Tag Archives: Trauma

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Hypovolaemic shock and pre-hospital hypertonic saline

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No benefit was shown in a trial of hypertonic saline (with or without dextran) versus 0.9% saline in patients with hemorrhagic shock, in a study that was terminated early. Compare this to a similar study on head injured patients without shock by the same investigators.

OBJECTIVE: To determine whether out-of-hospital administration of hypertonic fluids would improve survival after severe injury with hemorrhagic shock.
BACKGROUND: Hypertonic fluids have potential benefit in the resuscitation of severely injured patients because of rapid restoration of tissue perfusion, with a smaller volume, and modulation of the inflammatory response, to reduce subsequent organ injury.
METHODS: Multicenter, randomized, blinded clinical trial, May 2006 to August 2008, 114 emergency medical services agencies in North America within the Resuscitation Outcomes Consortium. Inclusion criteria: injured patients, age ≥ 15 years with hypovolemic shock (systolic blood pressure ≤ 70 mm Hg or systolic blood pressure 71-90 mm Hg with heart rate ≥ 108 beats per minute). Initial resuscitation fluid, 250 mL of either 7.5% saline per 6% dextran 70 (hypertonic saline/dextran, HSD), 7.5% saline (hypertonic saline, HS), or 0.9% saline (normal saline, NS) administered by out-of-hospital providers. Primary outcome was 28-day survival. On the recommendation of the data and safety monitoring board, the study was stopped early (23% of proposed sample size) for futility and potential safety concern.
RESULTS: A total of 853 treated patients were enrolled, among whom 62% were with blunt trauma, 38% with penetrating. There was no difference in 28-day survival-HSD: 74.5% (0.1; 95% confidence interval [CI], -7.5 to 7.8); HS: 73.0% (-1.4; 95% CI, -8.7-6.0); and NS: 74.4%, P = 0.91. There was a higher mortality for the postrandomization subgroup of patients who did not receive blood transfusions in the first 24 hours, who received hypertonic fluids compared to NS [28-day mortality-HSD: 10% (5.2; 95% CI, 0.4-10.1); HS: 12.2% (7.4; 95% CI, 2.5-12.2); and NS: 4.8%, P < 0.01].
CONCLUSION: Among injured patients with hypovolemic shock, initial resuscitation fluid treatment with either HS or HSD compared with NS, did not result in superior 28-day survival. However, interpretation of these findings is limited by the early stopping of the trial.

Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock: a randomized, placebo controlled trial
Ann Surg. 2011 Mar;253(3):431-41

All Updates, Kids, Resus, Trauma, Ultrasound

FAST in kids has low sensitivity

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The abstract says it all – don’t use FAST to rule out significant abdominal free fluid in kids with blunt abdominal trauma. Fine as a rule-in test (for free fluid) though.

Objectives:  Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT.

Methods:  This was a prospective observational study of consecutive children (0–17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery.

Results:  The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%).

Conclusion:  In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making

Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma
Acad Emerg Med. 2011 May;18(5):477-82

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Steroids for trauma

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A French study on adult patients intubated for multiple trauma assessed the effect of a one week course of stress-dose hydrocortisone therapy against placebo on the incidence of hospital-acquired pneumonia. Multiple trauma was defined as having 2 or more traumatic injuries and an injury severity score higher than 15. The primary outcome measure was hospital-acquired pneumonia, defined by robust criteria and requiring positive lower respiratory tract microbiology. The study was not powered to detect a difference in mortality. The authors conclude that a stress dose of hydrocortisone for 7 days is associated with a reduction in the rate of hospital-acquired pneumonia at day 28 together with a decreased requirement for mechanical ventilation and length of ICU stay in trauma patients.
An accompanying editorial, highlighting the contrast in these results with those of other steroid-studies such as the CRASH trial, which used higher doses of steroid for a shorter period, cautions:
“the overall evidence suggests that further study with a larger sample size is needed to better define the safety profile and risk of mortality in this patient population.”

Context The role of stress-dose hydrocortisone in the management of trauma patients is currently unknown.

Objective To test the efficacy of hydrocortisone therapy in trauma patients.

Design, Setting, and Patients Multicenter, randomized, double-blind, placebo-controlled HYPOLYTE (Hydrocortisone Polytraumatise) study. From November 2006 to August 2009, 150 patients with severe trauma were included in 7 intensive care units in France.

Intervention Patients were randomly assigned to a continuous intravenous infusion of either hydrocortisone (200 mg/d for 5 days, followed by 100 mg on day 6 and 50 mg on day 7) or placebo. The treatment was stopped if patients had an appropriate adrenal response.

Main Outcome Measure Hospital-acquired pneumonia within 28 days. Secondary outcomes included the duration of mechanical ventilation, hyponatremia, and death.

Results One patient withdrew consent. An intention-to-treat (ITT) analysis included the 149 patients, a modified ITT analysis included 113 patients with corticosteroid insufficiency. In the ITT analysis, 26 of 73 patients (35.6%) treated with hydrocortisone and 39 of 76 patients (51.3%) receiving placebo developed hospital-acquired pneumonia by day 28 (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.30-0.83; P = .007). In the modified ITT analysis, 20 of 56 patients (35.7%) in the hydrocortisone group and 31 of 57 patients (54.4%) in the placebo group developed hospital-acquired pneumonia by day 28 (HR, 0.47; 95% CI, 0.25-0.86; P = .01). Mechanical ventilation–free days increased with hydrocortisone by 4 days (95% CI, 2-7; P = .001) in the ITT analysis and 6 days (95% CI, 2-11; P < .001) in the modified ITT analysis. Hyponatremia was observed in 7 of 76 (9.2%) in the placebo group vs none in the hydrocortisone group (absolute difference, −9%; 95% CI, −16% to −3%; P = .01). Four of 76 patients (5.3%) in the placebo group and 6 of 73 (8.2%) in the hydrocortisone group died (absolute difference, 3%; 95% CI, −5% to 11%; P = .44).

Conclusion In intubated trauma patients, the use of an intravenous stress-dose of hydrocortisone, compared with placebo, resulted in a decreased risk of hospital-acquired pneumonia.

Hydrocortisone therapy for patients with multiple trauma: the randomized controlled HYPOLYTE study
JAMA. 2011 Mar 23;305(12):1201-9

All Updates, ICU, Resus, Trauma

Decompressive craniectomy for high ICP head trauma

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Bilateral decompressive craniectomy for severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first line therapies did not improve neurological outcome. This was the Australasian DECRA study.

Emergency Medicine Ireland reviews the paper here.
Another study on decompressive craniectomy, the RESCUE-ICP study, is ongoing, with 306/400 patients now recruited. The RESCUE-ICP investigators make the following comment on the DECRA trial:
“The study showed a significant decrease in intracranial pressure in patients in the surgical group. However, although ICP was lowered by surgery, ICP was not excessively high in the medical group (mean ICP below 24 mmHg pre-randomisation).
RESCUE-ICP differs from DECRA in terms of ICP threshold (25 vs 20 mmHg), timing of surgery (any time after injury vs within 72 hours post-injury), acceptance of contusions and longer follow up (2 years).
The cohort profiles and criteria for entry and randomisation between the DECRA and RESCUE-ICP are therefore very different. Hence the results from the DECRA study should not deter recruitment into RESCUE-ICP. Randomising patients into the RESCUE-ICP study is now even more important!”

Background
It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.
Methods
From December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final primary outcome was the score on the Extended Glasgow Outcome Scale at 6 months.
Results
Patients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P=0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P=0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%).
Conclusions
In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes

Decompressive Craniectomy in Diffuse Traumatic Brain Injury
N Engl J Med. 2011 Apr 21;364(16):1493-502

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Military vascular injury to the torso is deadly

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Outcomes are described for military personnel with vascular injury sustained in Afghanistan and Iraq.

BACKGROUND: Military injuries to named blood vessels are complex limb- and life-threatening wounds that pose significant difficulties in prehospital and surgical management. The aim of this study was to provide a comprehensive description of the epidemiology, treatment and outcome of vascular injury among service personnel deployed on operations in Afghanistan and Iraq.
METHODS: Data from the British Joint Theatre Trauma Registry were combined with hospital records to review all cases of vascular trauma in deployed service personnel over a 5-year interval ending in January 2008.
RESULTS: Of 1203 injured service personnel, 110 sustained injuries to named vessels; 66 of them died before any surgical intervention. All 25 patients who sustained an injury to a named vessel in the abdomen or thorax died; 24 did not survive to undergo surgery and one casualty in extremis underwent a thoracotomy, but died. Six of 17 patients with cervical vascular injuries survived to surgical intervention; two died after surgery. Of 76 patients with extremity vascular injuries, 37 survived to surgery with one postoperative death. Interventions on 38 limbs included 19 damage control procedures (15 primary amputations, 4 vessel ligations) and 19 definitive limb revascularization procedures (11 interposition vein grafts, 8 direct repairs), four of which failed necessitating three amputations.
CONCLUSION: In operable patients with extremity injury, amputation or ligation is often required for damage control and preservation of life. Favourable limb salvage rates are achievable in casualties able to withstand revascularization. Despite marked progress in contemporary battlefield trauma care, torso vascular injury is usually not amenable to surgical intervention.

Outcome after vascular trauma in a deployed military trauma system
Br J Surg. 2011 Feb;98(2):228-34

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Pre-hospital transcranial Doppler

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The SAMU (Service d’aide médicale urgente) guys have had a run of interesting pre-hospital publications lately. In this study, one of their ultrasound-wielding physicians travelled in a car to meet comatose head injured patients in a large semi-rural territory area with up to a 120–160-min transport time to a hospital with emergency neurosurgical capability. Pre-hospital transcranial Doppler was done, the results of which appear to have influenced treatment decisions, including the pre-hospital administration of noradrenaline (norepinephrine). I think this study has answered the ‘can it be done?’ question, but further work is needed to determine whether it really makes a difference to outcome.

Background: Investigation of the feasibility and usefulness of pre-hospital transcranial Doppler (TCD) to guide early goal-directed therapy following severe traumatic brain injury (TBI).
Methods: Prospective, observational study of 18 severe TBI patients during pre-hospital medical care. TCD was performed to estimate cerebral perfusion in the field and upon arrival at the Level 1 trauma centre. Specific therapy (mannitol, noradrenaline) aimed at improving cerebral perfusion was initiated if the initial TCD was abnormal (defined by a pulsatility index >1.4 and low diastolic velocity).
Results: Nine patients had a normal initial TCD and nine an abnormal one, without a significant difference between groups in terms of the Glasgow Coma Scale or the mean arterial pressure. Among patients with an abnormal TCD, four presented with an initial areactive bilateral mydriasis. Therapy normalized TCD in five patients, with reversal of the initial mydriasis in two cases. Among these five patients for whom TCD was corrected, only two died within the first 48 h. All four patients for whom the TCD could not be corrected during transport died within 48 h. Only patients with an initial abnormal TCD required emergent neurosurgery (3/9). Mortality at 48 h was significantly higher for patients with an initial abnormal TCD.
Conclusions: Our preliminary study suggests that TCD could be used in pre-hospital care to detect patients whose cerebral perfusion may be impaired.

Pre-hospital transcranial Doppler in severe traumatic brain injury: a pilot study
Acta Anaesthesiol Scand. 2011 Apr;55(4):422-8

All Updates, ICU, Resus, Trauma

Fever in head injury might not be bad

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Thanks to Michael McGonigal MD for highlighting this in his excellent Trauma Professional’s Blog:

  • Body temperature does not necessarily reflect brain temperature
  • Low brain temperature was independently associated with a worse outcome in a recent study
  • Brain temperature within the range of 36.5°C to 38°C was associated with a lower probability of death in this study
  • There are no randomised studies on which to base the practice of aggressive cooling of febrile patients with traumatic brain injury

There are few prospective studies reporting the effect of spontaneous temperature changes on outcome after severe traumatic brain injury (TBI). Where studies have been conducted, results are based on systemic rather than brain temperature per se. However, body temperature is not a reliable surrogate for brain temperature. Consequently, the effect of brain temperature changes on outcome in the acute phase after TBI is not clear. Continuous intraparenchymal brain temperature was measured in consecutive admissions of severe TBI patients during the course of the first 5 days of admission to the intensive care unit (ICU). Patients received minimal temperature altering therapy during their ICU stay. Logistic regression was used to explore the relationship between the initial, the 24-h mean, and the 48-h mean brain temperature with outcome for mortality at 30 days and outcome at 3 months. Multifactorial analysis was performed to account for potential confounders. At the 24-h time point, brain temperature within the range of 36.5°C to 38°C was associated with a lower probability of death (10-20%). Brain temperature outside of this range was associated with a higher probability of death and poor 3-month neurological outcome. After adjusting for other predictors of outcome, low brain temperature was independently associated with a worse outcome. Lower brain temperatures (below 37°C) are independently associated with a higher mortality rate after severe TBI. The results suggest that, contrary to current opinion, temperatures within the normal to moderate fever range during the acute post-TBI period do not impose an additional risk for a poor outcome after severe TBI.

The effect of spontaneous alterations in brain temperature on outcome: a prospective observational cohort study in patients with severe traumatic brain injury.
J Neurotrauma. 2010 Dec;27(12):2157-64

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London trauma deaths described

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Doctors from Britain’s most established major trauma centre – the Royal London Hospital – have produced mortality data over a four year period of trauma team activations.

 

Introduction Trauma data collection by UK hospitals is non-mandatory and data regarding trauma mortality are deficient. Our aim was to provide a contemporary description of mortality in a maturing trauma-receiving hospital serving an inner-city population.
Methods A prospectively maintained registry was analysed for demographics; injury mechanism; and time, location and cause of death in trauma patients admitted via the Emergency Department between 2004 and 2008.
Results 4986 trauma team activations yielded 4243 complete cases. The number of patients rose from 784 in 2004-2005 to 1400 in 2007/8. 302 (7%) of these died. All-cause mortality fell from 8.8% to 5.8% (p=0.0075). Blunt trauma (predominantly falls from height and road traffic collisions) accounted for 79% of admissions but 87% of mortality. Penetrating trauma accounted for 21% of admissions and 13% of mortality. Most penetrating injury deaths were from stabbing injury (31/40) as opposed to gunshot wounds (8/40). The biggest cause of death was central nervous system injury (47.7%) followed by haemorrhage (26.2%). Penetrating injury death was associated with marked shock and acidosis compared to blunt mechanisms-mean (SD) admission systolic blood pressure 25.4 (45.7) versus 105.5 (60.5) mm Hg; mean (SD) base excess -21.84 (7.2) versus 9.71 (8.45) mmol, respectively. No classical trimodal distribution of death was observed.
Conclusion Despite current focus on death from knife and gun crime, the vast majority of trauma mortality arises from blunt aetiology. Maturation of our systems of care has been associated with a drop in mortality as institutional trauma volumes increase and clinical infrastructure develops.

Deaths from trauma in London—a single centre experience
Emerg Med J 2011;28:305-309

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Military trauma care meets standards

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Recent recommendations were made regarding trauma care in the UK by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).
British military physicians at the UK military field hospital, Camp Bastion, Helmand Province, Afghanistan, evaluated their trauma cases against these standards. It is apparent that the trauma care provided to some people in Afghanistan outclasses that delivered within much of the UK.

Military medical teams

Background The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on trauma management, published in 2007, defined standards for United Kingdom (UK) hospitals dealing with trauma. This study compared the NCEPOD standards with the performance of a UK military field hospital in Afghanistan. Setting UK military field hospital, Camp Bastion, Helmand Province, Afghanistan.
Materials and methods Data were collected prospectively for all patients fulfilling the trauma team activation criteria during the 3 months of Operation Herrick IXa (from mid October 2008 to mid January 2009) and combined with a retrospective review of prehospital documentation, trauma resuscitation notes, operations notes and transfer notes for these patients.
Results During the study period, there were 226 trauma team activations. Of those patients brought to the medical facility at Camp Bastion by UK assets, 93.7% were accompanied by a doctor with advanced airway skills, although only 6.2% of the patients required such an intervention. Consultants in emergency medicine and anaesthesia were present in 100% of cases and were directly involved (in either leading the team or performing airway management) in 63.5% and 77.6% of cases respectively. Of those patients requiring operative intervention, 98.1% had this performed by a consultant surgeon. Of those patients requiring CT, 93.6% of cases had this performed within 1 h of arrival.
Conclusions Trauma patients presenting to the medical facility at Camp Bastion during Operation Herrick IXa, irrespective of their nationality or background, received a high standard of medical care when compared with the NCEPOD standards

National Confidential Enquiry into Patient Outcome and Death recommendations
Pre-hospital care
All agencies involved in trauma management, including emergency medical services, should be integrated into the clinical governance programmes of a regional trauma service. Airway management in trauma patients is often challenging, and the pre-hospital response for these patients should include someone with the skill to secure the airway, (including the use of rapid sequence intubation), and maintain adequate ventilation.
Hospital reception
A trauma team should be available 24 h a day, 7 days a week. This is an essential part of an organised trauma response system. A consultant must be the team leader for the management of the severely injured patient.
Airway and breathing
The current structure of prehospital management is insufficient. There is a high incidence of failed intubation and a high incidence of patients arriving at hospital with a partially or completely obstructed airway. Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation. This may be through the provision of personnel with the ability to provide anaesthesia and intubation in the prehospital phase or through the use of alternative airway devices.
Circulation
Trauma laparotomy is extremely challenging and requires consultant presence within the operating theatre. If CT is to be performed, all necessary images should be obtained at the same time, and routine use of head-to-toe scanning is recommended in the adult trauma patient if no indication for immediate intervention exists.
Head injuries
Patients with severe head injury should have a CT of the head performed as soon as possible after admission and within 1 hour of arrival at the hospital. All patients with severe head injury should be transferred to a neurosurgical critical care centre irrespective of the requirement for surgical intervention.
Transfers
There should be standardised transfer documentation of patient details, injuries, results of investigations and management, with records kept at the dispatching and receiving hospitals.
A comparison of civilian (National Confidential Enquiry into Patient Outcome and Death) trauma standards with current practice in a deployed field hospital in Afghanistan.
Emerg Med J 2011;28:310-312

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Limits on resuscitative thoractomy in ED

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Eighteen trauma centers contributed ED resuscitative thoracotomy data to a study that commenced enrollment in January 2003. During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3; the youngest was a 15-year-old female and the oldest was a 64-year-old male; 93% were male. Injury mechanism was stab wound (SW) in 30 patients, gunshot wound (GSW) in 21 patients, and blunt trauma in 5 patients.
The most common injury was a SW to a ventricle (n =17), accounting for 30% of survivors, followed by a GSW to the lung (n =9) in 16%. There were five survivors (9%) after blunt trauma. Two patients were revived with isolated head trauma who had deteriorated from extensive hemorrhage, one from an open blunt skull fracture (who had 5 minutes of prehospital CPR and left the hospital neurologically intact.) and the other from SWs to the scalp. Two patients also survived with isolated neck injuries: a SW to the vertebral artery and a GSW to the internal carotid artery.
34% of survivors underwent prehospital CPR. Corroborating the reported duration of CPR, the mean base deficit (BD) was 23.3 mequiv/L (range, 14–32 mequiv/L) in those undergoing CPR >5 minutes. In the SW group, the duration was 2 minutes to 10 minutes; the sole survivor after 10 minutes had ventricular wounds with pericardial tamponade. In the GSW group, prehospital CPR was from 1 minute to 15 minutes. The only patient surviving with 15 minutes of CPR also had a ventricular wound with pericardial tamponade but had a moderate neurologic deficit at discharge. In the blunt group, CPR ranged from 3 minutes to 9 minutes; the survivor with 9 minutes of CPR had an atrial rupture with pericardial tamponade.
Seven patients survived with asystole at ED arrival; of significance, all patients had pericardial tamponade. At the time of hospital discharge, three of these patients (43%) had functional neurologic recovery.
The authors state: ‘most recent edition of the ACSCOT advanced trauma life support manual continues to declare “patients sustaining blunt injuries who arrive pulseless but with myocardial electrical activity are not candidates for resuscitative thoracotomy”. But these statements are not congruent with most of the recent literature.‘

Recommended Limits of Resuscitative Thoracotomy in the ED

 

BACKGROUND: Since the promulgation of emergency department (ED) thoracotomy >40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival.
METHODS: Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively.
RESULTS: During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge.
CONCLUSION: Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.
Defining the Limits of Resuscitative Emergency Department Thoracotomy: A Contemporary Western Trauma Association Perspective
J Trauma. 2011 Feb;70(2):334-339.