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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
difcult 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 eld/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.
178
Table 1
Systematic review of the published case series regarding pediatric EDT along with data
from Ryder Trauma Center.
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
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) [613]. 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 specic 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 identied. 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 eld, 46% had initial VS
and 67% had SOL. Upon arrival, 25% had VS and 56% had SOL. Those
who lost VS in the eld 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
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 eld
SOL in eld
Time without vitals in eld (minutes)
VS ED
SOL ED
ROSC
Survival
Experience of Ryder Trauma Center 19912012.
90%
16
12%
88%
8%
2%
74%
15%
2%
41
46%
67%
15 16
25%
56%
38%
3.3%
179
Fig. 1. Outcomes according to MOI, presence of VS/SOL. Experience of Ryder Trauma Center 19912012.
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 sufcient
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%
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
180
Fig. 2. Systematic review. Outcomes of ROSC, survival between blunt and penetrating.
Despite these limitations, this is one of the largest series report and
the rst systematic review regarding pediatric EDT. The lack of extensive
experience with this resuscitative measure in children and adolescents
still prohibits the establishment of guidelines specic 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 benet 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
weve had a poor survival rate but weve had a number of
patients who actually were able to harvest organs and help
contribute to other patients.
Response: DR. CASEY ALLEN Thats actually a very interesting question
because were looking into that right now in adults as well as
children. However, I dont have that information available at
this time.
Steven Stylianos (New York, NY) Thats 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 ndings
into your trauma algorithms?
Response: DR. CASEY ALLEN I think its 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.
181
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