Skip to main content

Advertisement

SpringerLink
Log in

Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center

  • Original Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

To investigate survival after emergency department thoracotomy (EDT) in a physician-staffed emergency medicine system.

Methods

This single-center retrospective study included all in extremis trauma patients who underwent EDT between 2013 and 2021 in a military level 1 trauma center. CPR time exceeding 15 minutes for penetrating trauma of 10 minutes for blunt trauma, and identified head injury were the exclusion criteria.

Results

Thirty patients (73% male, 22/30) with a median age of 42 y/o [27–64], who presented mostly with polytrauma (60%, 18/30), blunt trauma (60%, 18/30), and severe chest trauma with a median AIS of 4 3–5 underwent EDT. Mean prehospital time was 58 min (4–73). On admission, the mean ISS was 41 29–50, and 53% (16/30) of patients had lost all signs of life (SOL) before EDT. On initial work-up, Hb was 9.6 g/dL [7.0–11.1], INR was 2.5 [1.7–3.2], pH was 7.0 [6.8–7.1], and lactate level was 11.1 [7.0–13.1] mmol/L. Survival rates at 24 h and 90 days after penetrating versus blunt trauma were 58 and 41% versus 16 and 6%, respectively. If SOL were present initially, these values were 100 and 80% versus 22 and 11%.

Conclusion

Among in extremis patients supported in a physician-staffed emergency medicine system, implementation of a trauma protocol with EDT resulted in overall survival rates of 33% at 24 h and 20% at 90 days. Best survival was observed for penetrating trauma or in the presence of SOL on admission.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

ABG:

Arterial blood gas

ACDS:

Advanced course for deployment surgery

AIS:

Abbreviated injury scale

BP:

Blood pressure

CPR:

Cardiopulmonary resuscitation

ER:

Emergency room

EDT:

Emergency department thoracotomy

FAST:

Focused assessment with sonography in trauma

FFP:

Fresh-frozen plasma

FLYP:

French lyophilized plasma

GOS:

Glasgow outcome scale

GOSE:

Extended Glasgow outcome scale

HR:

Heart rate

ICU:

Intensive-care unit

IQR:

Interquartile range

LOMI:

Location of major injury

MOI:

Mechanism of injury

NTDB:

National trauma databank

RBC:

Packed red blood cell

REBOA:

Resuscitative endovascular balloon occlusion of the aorta

SBP:

Systolic blood pressure

SOL:

Signs of life

References

  1. Boddaert G, Hornez E, De Lesquen H, et al. Resuscitation thoracotomy. J Visc Surg. 2017;154(Suppl 1):S35–41. https://doi.org/10.1016/j.jviscsurg.2017.07.003.

    Article  PubMed  Google Scholar 

  2. Benkhadra M, Honnart D, Lenfant F, Trouilloud P, Girard C, Freysz M. Intérêts des manoeuvres de réanimation à thorax ouvert en France ? (Open chest cardiopulmonary resuscitation: is there an interest in France?). Ann Fr Anesth Reanim. 2008;27(11):920–33. https://doi.org/10.1016/j.annfar.2008.06.014.

    Article  CAS  PubMed  Google Scholar 

  3. Mancini A, Bonne A, Pirvu A, et al. Retrospective study of thoracotomy performed in a French level 1-trauma center. J Visc Surg. 2017;154(6):401–6. https://doi.org/10.1016/j.jviscsurg.2017.05.007.

    Article  CAS  PubMed  Google Scholar 

  4. Schulz-Drost S, Merschin D, Gümbel D, et al. Emergency department thoracotomy of severely injured patients: an analysis of the traumaregister DGU®. Eur J Trauma Emerg Surg. 2020;46(3):473–85. https://doi.org/10.1007/s00068-019-01212-3.

    Article  PubMed  Google Scholar 

  5. Narvestad JK, Meskinfamfard M, Søreide K. Emergency resuscitative thoracotomy performed in European civilian trauma patients with blunt or penetrating injuries: a systematic review. Eur J Trauma Emerg Surg. 2016;42(6):677–85. https://doi.org/10.1007/s00068-015-0559-z.

    Article  CAS  PubMed  Google Scholar 

  6. Bouzat P, Raux M, David JS, et al. Chest trauma: first 48 hours management. ACCPM. 2017;36(2):135–45. https://doi.org/10.1016/j.accpm.2017.01.003.

    Article  PubMed  Google Scholar 

  7. Burlew CC, Moore EE, Moore FA, et al. Western trauma association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359–63. https://doi.org/10.1097/TA.0b013e318270d2df.

    Article  PubMed  Google Scholar 

  8. Bonnet S, Gonzalez F, Mathieu L, et al. The French Advanced Course for Deployment Surgery (ACDS) called Cours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX): history of its development and future prospects. J R Army Med Corps. 2016;162(5):343–7. https://doi.org/10.1136/jramc-2015-000528.

    Article  PubMed  Google Scholar 

  9. De Lesquen H, Beranger F, Natale C, Boddaert G, Avaro JP. Resuscitation thoracotomy-technical aspects. J Visc Surg. 2017;154(Suppl 1):S61–7. https://doi.org/10.1016/j.jviscsurg.2017.09.004.

    Article  PubMed  Google Scholar 

  10. Sturm JA, Pape HC, Dienstknecht T. Trauma care in Germany: an inclusive system. Clin Orthop Relat Res. 2013;471(9):2912–23. https://doi.org/10.1007/s11999-013-2967-x.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190(3):288–98. https://doi.org/10.1016/s1072-7515(99)00233-1.

    Article  CAS  PubMed  Google Scholar 

  12. Moore HB, Moore EE, Burlew CC, et al. Establishing benchmarks for resuscitation of traumatic circulatory arrest: success-to-rescue and survival among 1708 patients. J Am Coll Surg. 2016;223(1):42–50. https://doi.org/10.1016/j.jamcollsurg.2016.04.013.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Segalini E, Di Donato L, Birindelli A, et al. Outcomes and indications for emergency thoracotomy after adoption of a more liberal policy in a western European level 1 trauma centre: 8-year experience. Updates Surg. 2019;71(1):121–7. https://doi.org/10.1007/s13304-018-0607-4.

    Article  PubMed  Google Scholar 

  14. Meredith JW, Evans G, Kilgo PD, et al. A comparison of the abilities of nine scoring algorithms in predicting mortality. J Trauma. 2002;53(4):621–9. https://doi.org/10.1097/00005373-200210000-00001.

    Article  PubMed  Google Scholar 

  15. Khorsandi M, Skouras C, Shah R. Is there any role for resuscitative emergency department thoracotomy in blunt trauma? Interact Cardiovasc Thorac Surg. 2013;16(4):509–16.

    Article  PubMed  Google Scholar 

  16. Simms ER, Flaris AN, Franchino X, Thomas MS, Caillot JL, Voiglio EJ. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study. World J Surg. 2013;37(6):1277–85. https://doi.org/10.1007/s00268-013-1961-5.

    Article  PubMed  Google Scholar 

  17. DuBose JJ, Morrison J, Moore LJ, et al. Does clamshell thoracotomy better facilitate thoracic life-saving procedures without increased complication compared with an anterolateral approach to resuscitative thoracotomy? Results from the American association for the surgery of trauma aortic occlusion for resuscitation in trauma and acute care surgery registry. J Am Coll Surg. 2020;231(6):713-719.e1. https://doi.org/10.1016/j.jamcollsurg.2020.09.002.

    Article  PubMed  Google Scholar 

  18. Avaro JP, Mardelle V, Roch A, et al. Forty-minute endovascular aortic occlusion increases survival in an experimental model of uncontrolled hemorrhagic shock caused by abdominal trauma. J Trauma. 2011;71(3):720–6. https://doi.org/10.1097/TA.0b013e318221a94a.

    Article  CAS  PubMed  Google Scholar 

  19. de Lesquen H, Beranger F, Berbis J, et al. Challenges in war-related thoracic injury faced by French military surgeons in Afghanistan (2009–2013) (published correction appears in Injury. 2016;47(12):2841. Lesquen, Henri de [corrected to de Lesquen, Henri). Injury. 2016;47(9):1939–44. https://doi.org/10.1016/j.injury.2016.06.008.

    Article  PubMed  Google Scholar 

  20. Undre S, Koutantji M, Sevdalis N, et al. Multidisciplinary crisis simulations: the way forward for training surgical teams. World J Surg. 2007;31(9):1843–53. https://doi.org/10.1007/s00268-007-9128-x21.

    Article  PubMed  Google Scholar 

  21. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the eastern association for the surgery of trauma. J Trauma Acute Care Surg. 2015;79(1):159–73. https://doi.org/10.1097/TA.0000000000000648.

    Article  PubMed  Google Scholar 

  22. Panossian VS, Nederpelt CJ, El Hechi MW, et al. Emergency resuscitative thoracotomy: a nationwide analysis of outcomes and predictors of futility. J Surg Res. 2020;255:486–94. https://doi.org/10.1016/j.jss.2020.05.048.

    Article  PubMed  Google Scholar 

  23. Dennis BM, Medvecz AJ, Gunter OL, Guillamondegui OD. Survey of trauma surgeon practice of emergency department thoracotomy. Am J Surg. 2016;212(3):440–5. https://doi.org/10.1016/j.amjsurg.2015.10.031.

    Article  PubMed  Google Scholar 

  24. Seamon MJ, Fisher CA, Gaughan J, et al. Prehospital procedures before emergency department thoracotomy: “scoop and run” saves lives. J Trauma. 2007;63(1):113–20. https://doi.org/10.1097/TA.0b013e31806842a1.

    Article  PubMed  Google Scholar 

  25. Gauss T, Ageron FX, Devaud ML, et al. Association of prehospital time to in-hospital trauma mortality in a physician-staffed emergency medicine system. JAMA Surg. 2019;154(12):1117–24. https://doi.org/10.1001/jamasurg.2019.3475.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Lustenberger T, Labler L, Stover JF, Keel MJ. Resuscitative emergency thoracotomy in a Swiss trauma centre. Br J Surg. 2012;99(4):541–8. https://doi.org/10.1002/bjs.7706.

    Article  CAS  PubMed  Google Scholar 

  27. Kinoshita T, Yamakawa K, Matsuda H, et al. The survival benefit of a novel trauma workflow that includes immediate whole-body computed tomography, surgery, and interventional radiology, all in one trauma resuscitation room: a retrospective historical control study. Ann Surg. 2019;269(2):370–6. https://doi.org/10.1097/SLA.0000000000002527.

    Article  PubMed  Google Scholar 

  28. Umemura Y, Watanabe A, Kinoshita T, Morita N, Yamakawa K, Fujimi S. Hybrid emergency room shows maximum effect on trauma resuscitation when used in patients with higher severity. J Trauma Acute Care Surg. 2021;90(2):232–9. https://doi.org/10.1097/TA.0000000000003020.

    Article  PubMed  Google Scholar 

  29. Manning JE, Rasmussen TE, Tisherman SA, Cannon JW. Emerging hemorrhage control and resuscitation strategies in trauma: endovascular to extracorporeal. J Trauma Acute Care Surg. 2020;89(2S):S50–8. https://doi.org/10.1097/TA.0000000000002747.

    Article  PubMed  Google Scholar 

Download references

Funding

The authors did not receive support from any organisation for the submitted work.

Author information

Authors and Affiliations

  1. ICU, Sainte Anne Military Teaching Hospital, Toulon, France

    Hilaire de Malleray, Michael Cardinale & Eric Meaudre

  2. Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France

    Jean-Philippe Avaro, Mathieu Vasse & Henri de Lesquen

  3. Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France

    Tristan Monchal, Stéphane Bourgouin & Paul Balandraud

Authors
  1. Hilaire de Malleray
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael Cardinale
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jean-Philippe Avaro
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eric Meaudre
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tristan Monchal
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Stéphane Bourgouin
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Mathieu Vasse
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Paul Balandraud
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Henri de Lesquen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Henri de Lesquen.

Ethics declarations

Conflict of interest

The authors do not have any conflicts of interest related to this manuscript.

Ethics approval

Our prospective registry of severe trauma patients has been registered by the Commission. Nationale de l'Informatique et des Libertés (CNIL) under number 2002878v0 reports anonymised information. This research study was conducted retrospectively from data obtained for clinical purposes. Ethical approval was waived by the local Ethics Committee and the French Society for Thoracic and Cardiovascular Surgery (FSTCVS) under registration number 2019–18 in view of the retrospective nature of the study and all the procedures being performed as part of routine care. This research has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Specific national laws have also been observed.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

de Malleray, H., Cardinale, M., Avaro, JP. et al. Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center. Eur J Trauma Emerg Surg 48, 4631–4638 (2022). https://doi.org/10.1007/s00068-022-01995-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-022-01995-y

Keywords

Search

Navigation