Journal of Pediatric Surgery 50 (2015) 177–181
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Pediatric emergency department thoracotomy: A large case series and systematic review Casey J. Allen, Evan J. Valle, Chad M. Thorson, Anthony R. Hogan, Eduardo A. Perez, Nicholas Namias, Tanya L. Zakrison, Holly L. Neville, Juan E. Sola ⁎ Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
a r t i c l e
i n f o
Article history: Received 5 October 2014 Accepted 6 October 2014 Key words: Resuscitative thoracotomy Children Adolescents Kids
a b s t r a c t Background/purpose: The emergency department thoracotomy (EDT) is rarely utilized in children, and is thus difficult to identify survival factors. We reviewed our experience and performed a systematic review of reports of EDT in pediatric patients. Methods: Patients age ≤18 years who received an EDT from 1991 to 2012 at our institution and all published case series were reviewed. Data analyzed include age, sex, mechanism of injury (MOI), injury patterns, presence of vital signs (VS) or signs of life (SOL) in the field/ED, return of spontaneous circulation (ROSC), and survival. Results: A total of 252 patients were analyzed. 84% were male. 51% sustained penetrating injuries, and median age was 15 years. Upon arrival, 17% had VS, and 35% had SOL. After EDT, 30% experienced ROSC. The survival rate was 1.6% for blunt trauma, 10.2% for penetrating injuries, and 6.0% overall. Conclusion: Survival of pediatric patients following EDT is comparable to recent analyses in adults. Children who sustain blunt injury and are without SOL have been uniformly unsalvageable. Children who sustain penetrating trauma and have SOL or are without SOL for a short time prior to arrival have been salvageable. There are no reported EDT survivors less than 14 years of age following blunt injury. © 2015 Elsevier Inc. All rights reserved.
Trauma remains the leading cause of morbidity and mortality in children and adolescents [1,2]. By recognizing this, care of the injured child has improved with aggressive efforts to standardize treatment. These efforts have influenced the morbidity and mortality rates associated with pediatric trauma [3–5]. The standardization of care of the pediatric trauma patient, however, has also created new problems that must be addressed. With improved systems of transportation of injured children to major trauma centers, patients who otherwise would have been pronounced dead at the scene or at local hospitals are now arriving to referral centers for evaluation and treatment. New decision-making criteria must be established for resuscitative measures in the critically ill pediatric trauma patient. In particular, the role of the emergency department thoracotomy (EDT) has not been fully defined. Although there are established guidelines for performing EDT in an adult, it has been difficult to identify trends and factors associated with survival in children because it is rarely utilized in the pediatric patient. To address this issue, we reviewed our experience at a level 1 trauma center and report the largest analysis over the past 25 years. In conjunction, we performed a systematic review of all published reports
⁎ Corresponding author at: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 450K, Miami, FL 33136. Tel.: + 1 305 243 5072. E-mail address: [email protected] (J.E. Sola). http://dx.doi.org/10.1016/j.jpedsurg.2014.10.042 0022-3468/© 2015 Elsevier Inc. All rights reserved.
regarding pediatric EDT to help identify the factors associated with morbidity and mortality. 1. Methods With respect to our institution, we analyzed all pediatric patients (age ≤ 18) who received an EDT from 1991 to 2012. Ryder Trauma Center (RTC), located at the University of Miami/Jackson Memorial Medical Center, is the only level 1 trauma center serving the 2.4 million residents of Miami-Dade County, Florida. On average, 4300 trauma patients per year are evaluated at RTC. Approximately, 10% of all patients evaluated and treated at this center are injured children. Demographics obtained from our trauma registry included age, sex, mechanism of injury (MOI), and Injury Severity Score (ISS). We reviewed patient records for the presence of vital signs (VS) and/or signs of life (SOL) in the field, time without VS in the field, presence of VS or SOL upon arrival, MOI, location of injuries, return of spontaneous circulation (ROSC), survival, and neurological function of the survivors upon discharge. Presence of VS is defined as a palpable peripheral pulse upon arrival with a recorded initial systolic blood pressure and/or heart rate. SOL is defined as breathing, pupillary reactivity, spontaneous movements, or mechanical cardiac activity. ROSC is resumption of sustained perfusing cardiac activity after cardiac arrest. Signs of ROSC include a palpable pulse or a measurable blood pressure as well as any breathing, coughing, or movement. This study was approved by the Institutional Review Board at the University of Miami Miller School Of Medicine.
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Table 1 Systematic review of the published case series regarding pediatric EDT along with data from Ryder Trauma Center.
Powell et al. The American Surgeon, 1988 Beaver et al. J Pediatric Surgery, 1987 Rothenberg et al. J Trauma, 1989 Sheikh and Culbertson, J Trauma, 1993 Hofbauer et al. Resuscitation, 2011 Easter et al. Resuscitation, 2012 Boatright et al. JACS, 2013 Ryder Trauma Center, Miami, FL. 1991-2012 Survival
Blunt
Penetrating
Survival
1/8 0/15 1/47 0/15 0/10 0/13 0/9 0/7 2/124
4/11 0/2 2/36 1/8 1/1 3/16 0/0 2/54 13/128
5/19 0/17 3/83 1/23 1/11 3/29 0/9 2/61 15/252
Blunt versus penetrating, survival.
For our systematic review of the published data, we obtained all case series regarding pediatric EDT and combined the data from those reports with the data from our institution (Table 1) [6–13]. These reports were obtained from a Medline search for all publications regarding EDT in the pediatric population for the past 40 year using the keywords “thoracotomy”, “emergency”, “trauma”, “resuscitation”, “pediatrics”, and “children”. Bibliographies of relevant publications were reviewed to identify reports that were not initially located with the Medline search. Variables extracted from each report include demographics, MOI, injury location, presence of VS and/or SOL upon arrival, ROSC, survival to discharge, and neurologic outcomes for survivors. For publications that did not report certain variables, those cases were systematically excluded when analyzing that missing variable. Although each series differs in the specific data reported, the information obtained was pooled and analyzed using the variables and outcomes reported by each series. To minimize bias, single case reports are presented in the discussion but did not contribute to the systematic analysis because a single case report does not represent a population. Parametric data are reported as mean ± standard deviation and nonparametric data are reported as median. 2. Results At RTC, a total of 61 pediatric patients who had an EDT performed were identified. Overall, our cohort was 90% were male, 88% sustained penetrating injuries, median age was 16 years, and median ISS was 41 (Table 2). MOIs included gunshot wound (GSW) (74%), stab wound (15%), and motor vehicle collision (8%). In the field, 46% had initial VS and 67% had SOL. Upon arrival, 25% had VS and 56% had SOL. Those who lost VS in the field were, on average, without VS for 15 ± 16 minutes prior to arrival. After EDT, 23 patients (38%) had ROSC. Of these, 21 expired (16 in OR, 4 in ED, 1 in ICU). Both survivors (15 and 16 years) sustained penetrating injury (1 isolated to chest, 1 isolated to abdomen),
CNS Chest/neck Abdomen/pelvis Extremity Multiple Survival
Blunt
Penetrating
Survival
0 3 0 0 4 0/7
0 29 7 3 15 2/54
0/0 1/32 1/7 0/3 0/19 2/61
Experience of Ryder Trauma Center 1991–2012.
had VS upon arrival, and were discharged with full neurological function. Injury locations and associated outcomes are depicted in Table 3. Fig. 1 displays the outcomes (ROSC and survival) according to MOI and presence of VS/SOL. Upon systematic review of the published data (including our data), a total of 252 pediatric patients were analyzed (Table 4). Of these, 84% were male, 51% sustained penetrating injury, and median age was 15 years. MOIs included GSW (34 %), stab wound (13%), MVC (11%), PHBC (9%), and fall (3%). Patients most commonly presented with major injury to the chest or neck (68%). Upon arrival, 17% had VS and 35% had SOL. After EDT, 30% experienced ROSC. An analysis of overall injury patterns and associated outcomes is depicted in Table 5. The survival rate for EDT was 1.6% in blunt trauma, 10.2% in penetrating injuries, and 6.0% overall. Fig. 2 depicts the outcomes of the entire population comprised by the systematic review, divided by blunt and penetrating injury, with details regarding presence of SOL and/or VS upon arrival within each subpopulation. The 2 reported survivors within the blunt population both sustained multiple system injuries, whereas within the penetrating population, the 13 survivors sustained injury to the chest/neck (n = 9), abdomen/pelvis (n = 1), extremities (n = 1), or multiple systems (n = 2). All reported survivors were discharged with full neurological function. When analyzing the younger pediatric population (≤ 12 years), there were 37 reported EDT; representing 15% of the population. Of these children, 25 (68%) sustained blunt injury, 15 (41%) arrived to the ED with SOL, and 4 (11%) arrived with VS. Only 6 children (16%) experienced ROSC, and only 1 ultimately survived. This patient, the youngest reported survivor, was a 9 year old male who sustained a stab wound to the heart [9]. The child presented to the ED physiologically stable, but eventually developed hemorrhagic shock and went into cardiac arrest [9]. The youngest survivor ever reported that sustained blunt force trauma and required an EDT was a 14 year old male involved in an MVC [10]. The patient arrived to the ED with VS but quickly deteriorated [10]. This patient was not included in the systematic review as it is a single case and not reported in a population series. 3. Discussion
Table 2 Demographics, MOI, outcomes (n = 61). Male Age (median) Blunt Penetrating Mechanism of injury
Table 3 Systems injured; blunt versus penetrating, survival (n = 61).
MVC PHBC GSW Stab Assault
ISS (median) VS in field SOL in field Time without vitals in field (minutes) VS ED SOL ED ROSC Survival Experience of Ryder Trauma Center 1991–2012.
90% 16 12% 88% 8% 2% 74% 15% 2% 41 46% 67% 15 ± 16 25% 56% 38% 3.3%
EDT is considered the most aggressive form of resuscitation for victims of trauma. Between 1965 and 1976, the use of EDT was reported to improve survival following penetrating chest trauma [14]. Soon thereafter, the utilization of EDT was reported as beneficial in adult patients with penetrating or blunt traumatic injuries [15,16]. The improved quality of pre-hospital emergency medical services combined with the development of specialized pediatric trauma centers has resulted in more critically injured children requiring evaluation on the brink of death (in extremis). With recent reports showing the detrimental outcomes associated with a prolonged pre-hospital period, there has been a push for emergency medical services in urban environments to “scoop and run” rather than “stay and play” [17,18]. Many of these patients in the past would have been pronounced dead at the scene or at their community hospital emergency department. During this development, the resuscitative thoracotomy was also added as an extension to ATLS techniques [19]. Now after 30 years, we are able to
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Fig. 1. Outcomes according to MOI, presence of VS/SOL. Experience of Ryder Trauma Center 1991–2012.
systematically review the current literature with this relatively aggressive resuscitative measure in the pediatric population. From our analysis, the mortality rates following EDT are similar between adults and children. In 2011, the Western Trauma Association (WTA) reviewed reports of the EDT in all populations. Their review showed a survival rate of 11.2% following penetrating injury and 1.6% following blunt trauma [20]. This is close comparison to our results showing a pediatric survival rate of 10.2 and 1.6% in penetrating and blunt injuries, respectively. Based upon their review that showed these early similarities, WTA recommended performing an EDT in all children under the same guidelines as that for adults [21]. Although our outcomes appear consistent with those reported by the WTA, our report shows a survival discrepancy between age groups within the pediatric population. For example, of all children less than the age of 13 years, only 1 survivor has been reported [9]. Also, there have been no reports of a survivor less than the age of 14 years who sustained blunt force trauma and required an EDT. In contrast to the adult population, all reported blunt pediatric survivors had at least SOL upon arrival. Within the penetrating trauma group, the survivors were also generally older with a median age of 17 years. There appears to be an age when a child acts physiologically similar to an adult. Why are there no reports of blunt survivors less than the age of 14 years? One likely explanation is that there has not been sufficient accumulated experience with the younger pediatric population to observe the ~2% survivability. Physiologically, however, younger pediatric Table 4 Demographics, MOI, outcomes (N = 252). Age (median) Male Blunt Penetrating MOI
SOL ED VS ED ROSC Survival Systematic review of published reports.
MVC PHBC Fall GSW Stab Assault Crush
15 84% 49% 51% 11% 9% 3% 34% 13% 1% 1% 35% 17% 30% 6.0%
patients have proportionately larger cranial, thoracic and abdominal organs, and are without a mature skeletal system, thus making them more vulnerable to severe injury from traumatic forces. Theoretically, because children have an increased physiologic reserve when compared to that of an adult [22], an injury that completely overwhelms their compensatory system is almost certainly non-survivable. Regardless, even if all EDTs were performed under a uniform set of guidelines, it appears this procedure is being over-performed in the pediatric population. Only 35% of all reported pediatric patients arrived with SOL. Although the current 2011 WTA guidelines recommend an EDT after a short time without SOL (15 minutes penetrating, 10 minutes blunt), the guidelines in place during which the reports in this systematic review were published recommended performing an EDT in a blunt trauma patient only when SOL were present [23]. It was assumed any patient who sustained blunt force trauma and arrived without SOL was dead and no intervention should be performed. Yet it appears the majority of pediatric EDTs for blunt trauma over the past 30 years have been performed in the absence of SOL. The over-performance of EDT was likely because of the lack of known survival factors and perhaps an overly aggressive approach when faced with a potential pediatric mortality. Anecdotal reports of successful heroic resuscitation in children may have fostered the idea that younger patients better tolerate the physiologic stresses of lifethreatening injuries and have improved functional outcomes [16,24]. Our conclusions oppose this theory. There is growing interest in the use of a resuscitative endovascular balloon occlusion of the aorta (REBOA) to control hemorrhagic shock in trauma patients. To our knowledge, the REBOA remains a new and still controversial tool. There are limited reports regarding its use in trauma patients. Recently, Brenner et al. tested the technical feasibility Table 5 Systems injured; overall, blunt versus penetrating, survival.
CNS Chest/neck Abdomen Extremity Multiple Unknown Survival
Blunt
Penetrating
Survival
5 5 2 0 63 49 2/124
0 66 19 3 26 14 13/128
0/5 8/71 2/21 0/3 4/89 1/63 15/252
Systematic review of published reports.
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Fig. 2. Systematic review. Outcomes of ROSC, survival between blunt and penetrating.
of its use on 6 trauma patients in hemorrhagic shock [25]. Although they concluded it is feasible to use, their indications to utilize the REBOA were not the same indications to perform an EDT [25]. Even though there is ongoing investigation of the REBOA in animal models, its traditional use in humans is during endovascular repair of abdominal aortic aneurysms. Some believe its main use in trauma could be for placement by emergency medical personnel to temporize a patient prior to transfer to definitive care. Morrison et al. claimed the “use of this technique in patients in haemorrhagic shock, who are injured in remote areas, would facilitate an extension of the window for salvage, and in turn permit transfer to definitive care” [26]. At our high volume level 1 trauma center, the REBOA is immediately available to the trauma and pediatric surgeons, however it is yet to be utilized. Its use in children, at our institution and throughout the country, is still very limited. For these reasons, no guidelines exist for use of the REBOA in pediatric trauma patients. From our experiences and upon review of published reports, we have come to several conclusions. Overall, the mortality rates are comparable between adults and pediatric patients following EDT. Children who sustain blunt force trauma and are without SOL at the scene of the injury have been uniformly unsalvageable. Children who sustain penetrating trauma and have SOL in the emergency department or are without SOL for a short period of time prior to arrival have been salvageable. There are no reported survivors in children less than the age of 14 years who required an EDT after sustaining blunt force trauma. There are no reported survivors in children less than the age of 9 years who required an EDT after sustaining penetrating trauma. There are limitations to this study. First, all of the data obtained from our institution were collected retrospectively, and thus not specifically collected for research purposes. As for all data reviewed, some of the variables may have been missing or misclassified. Also, differences in trauma management between physicians and institutions may not allow for generalizations to be made. Selection bias may have also affected results, as all EDT were performed at the discretion of the trauma physician. Publication bias also exists. It is likely other institutions have performed this procedure over the same time period, however none were published. Although we do have access to historical pediatric trauma registries, including the National Trauma Database
(NTDB), the information within these registries differs in comparison to that which we analyzed for this report. In 2014, Wyrick et al., using NTDB data from 2007 to 2010, attempted to define the presenting hemodynamic parameters that predict survival for pediatric patients undergoing an EDT [27]. They reviewed 316 children (70 blunt, 240 penetrating), with a survival to discharge of 31%. They concluded that when an EDT was performed for SBP ≤ 50 mmHg or for heart rate ≤ 70 bpm, less than 5% of patients survived. There were no survivors of blunt trauma when SBP was ≤ 60 mmHg or pulse was ≤ 80 bpm. However, a possible major limitation of their study is that the NTDB does not have a specific code for an emergency resuscitative thoracotomy, and the authors instead used “exploratory thoracotomy” to select their sample. Exploratory thoracotomy can be used to infer the definition of an EDT when a thoracotomy is performed within a short time of arrival to the ED (Wyrick et al. used 1 hour), however there are other indications to perform a thoracotomy (i.e. high output from chest tube with hemodynamic instability) that are not necessarily the same as for an EDT (loss of vital signs, etc.), and EDT may sometimes be performed after 1 hour of arrival to the ED. Also, the NTDB does not code when a patient has a transient ROSC following an EDT. Furthermore, this trauma registry does not specifically indicate when a patient arrives without vital signs, as this scenario can possibly lead to blank entries which may also be missing data points in the registry, nor does the NTDB indicate presence of SOL upon arrival. These variables (presence of VS/SOL upon arrival and ROSC) are the basis for the indication to perform an EDT and some of the outcomes assessed by both the ACS and WTA in adults. In addition, the NTDB by their own admission is susceptible to all of the limitations of all “convenience samples” including variance in data quality which is dependent on how well the individual hospitals implement accepted data standards, selection bias, information bias, and missing data. For these reasons, we needed to review in detail published reports and our own trauma center experience in order to analyze and obtain these data, pre-procedural conditions, and specific outcomes which are not generally available from registry data. Finally, the relatively small sample size prohibits definitive conclusions to be made; rather trends established. The EDT has been even more rarely performed in the younger group of pediatric patients, thus making it difficult to identify trends within this specific population.
C.J. Allen et al. / Journal of Pediatric Surgery 50 (2015) 177–181
Despite these limitations, this is one of the largest series report and the first systematic review regarding pediatric EDT. The lack of extensive experience with this resuscitative measure in children and adolescents still prohibits the establishment of guidelines specific to this population. Our review allows considerable trends to be made regarding this controversial topic. Overall, although outcomes appear similar to that of the adult population, there may be less benefit in the younger pediatric patient and in those who arrive without SOL after sustaining blunt force injury. Also, it appears that this procedure may be overperformed in the pediatric population, which may be because of the lack of known outcomes or overly aggressive approach in this population. Continued evaluation of this technique is warranted to develop adequate guidelines. Appendix A. Discussions Presented by Dr. Casey Allen, Miami, FL Discussant: DR. KURT HEISS (Atlanta, GA) One of the interesting things in the literature review about this item is that when we do emergency department thoracotomies the healthcare providers become the patients at risk and there is increased incidence of needle sticks and injuries by those who are participating in emergency department thoracotomies for what you describe as unindicated indications like blunt trauma with no vital signs at the time of arrival. Did you look at any of the negative impact of having done some of these thoracotomies on the providers that occurred at your institution? Response: Dr. CASEY ALLEN No, we did not directly analyze adverse effects to the healthcare providers in doing these procedures in those in whom it was frankly not indicated or presumed indicated but that is actually a very popular question in the trauma population. Discussant: DR. STEVEN LEE (Los Angeles, CA) Do you have any information as far as survival to organ donation? I know that we’ve had a poor survival rate but we’ve had a number of patients who actually were able to harvest organs and help contribute to other patients. Response: DR. CASEY ALLEN That’s actually a very interesting question because we’re looking into that right now in adults as well as children. However, I don’t have that information available at this time. Steven Stylianos (New York, NY) That’s a very important report that you just gave from one of the most sophisticated and effective trauma centers in our country, so thank you for that. Have you taken the next step to incorporate these findings into your trauma algorithms? Response: DR. CASEY ALLEN I think it’s just important to recognize the fact that there have not been any blunt survivors under the age of 14 and again there are a lot of reasons to why that may be, including the different hemodynamics of a pediatric patient, proportional size of their head and other organs. Our experience with children who arrive without signs of life, the victims of blunt injury have had very poor outcomes. For this reason, we do not perform this procedure on those patients anymore at our institution.
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Unidentified speaker I notice you have a 32% incidence of gunshot wounds. In our population in Australia, we serve a population of 1.2 million at a women’s and children’s hospital in Adelaide and we may see one gunshot wound a year and many a year goes by without a single gunshot wound. Just a huge contrast.
References [1] Gratz RR. Accidental injury in childhood: a literature review on pediatric trauma. J Trauma 1979;19(8):551–5. [2] Rivara FP. Epidemiology of violent deaths in children and adolescents in the United States. Pediatrician 1983;12(1):3–10. [3] Colombani PM, Buck JR, Dudgeon DL, et al. One-year experience in a regional pediatric trauma center. J Pediatr Surg 1985;20(1):8–13. [4] Haller Jr JA, Shorter N, Miller D, et al. Organization and function of a regional pediatric trauma center: does a system of management improve outcome? J Trauma 1983;23(8):691–6. [5] Mahoney WJ, D'Souza BJ, Haller JA, et al. Long-term outcome of children with severe head trauma and prolonged coma. Pediatrics 1983;71(5):756–62. [6] Beaver BL, Colombani PM, Buck JR, et al. Efficacy of emergency room thoracotomy in pediatric trauma. J Pediatr Surg 1987;22(1):19–23. [7] Boatright DH, Byyny RL, Hopkins E, et al. Validation of rules to predict emergent surgical intervention in pediatric trauma patients. J Am Coll Surg 2013;216(6): 1094–102 [1102 e1-6]. [8] Easter JS, Vinton DT, Haukoos JS. Emergent pediatric thoracotomy following traumatic arrest. Resuscitation 2012;83(12):1521–4. [9] Hofbauer M, Hupfl M, Figl M, et al. Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients. Resuscitation 2011;82(2):185–9. [10] Langer JC, Hoffman MA, Pearl RH, et al. Survival after emergency department thoracotomy in a child with blunt multisystem trauma. Pediatr Emerg Care 1989;5(4):255–6. [11] Powell RW, Gill EA, Jurkovich GJ, et al. Resuscitative thoracotomy in children and adolescents. Am Surg 1988;54(4):188–91. [12] Rothenberg SS, Moore EE, Moore FA, et al. Emergency department thoracotomy in children–a critical analysis. J Trauma 1989;29(10):1322–5. [13] Sheikh AA, Culbertson CB. Emergency department thoracotomy in children: rationale for selective application. J Trauma 1993;34(3):323–8. [14] Sherman MM, Saini VK, Yarnoz MD, et al. Management of penetrating heart wounds. Am J Surg 1978;135(4):553–8. [15] Baker CC, Thomas AN, Trunkey DD. The role of emergency room thoracotomy in trauma. J Trauma 1980;20(10):848–55. [16] Cogbill TH, Moore EE, Millikan JS, et al. Rationale for selective application of emergency department thoracotomy in trauma. J Trauma 1983;23(6):453–60. [17] Nirula R, Maier R, Moore E, et al. Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer's effect on mortality. J Trauma 2010;69(3): 595–9 [discussion 599–601]. [18] Smith RM, Conn AK. Prehospital care—scoop and run or stay and play? Injury 2009; 40(Suppl. 4):S23–6. [19] Advanced trauma life support for doctors ATLS: manuals for coordinators and faculty. 8th ed. Chicago, IL: American College of Surgeons; 2008. [20] Moore EE, Knudson MM, Burlew CC, et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma 2011;70(2):334–9. [21] 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. [22] Fallat ME. Pediatric Trauma. In: Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Upchurch GR, editors. Greenfield's surgery: scientific principles and practice. 4th ed. Lippincott Williams & Wilkins; 2006;468:467–79. [23] Working Group. Ad Hoc Subcommittee on Outcomes, American College of SurgeonsCommittee on Trauma. Working Group AHSoOACoSCoT: practice management guidelines for emergency department thoracotomy. J Am Coll Surg 2001;193(3):303–9. [24] Flynn TC, Ward RE, Miller PW. Emergency department thoracotomy. Ann Emerg Med 1982;11(8):413–6. [25] Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg 2013;75(3):506–11. [26] Morrison JJ, Lendrum RA, Jansen JO. Resuscitative endovascular balloon occlusion of the aorta (REBOA): a bridge to definitive haemorrhage control for trauma patients in Scotland? Surgeon 2014;12(3):119–20. [27] Wyrick DL, Dassinger MS, Bozeman AP, et al. Hemodynamic variables predict the outcome of emergency thoracotomy in the pediatric trauma population. J Pediatr Surg 2014;49(9):1382–4.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Pediatric emergency department thoracotomy: A large case series and systematic review Casey J. Allen, Evan J. Valle, Chad M. Thorson, Anthony R. Hogan, Eduardo A. Perez, Nicholas Namias, Tanya L. Zakrison, Holly L. Neville, Juan E. Sola ⁎ Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
a r t i c l e
i n f o
Article history: Received 5 October 2014 Accepted 6 October 2014 Key words: Resuscitative thoracotomy Children Adolescents Kids
a b s t r a c t Background/purpose: The emergency department thoracotomy (EDT) is rarely utilized in children, and is thus difficult to identify survival factors. We reviewed our experience and performed a systematic review of reports of EDT in pediatric patients. Methods: Patients age ≤18 years who received an EDT from 1991 to 2012 at our institution and all published case series were reviewed. Data analyzed include age, sex, mechanism of injury (MOI), injury patterns, presence of vital signs (VS) or signs of life (SOL) in the field/ED, return of spontaneous circulation (ROSC), and survival. Results: A total of 252 patients were analyzed. 84% were male. 51% sustained penetrating injuries, and median age was 15 years. Upon arrival, 17% had VS, and 35% had SOL. After EDT, 30% experienced ROSC. The survival rate was 1.6% for blunt trauma, 10.2% for penetrating injuries, and 6.0% overall. Conclusion: Survival of pediatric patients following EDT is comparable to recent analyses in adults. Children who sustain blunt injury and are without SOL have been uniformly unsalvageable. Children who sustain penetrating trauma and have SOL or are without SOL for a short time prior to arrival have been salvageable. There are no reported EDT survivors less than 14 years of age following blunt injury. © 2015 Elsevier Inc. All rights reserved.
Trauma remains the leading cause of morbidity and mortality in children and adolescents [1,2]. By recognizing this, care of the injured child has improved with aggressive efforts to standardize treatment. These efforts have influenced the morbidity and mortality rates associated with pediatric trauma [3–5]. The standardization of care of the pediatric trauma patient, however, has also created new problems that must be addressed. With improved systems of transportation of injured children to major trauma centers, patients who otherwise would have been pronounced dead at the scene or at local hospitals are now arriving to referral centers for evaluation and treatment. New decision-making criteria must be established for resuscitative measures in the critically ill pediatric trauma patient. In particular, the role of the emergency department thoracotomy (EDT) has not been fully defined. Although there are established guidelines for performing EDT in an adult, it has been difficult to identify trends and factors associated with survival in children because it is rarely utilized in the pediatric patient. To address this issue, we reviewed our experience at a level 1 trauma center and report the largest analysis over the past 25 years. In conjunction, we performed a systematic review of all published reports
⁎ Corresponding author at: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 450K, Miami, FL 33136. Tel.: + 1 305 243 5072. E-mail address: [email protected] (J.E. Sola). http://dx.doi.org/10.1016/j.jpedsurg.2014.10.042 0022-3468/© 2015 Elsevier Inc. All rights reserved.
regarding pediatric EDT to help identify the factors associated with morbidity and mortality. 1. Methods With respect to our institution, we analyzed all pediatric patients (age ≤ 18) who received an EDT from 1991 to 2012. Ryder Trauma Center (RTC), located at the University of Miami/Jackson Memorial Medical Center, is the only level 1 trauma center serving the 2.4 million residents of Miami-Dade County, Florida. On average, 4300 trauma patients per year are evaluated at RTC. Approximately, 10% of all patients evaluated and treated at this center are injured children. Demographics obtained from our trauma registry included age, sex, mechanism of injury (MOI), and Injury Severity Score (ISS). We reviewed patient records for the presence of vital signs (VS) and/or signs of life (SOL) in the field, time without VS in the field, presence of VS or SOL upon arrival, MOI, location of injuries, return of spontaneous circulation (ROSC), survival, and neurological function of the survivors upon discharge. Presence of VS is defined as a palpable peripheral pulse upon arrival with a recorded initial systolic blood pressure and/or heart rate. SOL is defined as breathing, pupillary reactivity, spontaneous movements, or mechanical cardiac activity. ROSC is resumption of sustained perfusing cardiac activity after cardiac arrest. Signs of ROSC include a palpable pulse or a measurable blood pressure as well as any breathing, coughing, or movement. This study was approved by the Institutional Review Board at the University of Miami Miller School Of Medicine.
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Table 1 Systematic review of the published case series regarding pediatric EDT along with data from Ryder Trauma Center.
Powell et al. The American Surgeon, 1988 Beaver et al. J Pediatric Surgery, 1987 Rothenberg et al. J Trauma, 1989 Sheikh and Culbertson, J Trauma, 1993 Hofbauer et al. Resuscitation, 2011 Easter et al. Resuscitation, 2012 Boatright et al. JACS, 2013 Ryder Trauma Center, Miami, FL. 1991-2012 Survival
Blunt
Penetrating
Survival
1/8 0/15 1/47 0/15 0/10 0/13 0/9 0/7 2/124
4/11 0/2 2/36 1/8 1/1 3/16 0/0 2/54 13/128
5/19 0/17 3/83 1/23 1/11 3/29 0/9 2/61 15/252
Blunt versus penetrating, survival.
For our systematic review of the published data, we obtained all case series regarding pediatric EDT and combined the data from those reports with the data from our institution (Table 1) [6–13]. These reports were obtained from a Medline search for all publications regarding EDT in the pediatric population for the past 40 year using the keywords “thoracotomy”, “emergency”, “trauma”, “resuscitation”, “pediatrics”, and “children”. Bibliographies of relevant publications were reviewed to identify reports that were not initially located with the Medline search. Variables extracted from each report include demographics, MOI, injury location, presence of VS and/or SOL upon arrival, ROSC, survival to discharge, and neurologic outcomes for survivors. For publications that did not report certain variables, those cases were systematically excluded when analyzing that missing variable. Although each series differs in the specific data reported, the information obtained was pooled and analyzed using the variables and outcomes reported by each series. To minimize bias, single case reports are presented in the discussion but did not contribute to the systematic analysis because a single case report does not represent a population. Parametric data are reported as mean ± standard deviation and nonparametric data are reported as median. 2. Results At RTC, a total of 61 pediatric patients who had an EDT performed were identified. Overall, our cohort was 90% were male, 88% sustained penetrating injuries, median age was 16 years, and median ISS was 41 (Table 2). MOIs included gunshot wound (GSW) (74%), stab wound (15%), and motor vehicle collision (8%). In the field, 46% had initial VS and 67% had SOL. Upon arrival, 25% had VS and 56% had SOL. Those who lost VS in the field were, on average, without VS for 15 ± 16 minutes prior to arrival. After EDT, 23 patients (38%) had ROSC. Of these, 21 expired (16 in OR, 4 in ED, 1 in ICU). Both survivors (15 and 16 years) sustained penetrating injury (1 isolated to chest, 1 isolated to abdomen),
CNS Chest/neck Abdomen/pelvis Extremity Multiple Survival
Blunt
Penetrating
Survival
0 3 0 0 4 0/7
0 29 7 3 15 2/54
0/0 1/32 1/7 0/3 0/19 2/61
Experience of Ryder Trauma Center 1991–2012.
had VS upon arrival, and were discharged with full neurological function. Injury locations and associated outcomes are depicted in Table 3. Fig. 1 displays the outcomes (ROSC and survival) according to MOI and presence of VS/SOL. Upon systematic review of the published data (including our data), a total of 252 pediatric patients were analyzed (Table 4). Of these, 84% were male, 51% sustained penetrating injury, and median age was 15 years. MOIs included GSW (34 %), stab wound (13%), MVC (11%), PHBC (9%), and fall (3%). Patients most commonly presented with major injury to the chest or neck (68%). Upon arrival, 17% had VS and 35% had SOL. After EDT, 30% experienced ROSC. An analysis of overall injury patterns and associated outcomes is depicted in Table 5. The survival rate for EDT was 1.6% in blunt trauma, 10.2% in penetrating injuries, and 6.0% overall. Fig. 2 depicts the outcomes of the entire population comprised by the systematic review, divided by blunt and penetrating injury, with details regarding presence of SOL and/or VS upon arrival within each subpopulation. The 2 reported survivors within the blunt population both sustained multiple system injuries, whereas within the penetrating population, the 13 survivors sustained injury to the chest/neck (n = 9), abdomen/pelvis (n = 1), extremities (n = 1), or multiple systems (n = 2). All reported survivors were discharged with full neurological function. When analyzing the younger pediatric population (≤ 12 years), there were 37 reported EDT; representing 15% of the population. Of these children, 25 (68%) sustained blunt injury, 15 (41%) arrived to the ED with SOL, and 4 (11%) arrived with VS. Only 6 children (16%) experienced ROSC, and only 1 ultimately survived. This patient, the youngest reported survivor, was a 9 year old male who sustained a stab wound to the heart [9]. The child presented to the ED physiologically stable, but eventually developed hemorrhagic shock and went into cardiac arrest [9]. The youngest survivor ever reported that sustained blunt force trauma and required an EDT was a 14 year old male involved in an MVC [10]. The patient arrived to the ED with VS but quickly deteriorated [10]. This patient was not included in the systematic review as it is a single case and not reported in a population series. 3. Discussion
Table 2 Demographics, MOI, outcomes (n = 61). Male Age (median) Blunt Penetrating Mechanism of injury
Table 3 Systems injured; blunt versus penetrating, survival (n = 61).
MVC PHBC GSW Stab Assault
ISS (median) VS in field SOL in field Time without vitals in field (minutes) VS ED SOL ED ROSC Survival Experience of Ryder Trauma Center 1991–2012.
90% 16 12% 88% 8% 2% 74% 15% 2% 41 46% 67% 15 ± 16 25% 56% 38% 3.3%
EDT is considered the most aggressive form of resuscitation for victims of trauma. Between 1965 and 1976, the use of EDT was reported to improve survival following penetrating chest trauma [14]. Soon thereafter, the utilization of EDT was reported as beneficial in adult patients with penetrating or blunt traumatic injuries [15,16]. The improved quality of pre-hospital emergency medical services combined with the development of specialized pediatric trauma centers has resulted in more critically injured children requiring evaluation on the brink of death (in extremis). With recent reports showing the detrimental outcomes associated with a prolonged pre-hospital period, there has been a push for emergency medical services in urban environments to “scoop and run” rather than “stay and play” [17,18]. Many of these patients in the past would have been pronounced dead at the scene or at their community hospital emergency department. During this development, the resuscitative thoracotomy was also added as an extension to ATLS techniques [19]. Now after 30 years, we are able to
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Fig. 1. Outcomes according to MOI, presence of VS/SOL. Experience of Ryder Trauma Center 1991–2012.
systematically review the current literature with this relatively aggressive resuscitative measure in the pediatric population. From our analysis, the mortality rates following EDT are similar between adults and children. In 2011, the Western Trauma Association (WTA) reviewed reports of the EDT in all populations. Their review showed a survival rate of 11.2% following penetrating injury and 1.6% following blunt trauma [20]. This is close comparison to our results showing a pediatric survival rate of 10.2 and 1.6% in penetrating and blunt injuries, respectively. Based upon their review that showed these early similarities, WTA recommended performing an EDT in all children under the same guidelines as that for adults [21]. Although our outcomes appear consistent with those reported by the WTA, our report shows a survival discrepancy between age groups within the pediatric population. For example, of all children less than the age of 13 years, only 1 survivor has been reported [9]. Also, there have been no reports of a survivor less than the age of 14 years who sustained blunt force trauma and required an EDT. In contrast to the adult population, all reported blunt pediatric survivors had at least SOL upon arrival. Within the penetrating trauma group, the survivors were also generally older with a median age of 17 years. There appears to be an age when a child acts physiologically similar to an adult. Why are there no reports of blunt survivors less than the age of 14 years? One likely explanation is that there has not been sufficient accumulated experience with the younger pediatric population to observe the ~2% survivability. Physiologically, however, younger pediatric Table 4 Demographics, MOI, outcomes (N = 252). Age (median) Male Blunt Penetrating MOI
SOL ED VS ED ROSC Survival Systematic review of published reports.
MVC PHBC Fall GSW Stab Assault Crush
15 84% 49% 51% 11% 9% 3% 34% 13% 1% 1% 35% 17% 30% 6.0%
patients have proportionately larger cranial, thoracic and abdominal organs, and are without a mature skeletal system, thus making them more vulnerable to severe injury from traumatic forces. Theoretically, because children have an increased physiologic reserve when compared to that of an adult [22], an injury that completely overwhelms their compensatory system is almost certainly non-survivable. Regardless, even if all EDTs were performed under a uniform set of guidelines, it appears this procedure is being over-performed in the pediatric population. Only 35% of all reported pediatric patients arrived with SOL. Although the current 2011 WTA guidelines recommend an EDT after a short time without SOL (15 minutes penetrating, 10 minutes blunt), the guidelines in place during which the reports in this systematic review were published recommended performing an EDT in a blunt trauma patient only when SOL were present [23]. It was assumed any patient who sustained blunt force trauma and arrived without SOL was dead and no intervention should be performed. Yet it appears the majority of pediatric EDTs for blunt trauma over the past 30 years have been performed in the absence of SOL. The over-performance of EDT was likely because of the lack of known survival factors and perhaps an overly aggressive approach when faced with a potential pediatric mortality. Anecdotal reports of successful heroic resuscitation in children may have fostered the idea that younger patients better tolerate the physiologic stresses of lifethreatening injuries and have improved functional outcomes [16,24]. Our conclusions oppose this theory. There is growing interest in the use of a resuscitative endovascular balloon occlusion of the aorta (REBOA) to control hemorrhagic shock in trauma patients. To our knowledge, the REBOA remains a new and still controversial tool. There are limited reports regarding its use in trauma patients. Recently, Brenner et al. tested the technical feasibility Table 5 Systems injured; overall, blunt versus penetrating, survival.
CNS Chest/neck Abdomen Extremity Multiple Unknown Survival
Blunt
Penetrating
Survival
5 5 2 0 63 49 2/124
0 66 19 3 26 14 13/128
0/5 8/71 2/21 0/3 4/89 1/63 15/252
Systematic review of published reports.
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Fig. 2. Systematic review. Outcomes of ROSC, survival between blunt and penetrating.
of its use on 6 trauma patients in hemorrhagic shock [25]. Although they concluded it is feasible to use, their indications to utilize the REBOA were not the same indications to perform an EDT [25]. Even though there is ongoing investigation of the REBOA in animal models, its traditional use in humans is during endovascular repair of abdominal aortic aneurysms. Some believe its main use in trauma could be for placement by emergency medical personnel to temporize a patient prior to transfer to definitive care. Morrison et al. claimed the “use of this technique in patients in haemorrhagic shock, who are injured in remote areas, would facilitate an extension of the window for salvage, and in turn permit transfer to definitive care” [26]. At our high volume level 1 trauma center, the REBOA is immediately available to the trauma and pediatric surgeons, however it is yet to be utilized. Its use in children, at our institution and throughout the country, is still very limited. For these reasons, no guidelines exist for use of the REBOA in pediatric trauma patients. From our experiences and upon review of published reports, we have come to several conclusions. Overall, the mortality rates are comparable between adults and pediatric patients following EDT. Children who sustain blunt force trauma and are without SOL at the scene of the injury have been uniformly unsalvageable. Children who sustain penetrating trauma and have SOL in the emergency department or are without SOL for a short period of time prior to arrival have been salvageable. There are no reported survivors in children less than the age of 14 years who required an EDT after sustaining blunt force trauma. There are no reported survivors in children less than the age of 9 years who required an EDT after sustaining penetrating trauma. There are limitations to this study. First, all of the data obtained from our institution were collected retrospectively, and thus not specifically collected for research purposes. As for all data reviewed, some of the variables may have been missing or misclassified. Also, differences in trauma management between physicians and institutions may not allow for generalizations to be made. Selection bias may have also affected results, as all EDT were performed at the discretion of the trauma physician. Publication bias also exists. It is likely other institutions have performed this procedure over the same time period, however none were published. Although we do have access to historical pediatric trauma registries, including the National Trauma Database
(NTDB), the information within these registries differs in comparison to that which we analyzed for this report. In 2014, Wyrick et al., using NTDB data from 2007 to 2010, attempted to define the presenting hemodynamic parameters that predict survival for pediatric patients undergoing an EDT [27]. They reviewed 316 children (70 blunt, 240 penetrating), with a survival to discharge of 31%. They concluded that when an EDT was performed for SBP ≤ 50 mmHg or for heart rate ≤ 70 bpm, less than 5% of patients survived. There were no survivors of blunt trauma when SBP was ≤ 60 mmHg or pulse was ≤ 80 bpm. However, a possible major limitation of their study is that the NTDB does not have a specific code for an emergency resuscitative thoracotomy, and the authors instead used “exploratory thoracotomy” to select their sample. Exploratory thoracotomy can be used to infer the definition of an EDT when a thoracotomy is performed within a short time of arrival to the ED (Wyrick et al. used 1 hour), however there are other indications to perform a thoracotomy (i.e. high output from chest tube with hemodynamic instability) that are not necessarily the same as for an EDT (loss of vital signs, etc.), and EDT may sometimes be performed after 1 hour of arrival to the ED. Also, the NTDB does not code when a patient has a transient ROSC following an EDT. Furthermore, this trauma registry does not specifically indicate when a patient arrives without vital signs, as this scenario can possibly lead to blank entries which may also be missing data points in the registry, nor does the NTDB indicate presence of SOL upon arrival. These variables (presence of VS/SOL upon arrival and ROSC) are the basis for the indication to perform an EDT and some of the outcomes assessed by both the ACS and WTA in adults. In addition, the NTDB by their own admission is susceptible to all of the limitations of all “convenience samples” including variance in data quality which is dependent on how well the individual hospitals implement accepted data standards, selection bias, information bias, and missing data. For these reasons, we needed to review in detail published reports and our own trauma center experience in order to analyze and obtain these data, pre-procedural conditions, and specific outcomes which are not generally available from registry data. Finally, the relatively small sample size prohibits definitive conclusions to be made; rather trends established. The EDT has been even more rarely performed in the younger group of pediatric patients, thus making it difficult to identify trends within this specific population.
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Despite these limitations, this is one of the largest series report and the first systematic review regarding pediatric EDT. The lack of extensive experience with this resuscitative measure in children and adolescents still prohibits the establishment of guidelines specific to this population. Our review allows considerable trends to be made regarding this controversial topic. Overall, although outcomes appear similar to that of the adult population, there may be less benefit in the younger pediatric patient and in those who arrive without SOL after sustaining blunt force injury. Also, it appears that this procedure may be overperformed in the pediatric population, which may be because of the lack of known outcomes or overly aggressive approach in this population. Continued evaluation of this technique is warranted to develop adequate guidelines. Appendix A. Discussions Presented by Dr. Casey Allen, Miami, FL Discussant: DR. KURT HEISS (Atlanta, GA) One of the interesting things in the literature review about this item is that when we do emergency department thoracotomies the healthcare providers become the patients at risk and there is increased incidence of needle sticks and injuries by those who are participating in emergency department thoracotomies for what you describe as unindicated indications like blunt trauma with no vital signs at the time of arrival. Did you look at any of the negative impact of having done some of these thoracotomies on the providers that occurred at your institution? Response: Dr. CASEY ALLEN No, we did not directly analyze adverse effects to the healthcare providers in doing these procedures in those in whom it was frankly not indicated or presumed indicated but that is actually a very popular question in the trauma population. Discussant: DR. STEVEN LEE (Los Angeles, CA) Do you have any information as far as survival to organ donation? I know that we’ve had a poor survival rate but we’ve had a number of patients who actually were able to harvest organs and help contribute to other patients. Response: DR. CASEY ALLEN That’s actually a very interesting question because we’re looking into that right now in adults as well as children. However, I don’t have that information available at this time. Steven Stylianos (New York, NY) That’s a very important report that you just gave from one of the most sophisticated and effective trauma centers in our country, so thank you for that. Have you taken the next step to incorporate these findings into your trauma algorithms? Response: DR. CASEY ALLEN I think it’s just important to recognize the fact that there have not been any blunt survivors under the age of 14 and again there are a lot of reasons to why that may be, including the different hemodynamics of a pediatric patient, proportional size of their head and other organs. Our experience with children who arrive without signs of life, the victims of blunt injury have had very poor outcomes. For this reason, we do not perform this procedure on those patients anymore at our institution.
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Unidentified speaker I notice you have a 32% incidence of gunshot wounds. In our population in Australia, we serve a population of 1.2 million at a women’s and children’s hospital in Adelaide and we may see one gunshot wound a year and many a year goes by without a single gunshot wound. Just a huge contrast.
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