- Email: [email protected]
Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma
Journal Pre-proof Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma James V. O’Connor, MD, FACS, Benjamin Moran, MD, Samuel M. Galvagno, Jr., DO, PhD, Molly Deane, MD, David V. Feliciano, MD, FACS, Thomas M. Scalea, MD, FACS, MCCM PII:
S1072-7515(20)30104-6
DOI:
https://doi.org/10.1016/j.jamcollsurg.2019.12.019
Reference:
ACS 9714
To appear in:
Journal of the American College of Surgeons
Received Date: 16 December 2019 Accepted Date: 16 December 2019
Please cite this article as: O’Connor JV, Moran B, Galvagno Jr SM, Deane M, Feliciano DV, Scalea TM, Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma, Journal of the American College of Surgeons (2020), doi: https:// doi.org/10.1016/j.jamcollsurg.2019.12.019. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc. on behalf of the American College of Surgeons.
1
Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma James V O’Connor, MD, FACS1, Benjamin Moran, MD1, Samuel M Galvagno Jr, DO, PhD2, Molly Deane, MD1, David V Feliciano, MD, FACS1, Thomas M Scalea, MD, FACS, MCCM1 1
Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 2 Department of Anesthesia, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD Disclosure Information: Nothing to disclose. Presented at the Southern Surgical Association 131st Annual Meeting, Hot Springs, VA, December 2019. Corresponding author: James V. O’Connor, MD, FACS 22 South Greene Street Shock Trauma Director’s Office Suite Baltimore, MD 21201 410-328-3587 [email protected]
Short title: Urgent Thoracotomy after Penetrating Trauma
2
Introduction: Approximately 15% of patients with penetrating thoracic trauma require an emergency center or operating room thoracotomy, usually for hemodynamic instability or persistent hemorrhage. The hypothesis in this study is that admission physiology, not vital signs, predicts the need for operating room thoracotomy. Methods: Trauma registry review, 2002-2017, of adult patients undergoing operating room thoracotomy within 6 hours of admission (emergency department thoracotomies excluded). Demographics, injuries, admission physiology, time to operating room (OR), operations, and outcomes were reviewed. Data are reported as mean (SD) or median (IQR). Results: Of the 301 consecutive patients in this 15-year review, 75.6% were male, mean age 31.1 years (11.5) and 41.5% had gunshot wounds. The median Injury Severity Score was 25 (16-29), time to OR 38 minutes (19-105), and 21.9% had a thoracic damage control operation. Mean admission systolic blood pressure was 115 mmHg (37), with only 23.9% <90 mmHg; however, admission pH 7.22 (0.14), base deficit 7.6 (6.1), and lactate 7.2 (4.5) were markedly abnormal. Overall, there were 136 (45.2%) patients with significant pulmonary injuries treated with 112 major non-anatomic resections, 17 lobectomies, and 7 pneumonectomies; respective mortalities were 2.7%, 11.8%, and 42.9%. There were 100 (33.2%), cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19%) combined thoracic injuries. Mortality for cardiac, great vessel, and aerodigestive injuries was 7%, 0%, and 14.3%, respectively. Overall mortality was 6.6%, 15.2% after damage control and 4.3% for all others. Conclusions: Shock characterized by acidosis, but not hypotension, is the most common presentation in patients who will need operating room thoracotomy after penetrating thoracic
3
trauma. Survival rates are excellent unless a pneumonectomy or damage control thoracotomy is required.
4
INTRODUCTION The management of penetrating thoracic trauma is predominantly nonoperative, with approximately one in five patients requiring surgery, generally for hemorrhage or hemodynamic instability. These patients typically are in shock, have life-threatening injuries and an operative mortality as high a 30% [1,2,3,4,5,6,7,8]. Mortality is higher with concurrent laparotomy, magnitude of pulmonary resection and number of organs injured [2,4,5,9]. For all penetrating trauma, hemorrhage continues to be the leading cause of early hospital deaths [10]. Although lung sparing techniques have improved survival, and thoracic damage control is beneficial in patients in profound shock, the overall mortality remains substantial [11,12,13,14,15]. Some published reports include both blunt and penetrating mechanisms, often with different definitions of emergent, resuscitative, urgent and exigent thoracotomy; however, few reviews include physiologic data. Variability in transport times, stab wounds versus gunshot wounds, and reports published in different decades are additional confounders when comparing results [2,4,7,8,9,16, 17,18]. The purpose of this study was to examine the management and outcomes of patients with penetrating thoracic trauma who required an urgent thoracotomy or sternotomy performed in the operating room within six hours of admission at a busy, urban Level 1 trauma center. The hypothesis was that admission physiology, not systolic blood pressure, would identify patients requiring urgent thoracotomy. METHODS The R Adams Cowley Shock Trauma registry from 2002 to 2017 was queried for patients with penetrating thoracic trauma who had a thoracotomy or median sternotomy within 6 hours of admission. Resuscitative and emergency department thoracotomies (EDT), and patients less than 16 years of age were excluded. Demographics, mode of transport, field transport time, time from
5
arrival to operation, Injury Severity Score (ISS), chest Abbreviated Injury Scale (AIS), Shock Index (SI), and admission physiologic and laboratory data were collected. Specific information regarding injuries, operative details, post-operative course, complications and mortality was obtained by one of the authors (MD, BM, SG, JVO) reviewing all charts. A relational database was created merging all these data. Descriptive statistics were applied. Continuous parametric data were analyzed using paired t-tests, and nonparametric continuous data were analyzed using the Wilcoxon rank-sum test. Chi-squared or Fisher exact tests were used as indicated for analysis of categorical data. Kaplan-Meier survival curves were constructed, and the log-rank test performed to detect statistical significance between curves. A multivariable logistic regression model was calculated to examine the association of variables with the outcome of mortality. The model was selected based on variable inflation factors and backward stepwise estimation with exclusion of variables with a P value > 0.10. Variables that were ultimately included in the model were age, Injury Severity Score (ISS), a requirement for thoracic damage control, and the total number of transfused units of red blood cells and fresh frozen plasma. Various covariates were tested to detect effect modification, and significant statistical interaction was found with age and ISS. These variables were included in the final model. Robust standard errors were calculated, and likelihood ratio tests were performed for each covariate. Regression diagnostics were performed. The Hosmer-Lemeshow and Pearson goodness-of-fit tests confirmed that the model adequately fit the data. All tests were two-tailed, and a P-value <0.05 was considered statistically significant. All tests were performed with Stata Version 12.1 (Stata Corp., College Station, TX). Data are reported as mean with standard deviation (SD) or median with interquartile range [IQR] as appropriate.
6
The study was approved by the Institutional Review Board of the University of Maryland School of Medicine. RESULTS From 2002-2017, 3,121 patients were admitted with penetrating thoracic trauma, of whom 733 (23.4%) underwent a thoracotomy or median sternotomy during their hospital course (emergency department thoracotomies excluded as noted above). There were 301 patients (41.1% of the operative group) who were explored in the operating room within 6 hours of admission and define the study population. The average age of the 301 patients was 31 (11.5) years, 75.6% were male, and 41.5% sustained gunshot wounds and 58.5% stab wounds (Table1). Transport to the Shock Trauma Center was by ground for 249 patients (82.7%) and the remainder by air, with median times of 23 minutes (16-35) and 43 minutes (36-55), respectively; 18 (6%) were transferred from other hospitals. Upon arrival, the median ISS, chest AIS, and Shock Index were 25 (16-29), 4 (3-5), and 0.88 (0.72-1.16), respectively. On admission the mean systolic blood pressure was 115 mmHg (37), with only 23.9% of patients < 90 mmHg and 32.4% < 110 mmHg. However, the pH 7.22 (0.14), base deficit -7.6 (6.1) mEq/L, lactate 7.2 (4.5) mmol/L, and temperature 35.8 degrees C (1.12) were markedly abnormal (Table 2). Indications for thoracic exploration were persistent hemodynamic instability, initial chest tube output >1,500 mL, chest tube output of 200 mL/hour for 2 to 3 consecutive hours, hemopericardium on cardiac ultrasound, pericardial window positive for blood, extravasation or acute vascular injury on imaging, and evidence of an aerodigestive injury. Median time to the operating room for the entire group was 38 minutes (19-105), and 66.4% of operations were performed within one hour of arrival. The choice of incision was 44.2% anterolateral thoracotomy, 34.5% median sternotomy, and 10.6% each for clamshell
7
thoracotomy and posterolateral thoracotomy (Table 3). Injuries documented at operation included the following: 136 (45.2%) pulmonary, 100 (33.2%) cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19.3%) combined major thoracic injuries (Table 4). Thoracic damage control operations were necessary in 66 (21.9%) patients, while a concurrent laparotomy was performed in 91 (30.2%). Median transfusion of red blood cells and fresh frozen plasma was 5.8 units (3-9.5) and 4 units (2-8), respectively. Of the 136 major pulmonary operations, there were 112 (82.4%) nonanatomic resections, 17 (12.5%) lobectomies, and 7 (5.1%) pneumonectomies (only most extensive procedures recorded) (Table 4). Mortality increased with the degree of resection with 2.7% for nonanatomic resection, 11.8% for lobectomy, and 42.9% for pneumonectomy. Cardiac injuries were diagnosed by precordial or transmediastinal wounds with hypotension, an extended, focused assessment for truncal trauma (eFAST) or a positive pericardial window. Stab wounds accounted for 75% of the cardiac injuries. Only11 patients (11%) had a pericardial window due to subcutaneous emphysema or the presence of a hemothorax compromising a surgeon-performed pericardial ultrasound. In decreasing frequency, the chambers injured were right ventricle, left ventricle, right atrium, and left atrium. Cardiopulmonary bypass was required in two patients, including one with a bullet fragment in the left atrium and another with an extensive left ventricular injury. A post-operative echocardiogram was obtained on all patients. Overall mortality for cardiac wounds was 7%, including 9.1% for gunshot wounds and 3% for stab wounds. Of the 30 great vessel injuries, there were 9 arterial, 15 venous and, 6 combined arterial and venous. Arteries were repaired primarily in 4, resection and interposition graft in 8, and 3 had a temporary intraluminal shunt as a damage control procedure. Venous injuries were
8
managed with lateral venorrhaphy in 7 and ligation in 14. If a shunt was placed at the index operation, an interposition graft was performed as a definitive procedure. All patients with injuries to the great vessels survived, with limb function unchanged from admission. The 14 patients with aerodigestive injuries all sustained gunshot wounds. Six (42.9%) were transferred from other hospitals, and the time from injury to operation could not be precisely determined. There were 7 injuries to the esophagus, 4 to the trachea, and 3 combined injuries; six of these were noted during exploration for a pulmonary or cardiac injury. The eight remaining patients were diagnosed by multiple-slice computerized tomography (CT), esophagoscopy and bronchoscopy, and explored through a posterolateral thoracotomy. Primary repair was performed in all patients, along with a muscle buttress. There were two death for a 14.3% mortality. Both patients were transfers, one with an esophageal injury and one with a combined tracheo-esophageal injury. Thoracic damage control was necessary in 66 patients (21.9%). Compared to the nondamage control group, these patients had significantly more gunshot wounds (61% vs. 41%, p=0.005), higher ISS (29 vs. 21, p<0.001), and a worse admission base deficit (-11.7 vs. -6.2, p<0.001). Also, the admission pH (7.1 vs. 7.3), temperature (35.2 vs. 36 degrees C0), and time to operation (34 vs.117 minutes) were significantly less (<0.001) in the patients needing damage control. Of interest, the admission systolic blood pressure and Shock Index were not significantly different between damage control and non-damage control patients. Median length of stay in the hospital (HLOS) and intensive care unit (ILOS) was 9.2 (617) and 3.8 (1-9) days, respectively. Median ventilator days was 2 (1-9), while veno-venous extracorporeal membrane oxygenation (VV ECMO) was used in 7 patients with a survival rate of 71.4%. Infections were the most common postoperative complication and included empyema
9
(6%), all managed operatively, superficial wound infection (6.3%), and bacteremia (5%). There were no mediastinal infections or sternal dehiscence. Postoperative cardiovascular support with vasopressors, inotropes, or both was required in 53 patients (17.6%), while 31 patients (10.3%) developed an acute renal failure requiring continuous renal replacement therapy (CRRT). Finally, postoperative deep venous thrombosis, pulmonary embolism, or both occurred in 4.3%, 3%, and 2% of patients, respectively. All patient with pulmonary emboli survived (Table 5). On discharge, all patients were neurologically intact, none required mechanical ventilation and only one was dialysis dependent. Almost one-quarter of the patients were discharged to an in-patient rehabilitation facility. There were 20 deaths for an overall mortality of 6.6%, including 15.2% in the damage control group and 4.3% in the remainder, which was statistically significant. (p=0.002). (Table 5). DISCUSSION Hemorrhage and hypotension are established indications for thoracotomy following penetrating chest trauma. A systolic blood pressure less than 90 mmHg has been the generally accepted definition of hypotension, without an established physiologic basis. Other reports have demonstrated the presence of shock among trauma patients with an admission systolic blood pressure less than 110 mmHg [19,20,21]. Acidosis, as a marker of inadequate tissue perfusion, strongly correlates with mortality in the trauma patient and has been demonstrated to be a better predictor of outcome then blood pressure [21,22,23,24]. It is compelling that the patients in our study were in shock, as demonstrated by pH, base deficit and lactate, but not by blood pressure. Additionally, only one-quarter of patients had a systolic blood pressure less than 90 mmHg and less than one-third were under 110 mmHg. Therefore, relying on blood pressure as a marker of
10
shock can underestimate the presence and degree of shock in injured patients [21,23]. While both lactate and base deficit are useful markers, an arterial blood gas is particularly helpful with chest trauma, as it characterizes the degree and compensation of shock, as well as the adequacy of ventilation and oxygenation. Although all patients were explored within six hours of admission, two-thirds went to the operating room within one hour, with hemorrhage, hemodynamic instability, hemopericardium, and need for a pericardial window as the most common indications. The indications for those explored after one hour were persistent bleeding from a thoracostomy tube, contrast extravasation on a chest CT scan or an aerodigestive injury diagnosed on esophagoscopy and/or bronchoscopy. Almost one-half the patients had a pulmonary resection, which was the most frequently performed procedure similar to other reports [2,4,5,6,7]. The severity of the parenchymal injury and clinical judgment determined the procedure performed. Lung sparing techniques were used when feasible, and non-anatomic resections performed with surgical staplers. The indication for a lobectomy or pneumonectomy was a hilar injury or extensive parenchymal destruction. Standard techniques were used for formal resection including suture ligation or stapling the hilar vessels and stapling the bronchi, which were covered with a muscle buttress. Mortality increased with the extent of pulmonary resection, which is consistent with other reports [1,4,8,25]. With the exception of pneumonectomy, mortality in our series was generally lower than previously reported. Mortality for non-anatomic resection was 2.7%, which is comparable to some studies [2, 8,9,25] and substantially lower than 20% in other reports [4,17,18]. Similarly, an 11.8% mortality for lobectomy is considerably less than the 28% to 38% reported by some authors [1,4,8,25]. Our 42.9% mortality for traumatic pneumonectomy is similar to others and reflects
11
the shock associated with a lobar or central hilar injury and acute post-operative right ventricular dysfunction [1,2,4,9]. Cardiac injury was present in one-third of patients, and surgeon-performed bedside ultrasonography was most commonly utilized to confirm the diagnosis. As noted over several decades, the FAST examination can be rapidly performed and, in the absence of a hemothorax, is reliable and accurate [26,27]. If the study is technically limited, a pericardial window is performed, which reliably diagnoses a hemopericardium [28,29]. Ten of the 11 (91%) pericardial windows in this review had a cardiac injury which required repair. The sole patient without a cardiac injury had bled from an internal mammary artery through a rent in the pericardium. Typically, mortality from cardiac injuries is higher with gunshot wounds, multiple chambers involved, emergency department thoracotomy and a delay to the operating room [30,31,32,33,34]. The morality in this review for patients with stab wounds repaired in the operating room is similar to the 5% to 13% reported by several authors [8,16,35,36]. The mortality for gunshot wounds; however, is appreciably less than previously reported [30,31,33,34,35,37]. We believe several factors account for this. Emergency department thoracotomies, with a mortality greater than 90% ,were excluded, and only one-quarter of our patients sustained a cardiac gunshot wound [32]. Short transport times, rapid diagnosis of hemopericardium and early operation all contributed to these noteworthy results. Penetrating injuries to the great vessels are infrequent and have an operative mortality ranging from 0% over 30%. Hemodynamic instability, associated venous injuries, gunshot wounds and, concomitant injuries contribute to the increased mortality [8,38,39]. Of interest, some studies have reported an operative mortality of only 0% to 5% [8,40,41,42]. The authors cite short transport times, improved resuscitation, rapid hemorrhage control and the use of
12
damage control as possible explanations for the increased survival. The nature and extent of the vascular injury, concomitant injuries and the patient’s physiologic status influence the decision regarding primary repair or the use of a temporary intraluminal vascular shunt with delayed reconstruction. Intrathoracic aerodigestive injuries are uncommon, often have associated injuries and, are associated with considerable morbidity and mortality. These injuries may be diagnosed preoperatively or discovered during exploration. Mortality from esophageal injuries ranges from 7.5% to 44% and increases with delay to definitive repair [43,44,45,46,47]. Although penetrating injuries to the thoracic trachea are less common than blunt injury, they have a substantial mortality ranging from 15% to 21% [48,49,50,51,52], as do combined tracheoesophageal injuries [53,54]. In this review, esophageal injuries were closed in 2 layers, widely drained and distal feeding access placed. Tracheal injuries were closed with interrupted absorbable sutures, and a tracheostomy was not performed. All esophageal, tracheal and combined injuries were buttressed with muscle [55]. The 14.3% mortality for patients with aerodigestive injury is consistent with other reports [45,50,52,54]. Both deaths occurred in patients transferred to our facility. As previously noted, the time from injury to operation is unknown, and may have impacted the outcome. Rapidly establishing the diagnosis, prompt operative intervention, primary repair and utilizing a muscle buttress are essential to a successful outcome. The role of thoracic damage control in the physiologically depleted, severely injured trauma patient, often with multiple torso injuries, is evolving [11,15]. The experience with the 66 damage control patients included in this study has been described in a recent publication from our institution [56].
13
This study has the limitations inherent in any retrospective, single institution study conducted over a decade and a half. Maryland has a highly integrated pre-hospital system including the Maryland State Police (MSP) Aviation Command providing all helicopter transport from the field, with an MSP paramedic providing advance care en route. In addition, our facility is an established, busy and well-resourced urban trauma center. Therefore, care should be exercised when generalizing these results. CONCLUSION This is the largest, single institution experience describing admission physiology in patients undergoing an operating room thoracotomy or median sternotomy within 6 hours of admission after a penetrating thoracic trauma. Several salient points require emphasis. There is the considerable discordance between admission blood pressure and the level of shock. Relying on a “normal” admission blood pressure in patients with penetrating thoracic wounds will result in failure to recognize the group with occult shock. As described, physiologic markers of inadequate tissue perfusion such as pH, base deficit and lactate reflect the presence and degree of shock, while an arterial blood gas provides crucial information on ventilation and oxygenation. Efficient field transport, rapid evaluation including physician performed ultrasound, expeditious operation, use of damage control when appropriate, sophisticated clinical judgment and, especially, early recognition of shock can yield superior results in patients with penetrating thoracic wounds.
14
REFERENCES 1. Carrillo EH, Block EF, Zeppa R, Sosa JL. Urgent lobectomy and pneumonectomy. Eur J Emerg Med 1994;1(3):126-30. 2. Karmy-Jones R, Jurkovich GJ, Shatz DV, et al. Management of traumatic lung injury: a Western Trauma Association multicenter review. J Trauma. 2001;51(6):1049-53. 3. Karmy-Jones R, Nathens A, Jurkovich GJ, et al. Urgent and emergent thoracotomy for penetrating chest trauma. J Trauma. 2004;56(3):664-8. 4. Martin MJ, McDonald JM, Mullenix PS, et al. Operative management and outcomes of traumatic lung resection. J Am Coll Surg. 2006;203(3):336-44. 5. Onat S, Ulku R, Avci A, et al. Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center. Injury. 2011;42(9):900-4. 6. Clarke DL, Quazi MA, Reddy K, Thomson SR. Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa. J Thorac Cardiovasc Surg. 2011;142(3):563-8. 7. Asensio JA, Ogun OA, Mazzini FN, et al. Predictors of outcome in 101 patients requiring emergent thoracotomy for penetrating pulmonary injuries. Eur J Trauma Emerg Surg. 2018;44(1):55-61. 8. Doll D, Eichler M, Vassiliu P, et al. Penetrating thoracic trauma patients with gross physiological derangement: a responsibility for the general surgeon in the absence of trauma or cardiothoracic surgeon? World J Surg. 2017;41(1):170-175. 9. Stewart KC, Urschel JD, Nakai SS, et al. Pulmonary resection for lung trauma. Ann Thorac Surg. 1997;63(6):1587-8.
15
10. Callcut RA, Kornblith LZ, Conroy AS, et al. The why and how our trauma patients die: a prospective multicenter Western Trauma Association study. J Trauma Acute Care Surg. 2019;86(5):864-870. 11. O’Connor JV, DuBose JJ, Scalea TM. Damage-control thoracic surgery: management and outcomes. J Trauma Acute Care Surg. 2014;77(5):660-665. 12. Wall MJ Jr, Villavicencio RT, Miller CC 3rd, et al. Pulmonary tractotomy as an abbreviated thoracotomy technique. J Trauma. 1998;45(6):1015-23. 13. Cothren C, Moore EE, Biffl WL, et al. Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries. J Trauma. 2002;53(3):483-7. 14. Gasparri M, Karmy-Jones R, Kralovich KA, et al. Pulmonary tractotomy versus lung resection: viable options in penetrating lung injury. J Trauma. 2001;51(6):1092-5. 15. Garcia A, Martinez J, Rodriguez J, et al. Damage-control techniques in the management of severe lung trauma. J Trauma Acute Care Surg. 2015;78(1):45-50. 16. Mandal AK, Sanusi M. Penetrating chest wounds: 24 years experience. World J Surg. 2001;25(9):1145-9. 17. Huh J, Wall MJ, Estrera AL, et al. Surgical management of traumatic pulmonary injury. Am J Surg. 2003;186(6):620-4. 18. Tominaga GT, Waxman K, Scannell G, et al. Emergency thoracotomy with lung resection following trauma. Am Surg. 1993;59(12):834-7. 19. Eastridge BJ, Salinas J, McManus JG, et al. Hypotension begins at 110 mm Hg: redefining “hypotension” with data. J Trauma. 2007;63(2):291-7.
16
20. Hasler RM, Nϋesch E, Jϋni P, et al. Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: mutlicentre cohort study. Resuscitation. 2012;83(4):476-81. 21. Clarke DL, Brysiewicz P, Sartorius B, et al. Hypotension of ≤ 110 mmHg is associated with increased mortality in South African patients after trauma. Scand J Surg. 2017;106(3):261-268. 22. Rutherford EJ, Morris JA Jr, Reed GW, Hall KS. Base deficit stratifies mortality and determines therapy. J Trauma. 1992;33(3):417-23. 23. Dunham MP, Sartorius B, Laing GL, et al. A comparison of base deficit and vital signs in the early assessment of patients with penetrating trauma in a high burden setting. Injury. 2017; 48(9):1972-1977. 24. Hodgman EI, Morse BC, Dente CJ, et al. Base deficit as a marker of survival after traumatic injury: consistent across changing patient populations and resuscitation paradigms. J Trauma Acute Care Surg. 2012;72(4):844-51. 25. Robison PD, Harman PK, Trinkle JK, Grover FL. Management of penetrating lung injuries in civilian practice. J Thorac Cardiovasc Surg. 1988;95(2):184-90. 26. Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma. 1999;46(4):543-51. 27. Ball CG, Williams BH, Wyrzykowski AD, et al. A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma. 2009;67(5):1123-4.
17
28. Brewster SA, Thirlby RC, Snyder WH 3rd. Subxiphoid pericardial window and penetrating cardiac trauma. Arch Surg. 1988;123(8):937-41. 29. Duncan AO, Scalea TM, Sclafani SJ, et al. Evaluation of occult cardiac injuries using subxiphoid pericardial window. J Trauma. 1989;29(7):955-9. 30. Campbell NC, Thomson SR, Muckart DJ, et al. Review of 1198 cases of penetrating cardiac trauma. Br J Surg. 1997;84(12):1737-40. 31. Tyburski JG, Astra L, Wilson RF, et al. Factors affecting prognosis with penetrating wounds of the heart. J Trauma. 2000;48(4):587-90. 32. Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190(3):288-98. 33. Pereira BM, Nogueira VB, Calderan TR, et al. Penetrating cardiac trauma: 20-y experience from a university teaching hospital. J Surg Res. 2013;183(2):792-7. 34. Morse BC, Mina MJ, Carr JS, et al. Penetrating cardiac injuries: A 36-year perspective at an urban, Level I trauma center. J Trauma Acute Care Surg. 2016;81(4):623-32. 35. Velmahos GC, Degiannis E, Souter I, Saadia R. Penetrating trauma to the heart: a relatively innocent injury. Surg. 1994;115(6):694-7. 36. Degiannis E, Loogna P, Doll D, et al. Penetrating cardiac injuries: recent experience in South Africa. World J Surg. 2006;30(7):1258-64. 37. Asensio JA, Murray J, Demetriades D, et al. Penetrating cardiac injuries: a prospective study of variables predicting outcomes. J Am Coll Surg. 1998;186(1):24-34. 38. Degiannis E, Velmahos G, Krawczykowski D, et al. Penetrating injuries of the subclavian vessels. Br J Surg. 1994;81(4):524-6.
18
39. Demetriades D, Rabinowitz B, Pezikis A, et al. Subclavian vascular injuries. Br J Surg. 1987;74(11):1001-3. 40. Fulton JO, de Groot KM, Buckels NJ, von Oppell UO. Penetrating injuries involving the intrathoracic great vessels. S Afr J Surg. 1997;35(2):82-6. 41. O’Connor JV, Scalea TM. Penetrating thoracic great vessel injury: impact of admission hemodynamics and preoperative imaging. J Trauma. 2010;68(4):834-7. 42. Sobnach S, Nicol JA, Nathire H, et al. An analysis of 50 surgically managed penetrating subclavian artery injuries. Eur J Vasc Endovasc Surg. 2010;39(2):155-9. 43. Symbas PN, Hatcher CR Jr, Vlasis SE. Esophageal gunshot injuries. Ann Surg. 1980;191(6):703-7. 44. Patel MS, Malinoski DJ, Zhou L, et al. Penetrating oesophageal injury: a contemporary analysis of the National Trauma Data Bank. Injury. 2013;44(1):48-55. 45. Asensio JA, Chahwan S, Forno W., et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001;50(2):289-96. 46. Xu AA, Breeze JL, Paulus JK, Bugaev N. Epidemiology of traumatic esophageal injury: An analysis of the National Trauma Data Bank. Am Surg. 2019;1;85(4):342349. 47. Gambhir S, Grigorian A, Swentek L., et al. Esophageal trauma: Analysis of incidence, morbidity and mortality. Am Surg. 2019;1;85(10):1134-1138. 48. Symbas PN, Hatcher CR Jr, Boehm GA. Acute penetrating tracheal trauma. Ann Thorac Surg. 1976;22(5):473-7.
19
49. Kelly JP, Webb WR, Moulder PV, et al. Management of airway trauma. I: tracheobronchial injuries. Ann Thorac Surg. 1985;40(6):551-5. 50. Rossbach MM, Johnson SB, Gomez MA, et al. Management of major tracheobronchial injuries: a 28-year experience. Ann Thorac Surg. 1998;65(1):182-6. 51. Balci AE, Eren N, Eren S, Ulkϋ R. Surgical treatment of post-traumatic tracheobronchial injuries: 14-year experience. Eur J Cardiothorac Surg. 2002;22(6):984-9. 52. Lyons JD, Feliciano DV, Wyrzykowski AD, Rozycki GS. Modern management of penetrating tracheal injuries. Am Surg. 2013;79(2):188-93. 53. Feliciano DV, Bitondo CG, Mattox KL, et al. Combined tracheoesophageal injuries. Am J Surg. 1985;150(6):710-5. 54. Kelly JP, Webb WR, Moulder PV, et al. Management of airway trauma. II: combined injuries of the trachea and esophagus. Ann Thorac Surg. 1987;43(2):160-3. 55. Losken A, Rozycki GS, Feliciano DV. The use of the sternocleidomastoid muscle flap in combined injuries to the esophagus and carotid artery or trachea. J Trauma. 2000;49(5):815-7. 56. Deane M, Galvagno SM, Moran B, et al. Shock, not blood pressure or shock index, determines the need for thoracic damage control following penetrating trauma. Shock. [In press].
20
Precis Urgent thoracotomy for penetrating thoracic trauma is associated with considerable mortality. Hypotension is a classic indication for thoracotomy in these patients. However, relying on blood pressure fails to identify patients in shock. Admission physiology is superior to blood pressure in predicting the need for urgent thoracotomy in patients with penetrating thoracic wounds.
21
Table 1. Demographics and Characteristics of the 301 Patients in This Study Characteristic Age, y, mean (SD) Male, n (%) Gunshot wound, n (%) Stab wound, n (%)
Data 31 (11.5) 228 (75.6) 125 (41.5) 176 (58.5)
Injury Severity Score, median (IQR)
25 (16-29)
Chest Abbreviated Injury Scale, median (IQR)
4 (3-5)
Patients were predominantly young, male, and severely injured.
22
Table 2. Admission Physiology and Systolic Blood Pressure Variable SBP, mmHg, mean (SD) SBP <90 mmHg, % Shock Index, median (IQR) Injury Severity Score, median (IQR) pH, mean (SD) Base deficit, mEq/L, mean (SD) Lactate, mmol/L, mean (SD)
Data 115 (37) 23.9 0.88 (0.72-1.16) 25 (16-29) 7.22 (0.14) 7.6 (6.1) 7.2 (4.5)
International Normalized Ratio, median 1.2 (1.1-1.4) (IQR) Temperature, C°, mean (SD) 35.8 (1.12) Note the discordance between the systolic blood pressure and physiology on arrival. Although the blood pressure is normal the pH, base deficit, lactate and temperature are all markedly abnormal, signifying shock. SBP, systolic blood pressure
23
Table 3. Operative Approach Approach
%
Anterolateral thoracotomy
44.2
Median sternotomy
34.5
Posterolateral thoracotomy
10.6
Bilateral anterolateral thoracotomy 10.6 (clamshell) Anterolateral thoracotomy was the most common incision. Cardiac and great vessel injury was preferentially explored through a sternotomy. Aerodigestive injuries diagnosed preoperatively were approached by posterolateral thoracotomy.
24
Table 4. Injuries and Operative Procedures Variable Data Pulmonary resection, n (%) 136 (45.2) Non-anatomic, n 112 Lobectomy, n 17 Pneumonectomy, n 7 Cardiac, n (%) 100 (33.2) Great vessel, n (%) 30 (9.9) Aerodigestive, n (%) 14 (4.7) Combined major intrathoracic, n (%) 58 (19.3) Concomitant laparotomy, n (%) 91 (30.2) Thoracic damage control, n (%) 66 (21.9) Time to OR, min, median (IQR) 38 (19-105) Transfusions units, median (IQR) Packed red blood cells 5.8 (3-9.5) Fresh frozen plasma 4 (2-8) Combined thoracic injury was frequent and almost one-third of patients required a laparotomy. Thoracic damage control was performed on the most severely injured and physiologically depleted patients. OR, operating room
25
Table 5. Operative Outcomes Outcome Hospital LOS, d, median (IQR)
Data 9.2 (6 -17)
ICU LOS, d, median (IQ% 3.8 (1-9) Ventilator days, median (IQR) 2 (1-9) Bacteremia, % 5 Wound infection, % 6.3 Empyema, % 6 Vasoactive infusion, % 17.6 Acute renal failure on CRRT, % 10.3 Discharged to in-patient rehabilitation, % 24.9 Mortality, n (%) 20 (6.6) Damage control 10 (15.2) Non-damage control 10 (4.3) Infections were the most common postoperative complication followed by dialysis dependent acute renal failure. Mortality among the damage control group was significantly higher than for the other patients (p=0.002). CRRT, continuous renal replacement therapy; LOS, length of stay
S1072-7515(20)30104-6
DOI:
https://doi.org/10.1016/j.jamcollsurg.2019.12.019
Reference:
ACS 9714
To appear in:
Journal of the American College of Surgeons
Received Date: 16 December 2019 Accepted Date: 16 December 2019
Please cite this article as: O’Connor JV, Moran B, Galvagno Jr SM, Deane M, Feliciano DV, Scalea TM, Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma, Journal of the American College of Surgeons (2020), doi: https:// doi.org/10.1016/j.jamcollsurg.2019.12.019. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc. on behalf of the American College of Surgeons.
1
Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma James V O’Connor, MD, FACS1, Benjamin Moran, MD1, Samuel M Galvagno Jr, DO, PhD2, Molly Deane, MD1, David V Feliciano, MD, FACS1, Thomas M Scalea, MD, FACS, MCCM1 1
Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 2 Department of Anesthesia, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD Disclosure Information: Nothing to disclose. Presented at the Southern Surgical Association 131st Annual Meeting, Hot Springs, VA, December 2019. Corresponding author: James V. O’Connor, MD, FACS 22 South Greene Street Shock Trauma Director’s Office Suite Baltimore, MD 21201 410-328-3587 [email protected]
Short title: Urgent Thoracotomy after Penetrating Trauma
2
Introduction: Approximately 15% of patients with penetrating thoracic trauma require an emergency center or operating room thoracotomy, usually for hemodynamic instability or persistent hemorrhage. The hypothesis in this study is that admission physiology, not vital signs, predicts the need for operating room thoracotomy. Methods: Trauma registry review, 2002-2017, of adult patients undergoing operating room thoracotomy within 6 hours of admission (emergency department thoracotomies excluded). Demographics, injuries, admission physiology, time to operating room (OR), operations, and outcomes were reviewed. Data are reported as mean (SD) or median (IQR). Results: Of the 301 consecutive patients in this 15-year review, 75.6% were male, mean age 31.1 years (11.5) and 41.5% had gunshot wounds. The median Injury Severity Score was 25 (16-29), time to OR 38 minutes (19-105), and 21.9% had a thoracic damage control operation. Mean admission systolic blood pressure was 115 mmHg (37), with only 23.9% <90 mmHg; however, admission pH 7.22 (0.14), base deficit 7.6 (6.1), and lactate 7.2 (4.5) were markedly abnormal. Overall, there were 136 (45.2%) patients with significant pulmonary injuries treated with 112 major non-anatomic resections, 17 lobectomies, and 7 pneumonectomies; respective mortalities were 2.7%, 11.8%, and 42.9%. There were 100 (33.2%), cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19%) combined thoracic injuries. Mortality for cardiac, great vessel, and aerodigestive injuries was 7%, 0%, and 14.3%, respectively. Overall mortality was 6.6%, 15.2% after damage control and 4.3% for all others. Conclusions: Shock characterized by acidosis, but not hypotension, is the most common presentation in patients who will need operating room thoracotomy after penetrating thoracic
3
trauma. Survival rates are excellent unless a pneumonectomy or damage control thoracotomy is required.
4
INTRODUCTION The management of penetrating thoracic trauma is predominantly nonoperative, with approximately one in five patients requiring surgery, generally for hemorrhage or hemodynamic instability. These patients typically are in shock, have life-threatening injuries and an operative mortality as high a 30% [1,2,3,4,5,6,7,8]. Mortality is higher with concurrent laparotomy, magnitude of pulmonary resection and number of organs injured [2,4,5,9]. For all penetrating trauma, hemorrhage continues to be the leading cause of early hospital deaths [10]. Although lung sparing techniques have improved survival, and thoracic damage control is beneficial in patients in profound shock, the overall mortality remains substantial [11,12,13,14,15]. Some published reports include both blunt and penetrating mechanisms, often with different definitions of emergent, resuscitative, urgent and exigent thoracotomy; however, few reviews include physiologic data. Variability in transport times, stab wounds versus gunshot wounds, and reports published in different decades are additional confounders when comparing results [2,4,7,8,9,16, 17,18]. The purpose of this study was to examine the management and outcomes of patients with penetrating thoracic trauma who required an urgent thoracotomy or sternotomy performed in the operating room within six hours of admission at a busy, urban Level 1 trauma center. The hypothesis was that admission physiology, not systolic blood pressure, would identify patients requiring urgent thoracotomy. METHODS The R Adams Cowley Shock Trauma registry from 2002 to 2017 was queried for patients with penetrating thoracic trauma who had a thoracotomy or median sternotomy within 6 hours of admission. Resuscitative and emergency department thoracotomies (EDT), and patients less than 16 years of age were excluded. Demographics, mode of transport, field transport time, time from
5
arrival to operation, Injury Severity Score (ISS), chest Abbreviated Injury Scale (AIS), Shock Index (SI), and admission physiologic and laboratory data were collected. Specific information regarding injuries, operative details, post-operative course, complications and mortality was obtained by one of the authors (MD, BM, SG, JVO) reviewing all charts. A relational database was created merging all these data. Descriptive statistics were applied. Continuous parametric data were analyzed using paired t-tests, and nonparametric continuous data were analyzed using the Wilcoxon rank-sum test. Chi-squared or Fisher exact tests were used as indicated for analysis of categorical data. Kaplan-Meier survival curves were constructed, and the log-rank test performed to detect statistical significance between curves. A multivariable logistic regression model was calculated to examine the association of variables with the outcome of mortality. The model was selected based on variable inflation factors and backward stepwise estimation with exclusion of variables with a P value > 0.10. Variables that were ultimately included in the model were age, Injury Severity Score (ISS), a requirement for thoracic damage control, and the total number of transfused units of red blood cells and fresh frozen plasma. Various covariates were tested to detect effect modification, and significant statistical interaction was found with age and ISS. These variables were included in the final model. Robust standard errors were calculated, and likelihood ratio tests were performed for each covariate. Regression diagnostics were performed. The Hosmer-Lemeshow and Pearson goodness-of-fit tests confirmed that the model adequately fit the data. All tests were two-tailed, and a P-value <0.05 was considered statistically significant. All tests were performed with Stata Version 12.1 (Stata Corp., College Station, TX). Data are reported as mean with standard deviation (SD) or median with interquartile range [IQR] as appropriate.
6
The study was approved by the Institutional Review Board of the University of Maryland School of Medicine. RESULTS From 2002-2017, 3,121 patients were admitted with penetrating thoracic trauma, of whom 733 (23.4%) underwent a thoracotomy or median sternotomy during their hospital course (emergency department thoracotomies excluded as noted above). There were 301 patients (41.1% of the operative group) who were explored in the operating room within 6 hours of admission and define the study population. The average age of the 301 patients was 31 (11.5) years, 75.6% were male, and 41.5% sustained gunshot wounds and 58.5% stab wounds (Table1). Transport to the Shock Trauma Center was by ground for 249 patients (82.7%) and the remainder by air, with median times of 23 minutes (16-35) and 43 minutes (36-55), respectively; 18 (6%) were transferred from other hospitals. Upon arrival, the median ISS, chest AIS, and Shock Index were 25 (16-29), 4 (3-5), and 0.88 (0.72-1.16), respectively. On admission the mean systolic blood pressure was 115 mmHg (37), with only 23.9% of patients < 90 mmHg and 32.4% < 110 mmHg. However, the pH 7.22 (0.14), base deficit -7.6 (6.1) mEq/L, lactate 7.2 (4.5) mmol/L, and temperature 35.8 degrees C (1.12) were markedly abnormal (Table 2). Indications for thoracic exploration were persistent hemodynamic instability, initial chest tube output >1,500 mL, chest tube output of 200 mL/hour for 2 to 3 consecutive hours, hemopericardium on cardiac ultrasound, pericardial window positive for blood, extravasation or acute vascular injury on imaging, and evidence of an aerodigestive injury. Median time to the operating room for the entire group was 38 minutes (19-105), and 66.4% of operations were performed within one hour of arrival. The choice of incision was 44.2% anterolateral thoracotomy, 34.5% median sternotomy, and 10.6% each for clamshell
7
thoracotomy and posterolateral thoracotomy (Table 3). Injuries documented at operation included the following: 136 (45.2%) pulmonary, 100 (33.2%) cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19.3%) combined major thoracic injuries (Table 4). Thoracic damage control operations were necessary in 66 (21.9%) patients, while a concurrent laparotomy was performed in 91 (30.2%). Median transfusion of red blood cells and fresh frozen plasma was 5.8 units (3-9.5) and 4 units (2-8), respectively. Of the 136 major pulmonary operations, there were 112 (82.4%) nonanatomic resections, 17 (12.5%) lobectomies, and 7 (5.1%) pneumonectomies (only most extensive procedures recorded) (Table 4). Mortality increased with the degree of resection with 2.7% for nonanatomic resection, 11.8% for lobectomy, and 42.9% for pneumonectomy. Cardiac injuries were diagnosed by precordial or transmediastinal wounds with hypotension, an extended, focused assessment for truncal trauma (eFAST) or a positive pericardial window. Stab wounds accounted for 75% of the cardiac injuries. Only11 patients (11%) had a pericardial window due to subcutaneous emphysema or the presence of a hemothorax compromising a surgeon-performed pericardial ultrasound. In decreasing frequency, the chambers injured were right ventricle, left ventricle, right atrium, and left atrium. Cardiopulmonary bypass was required in two patients, including one with a bullet fragment in the left atrium and another with an extensive left ventricular injury. A post-operative echocardiogram was obtained on all patients. Overall mortality for cardiac wounds was 7%, including 9.1% for gunshot wounds and 3% for stab wounds. Of the 30 great vessel injuries, there were 9 arterial, 15 venous and, 6 combined arterial and venous. Arteries were repaired primarily in 4, resection and interposition graft in 8, and 3 had a temporary intraluminal shunt as a damage control procedure. Venous injuries were
8
managed with lateral venorrhaphy in 7 and ligation in 14. If a shunt was placed at the index operation, an interposition graft was performed as a definitive procedure. All patients with injuries to the great vessels survived, with limb function unchanged from admission. The 14 patients with aerodigestive injuries all sustained gunshot wounds. Six (42.9%) were transferred from other hospitals, and the time from injury to operation could not be precisely determined. There were 7 injuries to the esophagus, 4 to the trachea, and 3 combined injuries; six of these were noted during exploration for a pulmonary or cardiac injury. The eight remaining patients were diagnosed by multiple-slice computerized tomography (CT), esophagoscopy and bronchoscopy, and explored through a posterolateral thoracotomy. Primary repair was performed in all patients, along with a muscle buttress. There were two death for a 14.3% mortality. Both patients were transfers, one with an esophageal injury and one with a combined tracheo-esophageal injury. Thoracic damage control was necessary in 66 patients (21.9%). Compared to the nondamage control group, these patients had significantly more gunshot wounds (61% vs. 41%, p=0.005), higher ISS (29 vs. 21, p<0.001), and a worse admission base deficit (-11.7 vs. -6.2, p<0.001). Also, the admission pH (7.1 vs. 7.3), temperature (35.2 vs. 36 degrees C0), and time to operation (34 vs.117 minutes) were significantly less (<0.001) in the patients needing damage control. Of interest, the admission systolic blood pressure and Shock Index were not significantly different between damage control and non-damage control patients. Median length of stay in the hospital (HLOS) and intensive care unit (ILOS) was 9.2 (617) and 3.8 (1-9) days, respectively. Median ventilator days was 2 (1-9), while veno-venous extracorporeal membrane oxygenation (VV ECMO) was used in 7 patients with a survival rate of 71.4%. Infections were the most common postoperative complication and included empyema
9
(6%), all managed operatively, superficial wound infection (6.3%), and bacteremia (5%). There were no mediastinal infections or sternal dehiscence. Postoperative cardiovascular support with vasopressors, inotropes, or both was required in 53 patients (17.6%), while 31 patients (10.3%) developed an acute renal failure requiring continuous renal replacement therapy (CRRT). Finally, postoperative deep venous thrombosis, pulmonary embolism, or both occurred in 4.3%, 3%, and 2% of patients, respectively. All patient with pulmonary emboli survived (Table 5). On discharge, all patients were neurologically intact, none required mechanical ventilation and only one was dialysis dependent. Almost one-quarter of the patients were discharged to an in-patient rehabilitation facility. There were 20 deaths for an overall mortality of 6.6%, including 15.2% in the damage control group and 4.3% in the remainder, which was statistically significant. (p=0.002). (Table 5). DISCUSSION Hemorrhage and hypotension are established indications for thoracotomy following penetrating chest trauma. A systolic blood pressure less than 90 mmHg has been the generally accepted definition of hypotension, without an established physiologic basis. Other reports have demonstrated the presence of shock among trauma patients with an admission systolic blood pressure less than 110 mmHg [19,20,21]. Acidosis, as a marker of inadequate tissue perfusion, strongly correlates with mortality in the trauma patient and has been demonstrated to be a better predictor of outcome then blood pressure [21,22,23,24]. It is compelling that the patients in our study were in shock, as demonstrated by pH, base deficit and lactate, but not by blood pressure. Additionally, only one-quarter of patients had a systolic blood pressure less than 90 mmHg and less than one-third were under 110 mmHg. Therefore, relying on blood pressure as a marker of
10
shock can underestimate the presence and degree of shock in injured patients [21,23]. While both lactate and base deficit are useful markers, an arterial blood gas is particularly helpful with chest trauma, as it characterizes the degree and compensation of shock, as well as the adequacy of ventilation and oxygenation. Although all patients were explored within six hours of admission, two-thirds went to the operating room within one hour, with hemorrhage, hemodynamic instability, hemopericardium, and need for a pericardial window as the most common indications. The indications for those explored after one hour were persistent bleeding from a thoracostomy tube, contrast extravasation on a chest CT scan or an aerodigestive injury diagnosed on esophagoscopy and/or bronchoscopy. Almost one-half the patients had a pulmonary resection, which was the most frequently performed procedure similar to other reports [2,4,5,6,7]. The severity of the parenchymal injury and clinical judgment determined the procedure performed. Lung sparing techniques were used when feasible, and non-anatomic resections performed with surgical staplers. The indication for a lobectomy or pneumonectomy was a hilar injury or extensive parenchymal destruction. Standard techniques were used for formal resection including suture ligation or stapling the hilar vessels and stapling the bronchi, which were covered with a muscle buttress. Mortality increased with the extent of pulmonary resection, which is consistent with other reports [1,4,8,25]. With the exception of pneumonectomy, mortality in our series was generally lower than previously reported. Mortality for non-anatomic resection was 2.7%, which is comparable to some studies [2, 8,9,25] and substantially lower than 20% in other reports [4,17,18]. Similarly, an 11.8% mortality for lobectomy is considerably less than the 28% to 38% reported by some authors [1,4,8,25]. Our 42.9% mortality for traumatic pneumonectomy is similar to others and reflects
11
the shock associated with a lobar or central hilar injury and acute post-operative right ventricular dysfunction [1,2,4,9]. Cardiac injury was present in one-third of patients, and surgeon-performed bedside ultrasonography was most commonly utilized to confirm the diagnosis. As noted over several decades, the FAST examination can be rapidly performed and, in the absence of a hemothorax, is reliable and accurate [26,27]. If the study is technically limited, a pericardial window is performed, which reliably diagnoses a hemopericardium [28,29]. Ten of the 11 (91%) pericardial windows in this review had a cardiac injury which required repair. The sole patient without a cardiac injury had bled from an internal mammary artery through a rent in the pericardium. Typically, mortality from cardiac injuries is higher with gunshot wounds, multiple chambers involved, emergency department thoracotomy and a delay to the operating room [30,31,32,33,34]. The morality in this review for patients with stab wounds repaired in the operating room is similar to the 5% to 13% reported by several authors [8,16,35,36]. The mortality for gunshot wounds; however, is appreciably less than previously reported [30,31,33,34,35,37]. We believe several factors account for this. Emergency department thoracotomies, with a mortality greater than 90% ,were excluded, and only one-quarter of our patients sustained a cardiac gunshot wound [32]. Short transport times, rapid diagnosis of hemopericardium and early operation all contributed to these noteworthy results. Penetrating injuries to the great vessels are infrequent and have an operative mortality ranging from 0% over 30%. Hemodynamic instability, associated venous injuries, gunshot wounds and, concomitant injuries contribute to the increased mortality [8,38,39]. Of interest, some studies have reported an operative mortality of only 0% to 5% [8,40,41,42]. The authors cite short transport times, improved resuscitation, rapid hemorrhage control and the use of
12
damage control as possible explanations for the increased survival. The nature and extent of the vascular injury, concomitant injuries and the patient’s physiologic status influence the decision regarding primary repair or the use of a temporary intraluminal vascular shunt with delayed reconstruction. Intrathoracic aerodigestive injuries are uncommon, often have associated injuries and, are associated with considerable morbidity and mortality. These injuries may be diagnosed preoperatively or discovered during exploration. Mortality from esophageal injuries ranges from 7.5% to 44% and increases with delay to definitive repair [43,44,45,46,47]. Although penetrating injuries to the thoracic trachea are less common than blunt injury, they have a substantial mortality ranging from 15% to 21% [48,49,50,51,52], as do combined tracheoesophageal injuries [53,54]. In this review, esophageal injuries were closed in 2 layers, widely drained and distal feeding access placed. Tracheal injuries were closed with interrupted absorbable sutures, and a tracheostomy was not performed. All esophageal, tracheal and combined injuries were buttressed with muscle [55]. The 14.3% mortality for patients with aerodigestive injury is consistent with other reports [45,50,52,54]. Both deaths occurred in patients transferred to our facility. As previously noted, the time from injury to operation is unknown, and may have impacted the outcome. Rapidly establishing the diagnosis, prompt operative intervention, primary repair and utilizing a muscle buttress are essential to a successful outcome. The role of thoracic damage control in the physiologically depleted, severely injured trauma patient, often with multiple torso injuries, is evolving [11,15]. The experience with the 66 damage control patients included in this study has been described in a recent publication from our institution [56].
13
This study has the limitations inherent in any retrospective, single institution study conducted over a decade and a half. Maryland has a highly integrated pre-hospital system including the Maryland State Police (MSP) Aviation Command providing all helicopter transport from the field, with an MSP paramedic providing advance care en route. In addition, our facility is an established, busy and well-resourced urban trauma center. Therefore, care should be exercised when generalizing these results. CONCLUSION This is the largest, single institution experience describing admission physiology in patients undergoing an operating room thoracotomy or median sternotomy within 6 hours of admission after a penetrating thoracic trauma. Several salient points require emphasis. There is the considerable discordance between admission blood pressure and the level of shock. Relying on a “normal” admission blood pressure in patients with penetrating thoracic wounds will result in failure to recognize the group with occult shock. As described, physiologic markers of inadequate tissue perfusion such as pH, base deficit and lactate reflect the presence and degree of shock, while an arterial blood gas provides crucial information on ventilation and oxygenation. Efficient field transport, rapid evaluation including physician performed ultrasound, expeditious operation, use of damage control when appropriate, sophisticated clinical judgment and, especially, early recognition of shock can yield superior results in patients with penetrating thoracic wounds.
14
REFERENCES 1. Carrillo EH, Block EF, Zeppa R, Sosa JL. Urgent lobectomy and pneumonectomy. Eur J Emerg Med 1994;1(3):126-30. 2. Karmy-Jones R, Jurkovich GJ, Shatz DV, et al. Management of traumatic lung injury: a Western Trauma Association multicenter review. J Trauma. 2001;51(6):1049-53. 3. Karmy-Jones R, Nathens A, Jurkovich GJ, et al. Urgent and emergent thoracotomy for penetrating chest trauma. J Trauma. 2004;56(3):664-8. 4. Martin MJ, McDonald JM, Mullenix PS, et al. Operative management and outcomes of traumatic lung resection. J Am Coll Surg. 2006;203(3):336-44. 5. Onat S, Ulku R, Avci A, et al. Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center. Injury. 2011;42(9):900-4. 6. Clarke DL, Quazi MA, Reddy K, Thomson SR. Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa. J Thorac Cardiovasc Surg. 2011;142(3):563-8. 7. Asensio JA, Ogun OA, Mazzini FN, et al. Predictors of outcome in 101 patients requiring emergent thoracotomy for penetrating pulmonary injuries. Eur J Trauma Emerg Surg. 2018;44(1):55-61. 8. Doll D, Eichler M, Vassiliu P, et al. Penetrating thoracic trauma patients with gross physiological derangement: a responsibility for the general surgeon in the absence of trauma or cardiothoracic surgeon? World J Surg. 2017;41(1):170-175. 9. Stewart KC, Urschel JD, Nakai SS, et al. Pulmonary resection for lung trauma. Ann Thorac Surg. 1997;63(6):1587-8.
15
10. Callcut RA, Kornblith LZ, Conroy AS, et al. The why and how our trauma patients die: a prospective multicenter Western Trauma Association study. J Trauma Acute Care Surg. 2019;86(5):864-870. 11. O’Connor JV, DuBose JJ, Scalea TM. Damage-control thoracic surgery: management and outcomes. J Trauma Acute Care Surg. 2014;77(5):660-665. 12. Wall MJ Jr, Villavicencio RT, Miller CC 3rd, et al. Pulmonary tractotomy as an abbreviated thoracotomy technique. J Trauma. 1998;45(6):1015-23. 13. Cothren C, Moore EE, Biffl WL, et al. Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries. J Trauma. 2002;53(3):483-7. 14. Gasparri M, Karmy-Jones R, Kralovich KA, et al. Pulmonary tractotomy versus lung resection: viable options in penetrating lung injury. J Trauma. 2001;51(6):1092-5. 15. Garcia A, Martinez J, Rodriguez J, et al. Damage-control techniques in the management of severe lung trauma. J Trauma Acute Care Surg. 2015;78(1):45-50. 16. Mandal AK, Sanusi M. Penetrating chest wounds: 24 years experience. World J Surg. 2001;25(9):1145-9. 17. Huh J, Wall MJ, Estrera AL, et al. Surgical management of traumatic pulmonary injury. Am J Surg. 2003;186(6):620-4. 18. Tominaga GT, Waxman K, Scannell G, et al. Emergency thoracotomy with lung resection following trauma. Am Surg. 1993;59(12):834-7. 19. Eastridge BJ, Salinas J, McManus JG, et al. Hypotension begins at 110 mm Hg: redefining “hypotension” with data. J Trauma. 2007;63(2):291-7.
16
20. Hasler RM, Nϋesch E, Jϋni P, et al. Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: mutlicentre cohort study. Resuscitation. 2012;83(4):476-81. 21. Clarke DL, Brysiewicz P, Sartorius B, et al. Hypotension of ≤ 110 mmHg is associated with increased mortality in South African patients after trauma. Scand J Surg. 2017;106(3):261-268. 22. Rutherford EJ, Morris JA Jr, Reed GW, Hall KS. Base deficit stratifies mortality and determines therapy. J Trauma. 1992;33(3):417-23. 23. Dunham MP, Sartorius B, Laing GL, et al. A comparison of base deficit and vital signs in the early assessment of patients with penetrating trauma in a high burden setting. Injury. 2017; 48(9):1972-1977. 24. Hodgman EI, Morse BC, Dente CJ, et al. Base deficit as a marker of survival after traumatic injury: consistent across changing patient populations and resuscitation paradigms. J Trauma Acute Care Surg. 2012;72(4):844-51. 25. Robison PD, Harman PK, Trinkle JK, Grover FL. Management of penetrating lung injuries in civilian practice. J Thorac Cardiovasc Surg. 1988;95(2):184-90. 26. Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma. 1999;46(4):543-51. 27. Ball CG, Williams BH, Wyrzykowski AD, et al. A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma. 2009;67(5):1123-4.
17
28. Brewster SA, Thirlby RC, Snyder WH 3rd. Subxiphoid pericardial window and penetrating cardiac trauma. Arch Surg. 1988;123(8):937-41. 29. Duncan AO, Scalea TM, Sclafani SJ, et al. Evaluation of occult cardiac injuries using subxiphoid pericardial window. J Trauma. 1989;29(7):955-9. 30. Campbell NC, Thomson SR, Muckart DJ, et al. Review of 1198 cases of penetrating cardiac trauma. Br J Surg. 1997;84(12):1737-40. 31. Tyburski JG, Astra L, Wilson RF, et al. Factors affecting prognosis with penetrating wounds of the heart. J Trauma. 2000;48(4):587-90. 32. Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190(3):288-98. 33. Pereira BM, Nogueira VB, Calderan TR, et al. Penetrating cardiac trauma: 20-y experience from a university teaching hospital. J Surg Res. 2013;183(2):792-7. 34. Morse BC, Mina MJ, Carr JS, et al. Penetrating cardiac injuries: A 36-year perspective at an urban, Level I trauma center. J Trauma Acute Care Surg. 2016;81(4):623-32. 35. Velmahos GC, Degiannis E, Souter I, Saadia R. Penetrating trauma to the heart: a relatively innocent injury. Surg. 1994;115(6):694-7. 36. Degiannis E, Loogna P, Doll D, et al. Penetrating cardiac injuries: recent experience in South Africa. World J Surg. 2006;30(7):1258-64. 37. Asensio JA, Murray J, Demetriades D, et al. Penetrating cardiac injuries: a prospective study of variables predicting outcomes. J Am Coll Surg. 1998;186(1):24-34. 38. Degiannis E, Velmahos G, Krawczykowski D, et al. Penetrating injuries of the subclavian vessels. Br J Surg. 1994;81(4):524-6.
18
39. Demetriades D, Rabinowitz B, Pezikis A, et al. Subclavian vascular injuries. Br J Surg. 1987;74(11):1001-3. 40. Fulton JO, de Groot KM, Buckels NJ, von Oppell UO. Penetrating injuries involving the intrathoracic great vessels. S Afr J Surg. 1997;35(2):82-6. 41. O’Connor JV, Scalea TM. Penetrating thoracic great vessel injury: impact of admission hemodynamics and preoperative imaging. J Trauma. 2010;68(4):834-7. 42. Sobnach S, Nicol JA, Nathire H, et al. An analysis of 50 surgically managed penetrating subclavian artery injuries. Eur J Vasc Endovasc Surg. 2010;39(2):155-9. 43. Symbas PN, Hatcher CR Jr, Vlasis SE. Esophageal gunshot injuries. Ann Surg. 1980;191(6):703-7. 44. Patel MS, Malinoski DJ, Zhou L, et al. Penetrating oesophageal injury: a contemporary analysis of the National Trauma Data Bank. Injury. 2013;44(1):48-55. 45. Asensio JA, Chahwan S, Forno W., et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001;50(2):289-96. 46. Xu AA, Breeze JL, Paulus JK, Bugaev N. Epidemiology of traumatic esophageal injury: An analysis of the National Trauma Data Bank. Am Surg. 2019;1;85(4):342349. 47. Gambhir S, Grigorian A, Swentek L., et al. Esophageal trauma: Analysis of incidence, morbidity and mortality. Am Surg. 2019;1;85(10):1134-1138. 48. Symbas PN, Hatcher CR Jr, Boehm GA. Acute penetrating tracheal trauma. Ann Thorac Surg. 1976;22(5):473-7.
19
49. Kelly JP, Webb WR, Moulder PV, et al. Management of airway trauma. I: tracheobronchial injuries. Ann Thorac Surg. 1985;40(6):551-5. 50. Rossbach MM, Johnson SB, Gomez MA, et al. Management of major tracheobronchial injuries: a 28-year experience. Ann Thorac Surg. 1998;65(1):182-6. 51. Balci AE, Eren N, Eren S, Ulkϋ R. Surgical treatment of post-traumatic tracheobronchial injuries: 14-year experience. Eur J Cardiothorac Surg. 2002;22(6):984-9. 52. Lyons JD, Feliciano DV, Wyrzykowski AD, Rozycki GS. Modern management of penetrating tracheal injuries. Am Surg. 2013;79(2):188-93. 53. Feliciano DV, Bitondo CG, Mattox KL, et al. Combined tracheoesophageal injuries. Am J Surg. 1985;150(6):710-5. 54. Kelly JP, Webb WR, Moulder PV, et al. Management of airway trauma. II: combined injuries of the trachea and esophagus. Ann Thorac Surg. 1987;43(2):160-3. 55. Losken A, Rozycki GS, Feliciano DV. The use of the sternocleidomastoid muscle flap in combined injuries to the esophagus and carotid artery or trachea. J Trauma. 2000;49(5):815-7. 56. Deane M, Galvagno SM, Moran B, et al. Shock, not blood pressure or shock index, determines the need for thoracic damage control following penetrating trauma. Shock. [In press].
20
Precis Urgent thoracotomy for penetrating thoracic trauma is associated with considerable mortality. Hypotension is a classic indication for thoracotomy in these patients. However, relying on blood pressure fails to identify patients in shock. Admission physiology is superior to blood pressure in predicting the need for urgent thoracotomy in patients with penetrating thoracic wounds.
21
Table 1. Demographics and Characteristics of the 301 Patients in This Study Characteristic Age, y, mean (SD) Male, n (%) Gunshot wound, n (%) Stab wound, n (%)
Data 31 (11.5) 228 (75.6) 125 (41.5) 176 (58.5)
Injury Severity Score, median (IQR)
25 (16-29)
Chest Abbreviated Injury Scale, median (IQR)
4 (3-5)
Patients were predominantly young, male, and severely injured.
22
Table 2. Admission Physiology and Systolic Blood Pressure Variable SBP, mmHg, mean (SD) SBP <90 mmHg, % Shock Index, median (IQR) Injury Severity Score, median (IQR) pH, mean (SD) Base deficit, mEq/L, mean (SD) Lactate, mmol/L, mean (SD)
Data 115 (37) 23.9 0.88 (0.72-1.16) 25 (16-29) 7.22 (0.14) 7.6 (6.1) 7.2 (4.5)
International Normalized Ratio, median 1.2 (1.1-1.4) (IQR) Temperature, C°, mean (SD) 35.8 (1.12) Note the discordance between the systolic blood pressure and physiology on arrival. Although the blood pressure is normal the pH, base deficit, lactate and temperature are all markedly abnormal, signifying shock. SBP, systolic blood pressure
23
Table 3. Operative Approach Approach
%
Anterolateral thoracotomy
44.2
Median sternotomy
34.5
Posterolateral thoracotomy
10.6
Bilateral anterolateral thoracotomy 10.6 (clamshell) Anterolateral thoracotomy was the most common incision. Cardiac and great vessel injury was preferentially explored through a sternotomy. Aerodigestive injuries diagnosed preoperatively were approached by posterolateral thoracotomy.
24
Table 4. Injuries and Operative Procedures Variable Data Pulmonary resection, n (%) 136 (45.2) Non-anatomic, n 112 Lobectomy, n 17 Pneumonectomy, n 7 Cardiac, n (%) 100 (33.2) Great vessel, n (%) 30 (9.9) Aerodigestive, n (%) 14 (4.7) Combined major intrathoracic, n (%) 58 (19.3) Concomitant laparotomy, n (%) 91 (30.2) Thoracic damage control, n (%) 66 (21.9) Time to OR, min, median (IQR) 38 (19-105) Transfusions units, median (IQR) Packed red blood cells 5.8 (3-9.5) Fresh frozen plasma 4 (2-8) Combined thoracic injury was frequent and almost one-third of patients required a laparotomy. Thoracic damage control was performed on the most severely injured and physiologically depleted patients. OR, operating room
25
Table 5. Operative Outcomes Outcome Hospital LOS, d, median (IQR)
Data 9.2 (6 -17)
ICU LOS, d, median (IQ% 3.8 (1-9) Ventilator days, median (IQR) 2 (1-9) Bacteremia, % 5 Wound infection, % 6.3 Empyema, % 6 Vasoactive infusion, % 17.6 Acute renal failure on CRRT, % 10.3 Discharged to in-patient rehabilitation, % 24.9 Mortality, n (%) 20 (6.6) Damage control 10 (15.2) Non-damage control 10 (4.3) Infections were the most common postoperative complication followed by dialysis dependent acute renal failure. Mortality among the damage control group was significantly higher than for the other patients (p=0.002). CRRT, continuous renal replacement therapy; LOS, length of stay