) | 25 (13 – 33) | <0.001 | 2,183 (16.6%) |
| Total AIS Systems Injured | 2.3 (1.3) | 2.5 (1.3) | 2.3 (1.3) | <0.001 | 142 (1.1%) |
| AIS Injury Rate by System | 142 (1.1%) | ||||
| Face | 1,518 (13.4%) | 215 (12.9%) | 1,733 (13.4%) | 0.59 | |
| Neck | 1,492 (13.2%) | 197 (11.9%) | 1,689 (13.0%) | 0.13 | |
| Thorax | 8,330 (73.6%) | 1,389 (83.6%) | 9,719 (74.9%) | <0.001 | |
| Abdomen | 4,653 (41.1%) | 797 (48.0%) | 5,450 (42.0%) | <0.001 | |
| Spine | 1,004 (8.9%) | 194 (11.7%) | 1,198 (9.2%) | <0.001 | |
| Upper Extremity | 4,284 (37.9%) | 648 (39.0%) | 4,932 (38.0%) | 0.37 | |
| Lower Extremity | 3,455 (30.5%) | 547 (32.9%) | 4,002 (30.8%) | 0.05 | |
| AIS Thorax | 3 (0 – 5) | 4 (3 – 5) | 3 (0 – 5) | <0.001 | 142 (1.1%) |
| AIS Abdomen | 0 (0 – 2) | 0 (0 – 3) | 0 (0 – 2) | <0.001 | 142 (1.1%) |
| Thorax Organ Injured | 0 (0%) | ||||
| Heart | 2,362 (20.6%) | 507 (30.5%) | 2,869 (21.9%) | <0.001 | |
| Lung | 3,379 (29.5%) | 681 (40.9%) | 4,060 (31.0%) | <0.001 | |
| Pericardium | 882 (7.7%) | 130 (7.8%) | 1,012 (7.7%) | 0.88 | |
| Thoracic Cavity | 4,090 (35.7%) | 831 (49.9%) | 4,921 (37.5%) | <0.001 | |
| Esophagus | 176 (1.5%) | 25 (1.5%) | 201 (1.5%) | 0.91 | |
| Diaphragm | 1,286 (11.2%) | 269 (16.2%) | 1,555 (11.9%) | <0.001 | |
| Aorta | 1,011 (8.8%) | 190 (11.4%) | 1,201 (9.2%) | <0.001 | |
| Trauma Center Level | <0.001 | 3,162 (24.1%) | |||
| Level I | 6,135 (71.1%) | 1,071 (80.8%) | 7,206 (72.4%) | ||
| Level II | 2,133 (24.7%) | 236 (17.8%) | 2,369 (23.8%) | ||
| Level III | 360 (4.2%) | 18 (1.4%) | 378 (3.8%) | ||
| Hospital Teaching Status | <0.001 | 82 (0.6%) | |||
| Non-Teaching | 1,259 (11.0%) | 109 (6.7%) | 1,368 (10.5%) | ||
| Community – Teaching | 3,813 (33.5%) | 420 (25.6%) | 4,233 (32.5%) | ||
| University – Teaching | 6,323 (55.5%) | 1,109 (67.7%) | 7,432 (57.0%) | ||
| ED Disposition | <0.001 | 0 (0%) | |||
| Operating Room | 1,987 (17.4%) | 553 (33.2%) | 2,540 (19.4%) | ||
| Deceased | 9,464 (82.6%) | 1,111 (66.8%) | 10,575 (80.6%) | ||
| Mortality | 10,818 (94.5%) | 1,590 (95.6%) | 12,408 (94.6%) | 0.07 | 0 (0%) |
Data presented as mean (SD), median (IQR) or n (%)
Abbreviations: SBP: Systolic blood pressure; bpm: beats per minute; RR: Respiratory rate; bpm*:breaths per minute; GCS: Glasgow coma scale; EMS: Emergency medical services; ISS: Injury Severity Score; AIS: Abbreviated injury scale; ED: Emergency Department
We utilized StataCorp v17.0, College Station, Texas, for all statistical analyses [27]. The institutional review board at the University of North Carolina at Chapel Hill exempted the study (IRB: 20–3018).
Results
Over the study period, 13,115 patients in the NTDB met our inclusion criteria (Figure 1). A resuscitative thoracotomy was performed in 12.7% (n=1,664) patients. Rates of resuscitative thoracotomy in patients with penetrating trauma and prehospital cardiac arrest increased throughout the study period, from 9.0% of patients in 2017 to 14.6% in 2021 (Figure 2). The study cohort was primarily male (88.6%) with a median age of 30 (24 – 41 years). The patients were primarily Black (55.1%), with white non-Hispanic and white Hispanic patients making up 21.7% and 6.6% of the study, respectively. The primary mechanism of penetrating injury was via a firearm (85.3%), compared to 14.7% of patients injured via stabbing (Table 1).
Figure 2.
Rates of resuscitative thoracotomies performed from 2017 – 2021, in adults with penetrating traumatic injuries with prehospital cardiac arrest, stratified by hospital teaching status
Patients that underwent a RT were younger (29 (23 – 39) vs. 30 (24 – 41) years, p<0.001), more often male (90.0% vs. 88.4%, p=0.05), Black (60.0% vs. 54.3%, p<0.001), and injured via a firearm (87.0% vs. 85.1%, p=0.04) than patients who did not undergo a thoracotomy. The two cohorts had equivocal comorbidities and vital signs upon arrival at the ED (Table 1). Resuscitative thoracotomy patients had a higher median ISS (26 (17 – 35) vs. 25 (11 – 33), p<0.001) than non-RT patients. Patients undergoing resuscitative thoracotomy were more likely to have thorax (83.6% vs. 73.6%, p<0.001) and abdominal injuries (48.0% vs. 41.1%, p<0.001) compared to those who did not (Table 1).
Patients who presented to a Level I trauma center (80.8% vs. 71.1%, p<0.001) and university-teaching hospital (67.7% vs. 55.5%, p<0.001) underwent a RT more often than not. Resuscitative thoracotomy patients survived to the operating room more often (33.2% vs. 17.4%, p<0.001) than non-RT patients. Non-thoracotomy patients died in the ED at a higher rate than those who underwent a RT (82.6% vs. 66.8%, p<0.001). There was no difference in crude mortality between patients who underwent a resuscitative thoracotomy and those who did not (95.6% vs. 94.5%, p=0.07; Table 1).
Upon multivariable logistic regression, patients that underwent a resuscitative thoracotomy had no statistically significant difference in adjusted odds of mortality (OR 0.82, 95%CI 0.56 – 1.21, p=0.32) compared to non-RT patients. There was no statistically significant difference in adjusted odds of mortality based on trauma center level status (Table 2). Multivariable logistic regression demonstrated that university-teaching hospitals were more likely to perform a resuscitative thoracotomy on patients in cardiac arrest secondary to penetrating trauma, with an adjusted odds ratio of 1.68 (95%CI 1.31 – 2.17, p<0.001), compared to non-teaching hospitals (Table 3).
Table 2.
Adjusted odds for in-hospital mortality of all adults with penetrating traumatic injuries and prehospital cardiac arrest (n=13,115)
| Odds Ratio (OR) | 95% CI | p-value | |
|---|---|---|---|
| Resuscitative Thoracotomy | 0.82 | 0.56 – 1.21 | 0.32 |
| Trauma Center Level (ref: Level I) | 0.95 | 0.64 – 1.41 | 0.79 |
| Level II | |||
| Level III | 0.98 | 0.41 – 2.36 | 0.97 |
Adjusted for age, sex, modified Charlson comorbidity index, SBP, pulse rate, total arrival GCS, Injury severity score, mechanism of penetrating injury, trauma center level, and hospital teaching status
CI: Confidence Interval; ref: reference group; SBP: Systolic blood pressure; GCS: Glasgow coma scale
Table 3.
Adjusted odds of performing a resuscitative thoracotomy in all adults with penetrating traumatic injuries and prehospital cardiac arrest based on hospital teaching status (n=13,115)
| Odds Ratio (OR) | 95% CI | p-value | |
|---|---|---|---|
| Hospital Teaching Status (ref: Non-Teaching)* | |||
| Community – Teaching | 1.29 | 0.98 – 1.69 | 0.06 |
| University – Teaching | 1.68 | 1.31 – 2.17 | <0.001 |
Adjusted for age, sex, modified Charlson comorbidity index, SBP, pulse rate, total arrival GCS, Injury severity score, mechanism of penetrating injury, and trauma center level
CI: Confidence Interval; ref: reference group; SBP: Systolic blood pressure; GCS: Glasgow coma scale
Subset analysis of patients who underwent thoracotomy, stratified by hospital teaching status (n=1,626), found 67.5% occurred at university-teaching hospitals, 25.8% at community-teaching hospitals, and 6.7% of resuscitative thoracotomies were performed at non-teaching hospitals (Table 4). Patients in the three cohorts (non-teaching, community-teaching, and university-teaching) were similar regarding age, sex, mechanism of penetrating injury, comorbidities, arrival vital signs, and total mean GCS on arrival. The injury severity score was not significantly different between the cohorts (Table 4). Crude mortality did not differ by hospital teaching status, with a 96.3% mortality rate in the non-teaching cohort, 95.7% in patients at community-teaching hospitals, and 95.4% in patients managed at university-teaching hospitals (p=0.87; Table 4).
Table 4.
Baseline characteristics of all adults with penetrating traumatic injuries with prehospital cardiac arrest who underwent resuscitative thoracotomy, stratified by teaching hospital status
| Hospital Type | Total | p-value | Total Missing Values | |||
|---|---|---|---|---|---|---|
| Non-Teaching | Community – Teaching | University – Teaching | ||||
| N=109 (6.7%) | N=420 (25.8%) | N=1,097 (67.5%) | N=1,626 | |||
| Age (years) | 32 (23 – 45) | 28 (22 – 38) | 30 (23 – 39) | 29 (23 – 39) | 0.07 | 41 (2.5%) |
| Sex (male) | 96 (90.6%) | 370 (88.1%) | 993 (91.0%) | 1,459 (90.2%) | 0.23 | 9 (0.6%) |
| Mechanism of Penetrating Injury | 0.37 | 8 (0.5) | ||||
| Stabbing | 18 (16.8%) | 49 (11.7%) | 143 (13.1%) | 210 (13.0%) | ||
| Firearm | 89 (83.2%) | 369 (88.3%) | 950 (86.9%) | 1,408 (87.0%) | ||
| Modified CCI | 0.0 (0.0) | 0.0 (0.2) | 0.0 (0.2) | 0.0 (0.2) | 0.36 | 231 (14.2%) |
| Arrival Vital Signs | ||||||
| SBP (mmHg) | 21 .6 (46.4) | 12.9 (35.6) | 12.2 (36.7) | 13 .0 (37.3) | 0.05 | 184 (11.3%) |
| Pulse Rate (bpm) | 22.6 (49.2) | 15.4 (39.4) | 11.7 (33.6) | 13.4 (36.4) | 0.01 | 162 (9.9%) |
| RR (bpm*) | 8.2 (9.1) | 8.8 (10.2) | 6.6 (9.5) | 7.3 (9.7) | 0.01 | 588 (36.2%) |
| Pulse Oximetry (%O2) | 32.4 (43.6) | 39.1 (45.8) | 29.5 (42.9) | 31.9 (43.8) | 0.03 | 777 (47.8%) |
| Total GCS – EMS | 4.8 (3.7) | 4.4 (3.4) | 5.0 (3.9) | 4.8 (3.8) | 0.13 | 736 (45.3%) |
| Total GCS – Arrival | 3.0 (0.4) | 3.2 (1.2) | 3.2 (1.3) | 3.2 (1.2) | 0.45 | 62 (3.8%) |
| ISS | 25 (17 – 35) | 26 (17 – 38) | 26 (17 – 34) | 26 (17 – 35) | 0.59 | 88 (5.4%) |
| Trauma Center Level | <0.001 | 337 (20.7%) | ||||
| Level I | 16 (18.4%) | 176 (57.9%) | 856 (95.3%) | 1,048 (81.3%) | ||
| Level II | 70 (80.5%) | 123 (40.5%) | 42 (4.7%) | 235 (18.2%) | ||
| Level III | 1 (1.1%) | 5 (1.6%) | 0 (0.0%) | 6 (0.5%) | ||
| ED Disposition | 0.47 | 0 (0%) | ||||
| Operating Room | 32 (29.4%) | 134 (31.9%) | 375 (34.2%) | 541 (33.3%) | ||
| Deceased | 77 (70.6%) | 286 (68.1%) | 722 (65.8%) | 1,085 (66.7%) | ||
| Mortality | 105 (96.3%) | 402 (95.7%) | 1,046 (95.4%) | 1,553 (95.5%) | 0.87 | 0 (0%) |
Data presented as mean (SD), median (IQR) or n (%)
Abbreviations: CCI: Charlson Comorbidity Index; SBP: Systolic blood pressure; bpm: beats per minute; RR: Respiratory rate; bpm*:breaths per minute; GCS: Glasgow coma scale; EMS: Emergency medical services; ISS: Injury Severity Score; ED: Emergency Department
The average annual rate of resuscitative thoracotomies over the study period was 8.0% (n=120) at non-teaching hospitals, 9.9% (n=420) at community-teaching hospitals, and 14.9% (n=1,097) at university-teaching hospitals. Rates of resuscitative thoracotomies increased at university-teaching hospitals, from 9.7% in 2017 to 17.5% in 2021 (Figure 2). Non-teaching and community-teaching hospital rates of resuscitative thoracotomies increased from 7.1% and 8.2% in 2017 to 10.0% and 10.4% in 2021, respectively (Figure 2).
Upon multivariable logistic regression, patients that underwent a RT at a university-teaching hospital (OR 0.44, 95% CI 0.06 – 3.05, p=0.41) or community-teaching hospital (OR 0.55, 95% CI 0.09 – 3.54, p=0.53) had no differences in adjusted odds of mortality compared to patients that underwent a RT at a non-teaching hospital (Table 5).
Table 5.
Adjusted odds for in-hospital mortality and of all adults with traumatic cardiac arrest following penetrating trauma who underwent a resuscitative thoracotomy based on hospital teaching status (n=1,638)
| Odds Ratio (OR) | 95% CI | p-value | |
|---|---|---|---|
| Hospital Teaching Status (ref: Non-Teaching)* | |||
| Community – Teaching | 0.55 | 0.09 – 3.54 | 0.53 |
| University – Teaching | 0.44 | 0.06 – 3.05 | 0.41 |
Adjusted for age, sex, modified Charlson comorbidity index, SBP, pulse rate, total arrival GCS, Injury severity
score, mechanism of penetrating injury, and trauma center level
CI: Confidence Interval; ref: reference group; SBP: Systolic blood pressure; GCS: Glasgow coma scale
Discussion
In our study of adults with prehospital cardiac arrest following penetrating trauma, 12.7% of patients underwent a resuscitative thoracotomy, with a 4.4% overall survival rate. Patients that underwent RT survived to the operating room at nearly twice the rate compared to non-RT patients, indicating that RT may be a useful adjunct to achieve definitive surgical intervention. However, resuscitative thoracotomies provided no mortality benefit in this population. Rates of RT increased throughout the study period, and we found that university-teaching hospitals perform resuscitative thoracotomies at nearly twice the rate of non-teaching hospitals. Despite increased odds of performing a RT, university-teaching hospital status conferred no mortality benefit in patients undergoing a RT.
Our results confer a lower overall survival rate for patients with penetrating injuries undergoing RT than most current literature. Despite improved guidelines and stricter criteria for the performance of a RT, rates continue to rise without evidence of a benefit. Our study utilizes an up-to-date, large national dataset that provides imperative insight regarding the current trends and outcomes on this topic.
Utilizing the WTA guidelines for RT indications, in 2012, Passos et al. evaluated 123 patients over 17 years at a single institution who underwent a RT for appropriateness [11,14]. They found 51% were considered inappropriate for thoracotomy based on the guidelines, primarily due to prolonged prehospital cardiac arrest. The mean ISS was 35 (SD19), and patients injured via penetrating trauma comprised 78% of the study. No patients survived following a RT in the inappropriate group, and this cohort had a 6% rate of needlestick injuries. Patients that underwent a RT with appropriate indication had a 5.0% survival rate. Passos et al. questioned if the decision to proceed with a RT in patients without indication was influenced by the low volume of penetrating trauma at their institution in conjunction with the need to educate surgical residents [11].
In 2018, Joseph et al. retrospectively reviewed 2,229 patients, with a median ISS of 27 (9–75), who underwent RT from 2010 to 2014 in the American College of Surgeons Trauma Quality Improvement Program (TQIP) [12]. They reported rates of RT decreased from 333 per 100,000 patients to 243 per 100,000 patients (p=0.002) over the study period and that the rate of overall survival increased from 7.9% to 11.3% (p<0.001). Penetrating injuries occurred in 56.3% of the population, with a subsequent 14.2% survival rate, compared to a 3.5% survival rate in patients with blunt traumatic injuries [12].
In 2020, Panossian et al. reviewed 2,012 patients in the TQIP database from 2010 to 2016 who underwent a resuscitative thoracotomy. The median ISS was 26, 66.7% were injured via a penetrating mechanism, and the overall survival rate was 19.9%. They reported survival rates of 26.0% and 7.6% for patients injured via penetrating and blunt mechanisms, respectively. Independent predictors of mortality included blunt trauma, age over 60 years, pulse <60 bpm, and no signs of life upon ED arrival [15].
Our study evaluates rates of resuscitative thoracotomy and subsequent mortality outcomes by hospital teaching status in the United States, utilizing an extensive national trauma database. Our study shows that university-teaching hospitals are performing the majority of resuscitative thoracotomies nationwide, at nearly 70%. In our study, over 93% of the university-teaching hospitals met Level I trauma center criteria. Despite the increased volume of resuscitative thoracotomies, mortality outcomes were equivocal across trauma center level and hospital teaching status. However, the rate of resuscitative thoracotomies continues to rise, particularly at university-teaching hospitals. These results may indicate a more liberal use of resuscitative thoracotomies as a mechanism of resident education in patients with borderline or inappropriate indications for thoracotomy. Simulation training for low-volume procedures, such as resuscitative thoracotomies, continues to improve, to prepare the learner without causing undue harm to patients or healthcare providers through potentially futile procedures [28–30]. Therefore, we recommend teaching hospitals prioritize simulation training of resuscitative thoracotomies and reserve performance of a RT for select patients meeting the strictest of guidelines. By improving simulation training and patient selection, outcomes in this population may subsequently improve.
There are inherent limitations in data quality, coding, and collection when utilizing large, national administrative datasets. Some data variation will be present, despite strict data coding requirements. Specific limitations of our study include a lack of data regarding the timing of the prehospital cardiac arrest, duration of CPR, and presence of signs of life, either on the scene or upon ED arrival. Additionally, the location of the resuscitative thoracotomy (ED vs. operating room), and RT case volume of the performing hospital, cannot be determined using the data bank. Measures of neurological outcome, healthcare personnel needlestick injuries, and quantities of blood product utilized would be pertinent information to assess further the risks associated with resuscitative thoracotomies.
Conclusion
Despite up-trending rates, a resuscitative thoracotomy may not improve mortality in adults with penetrating, traumatic cardiac arrest. University-teaching hospitals are nearly twice as likely to perform a resuscitative thoracotomy than non-teaching hospitals, with no subsequent improvement in mortality.
Highlights.
Resuscitative thoracotomy occurred in 12.7% of patients in cardiac arrest following penetrating trauma with rates up trending from 2017 to 2021
Crude mortality was similar in resuscitative thoracotomy and non-resuscitative thoracotomy patients (95.6% vs. 94.5%, p=0.07)
Resuscitative thoracotomy status confers no statistically significant difference in the adjusted odds of mortality (OR 0.82, 95%CI 0.56–1.21)
University-teaching hospitals had nearly twice the odds of performing a resuscitative thoracotomy than non-teaching hospitals
There was no difference in the adjusted odds of mortality in patients that underwent resuscitative thoracotomy based on hospital teaching status
Acknowledgements
Funding:
This work was supported by the National Institute of Health under award number: 5T32GM008450-23 (Atkins)
Footnotes
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Declarations of interest: None.
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