https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1053/jhep.2000.16597

Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy.

Practice management guidelines for emergency department thoracotomy. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma.

Background: Emergency department thoracotomy (EDT) has become standard therapy for patients who acutely arrest after injury. Patient selection is vitally important to achieve optimal outcomes without wasting valuable resources. The aim of this study was to determine the main factors that most influence survival after EDT. Study Design: Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates. Results: EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries. When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries. If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%. There was no clear single independent preoperative factor that could uniformly predict death. Conclusions: The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department. All three factors—MOI, LOMI, and SOL—should be taken into account when deciding whether to perform EDT. Uniform reporting guidelines are needed to further elucidate the role of EDT taking into account the combination of MOI, LOMI, and SOL.

https://www.journalacs.org/article/S1072-7515(99)00233-1/pdf

Survival after emergency department thoracotomy: review of published data from the past 25 years.

https://www.annemergmed.com/article/S0196-0644(05)82784-2/pdf

Emergency department echocardiography improves outcome in penetrating cardiac injury

BACKGROUNDWithin the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present

/pdf/an-evidence-based-approach-to-patient-selection-for-4uqphtq8fp.pdf

An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma

Blunt and penetrating injuries of the extrahepatic biliary system are rare and appear to be increasing in frequency. The severe morbidity associated with these lesions is related to incomplete efforts at diagnosis and errors in therapeutic decisions. The morbidity may be minimized by: 1) a high index of suspicion and awareness of these lesions; 2) complete exploration of all hematomas around the bile ducts to reduce the incidence of overlooked injuries; 3) meticulous repair of tangential injuries; and 4) primary biliary-enteric diversion for complete transection of the ducts. A knowledge of the various options in operative management is crucial since unexpected injuries are not uncommon.

The morbidity of injuries of the extra-hepatic biliary system.

The results of emergency room thoracotomy (ERT) and cardiorrhaphy for 91 patients with penetrating cardiac injuries admitted in extremis to Lincoln Medical and Mental Health Center from 1963 to 1981 are reviewed to determine criteria for selection of patients for this procedure. Four groups were defined based on the severity of the effects of their injuries. The survival rates were 32.1 and 33.3%, respectively, for Group I ('fatal') and Group II ('agonal') patients. There were no survivors in Group IV ('D.O.A.') patients for whom ERT is a fruitless procedure. Survival in Group III ('profound shock') patients was only 40%, which might have been improved if ERT had been performed without delay. We conclude that ERT is essential for patients with 'fatal' and 'agonal' wounds and advise prompt ERT for patients in 'profound shock' who do not respond immediately to rapid volume infusion.

Emergency room thoracotomy for penetrating cardiac injuries.

A method of quantifying the anatomic extent of injury to the heart, Penetrating Cardiac Trauma Index, (PCTI) and other thoracic organs has been proposed. The total extent of thoracic injury, Penetrating Thoracic Trauma Index (PTTI), was measured. When associated abdominal injury was present, it was assessed by the Penetrating Abdominal Trauma Index (PATI) of Moore et al. The severity of total injury sustained by the patient, represented by the Penetrating Trauma Index (PTI), was determined by the sum total of these scores. The extent of physiologic abnormality induced by cardiac penetration, (Physiologic Index or PI), was graded on a scale of increasing severity from 5-20 based on the vital signs of patients on admission. Analysis of 112 patients with penetrating cardiac injuries (1973-1983) revealed that the indices, PCTI and PI, showed an excellent correlation with survival (R2 = 0.827 and 0.928, respectively) as did the total extent of trauma (PTI). A composite prognostic score of the sum of PI and PTI demonstrated a significant separation of survivors from nonsurvivors (p less than 0.001). It is concluded that these anatomic (PCTI and PTI) and physiologic (PI) indices are valid and, with additional confirmation, may provide an objective method of evaluating penetrating cardiac injuries.

Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury

In 18 months, 44 patients underwent thoracotomy in an emergency department (ED) for penetrating thoracic injuries. Of 14 patients resuscitated, seven (50%) survived, and all were neurologically intact. Patients were classified according to the quality of signs of life in transit or upon arrival at the ED. Identical survival rates of 29% were noted for patients in Group I (profound shock) and in Group II (agonal), with survival at 14% for individuals in Group III ("dead" on arrival). There were no survivors among patients in Group IV ("dead" on the scene), and ED thoracotomy, in the authors' opinion, is fruitless in this group. In Groups I, II, and III, total salvage from cardiac injuries was six of 24 patients (25%), and for those with non-cardiac injuries, it was one of 11 (9%). The rate of survival from cardiac stab wounds in Groups I, II, and III, was five of 16 (31%) and one of eight (13%) for gunshot wounds. Five of the seven survivors (71%) arrived at the ED by rapid transport without the benefit of any pre-hospital life support. Patient classification appears to be a valuable tool in evaluating the benefit of ED thoracotomy. The neurological status of all survivors and pertinent transportation data should be included in all future studies of ED thoracotomy. "Scoop and run" in the urban setting with rapid transport capability may be superior to pre-hospital stabilization of victims of penetrating thoracic trauma.

Emergency department thoracotomy for penetrating injuries: predictive value of patient classification.

The authors report their experience with 14 patients with portal vein injuries (1976-1986) treated at a level I trauma center. Seven patients (50%) survived and included six of 10 patients (60%) who had venorrhaphy and one in whom the portal vein was ligated. Associated injuries were present in all the patients (mean Abdominal Trauma Index: 39.5) and accounted for the high mortality rate. Follow-up data after repair or ligation of the portal vein seldom are reported in the literature. The authors studied all three patients who survived portal venorrhaphy since 1982 by real-time ultrasonography. Patency of the repair could be established in two patients. In the third patient postvenorrhaphy thrombosis was diagnosed by ultrasonographic examination. Sequential ultrasonographic examinations demonstrated resolution of the thrombus on anticoagulant therapy. Ultrasonography provides a noninvasive and easily reproducible method of studying the portal vein after repair.

Michael Rohman

Papers

The morbidity of injuries of the extra-hepatic biliary system.

Emergency room thoracotomy for penetrating cardiac injuries.

Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury

Emergency department thoracotomy for penetrating injuries: predictive value of patient classification.

Portal vein injuries. Noninvasive follow-up of venorrhaphy.