Clinical paperRetrospective analysis of emergency room thoracotomy in pediatric severe trauma patients☆
Introduction
Trauma remains the most prevalent cause of death and morbidity in children over one year of age,1 resulting in significant economic, social and personal burden for their families.2 The development of trauma centers, with rapid transport systems and improved pre-hospital care for children3 has increased the number of patients routinely arriving at emergency departments, that in recent past would have succumbed to their injuries in the periphery.4 These and other advances in trauma care have increased the number of emergency department (ED) thoracotomies for open-chest cardiopulmonary resuscitation (OC-CPR) of the Advanced Trauma Life Support (ATLS) protocol in adult trauma as it has in children.
Since the first recorded attempt of OC-CPR on humans in 1880 by Paul Niehans, laboratory and clinical studies have demonstrated the superiority of OC-CPR compared to closed-chest cardiopulmonary resuscitation (CC-CPR), in regards to cardiac output, aortic blood pressure, blood flow, perfusion and survival.5
Although the integral role of ED thoracotomy for open cardiac massage has been extensively reviewed in the adult literature, this “heroic maneuver” remains very controversial and debated in children. To date there is no evidence to show that child trauma victims received OC-CPR with ED thoracotomy has more favorable survival outcome than adults. Sheikh and Culbertson,6 in their five year cohort study, found only one child (4.4%) out of 23 that underwent ED thoracotomy after blunt or penetrating trauma, survived to discharge. Beaver et al.7 have lost all of their 17 children, which arrived without any vital sign upon arrival. Rothenberg et al.8 showed a mortality rate of 98.6%, whereas only one child survived.
Actual existing experiences of this procedure as well as current survival-estimates and recommended guidelines have been gained mainly in the USA or South Africa while reports from European trauma centers are still lacking. The purpose of this study is to evaluate the effectiveness of the OC-CPR with ED thoracotomy for critically injured children at a central European urban level 1 trauma center.
Section snippets
Patients and methods
The department of Trauma surgery at the Medical University of Vienna is an urban Level I trauma center for adults and children serving a population base of approximately 2.2 million. ED thoracotomy was defined as a procedure performed emergently and in the trauma resuscitation room soon after arrival. Elective thoracotomies and thoracotomies performed in the operating theatre were excluded in this analysis. Records covering events prior to hospital admission, treatment at the ED and autopsy
Patient demographic
Over a sixteen-year period, from January 1992 to December 2008, 886 severely (ISS ≥ 16) injured pediatric trauma patients were admitted to the ED. A total of ninety-eight patients following blunt trauma and fourteen patients following penetrating trauma sustained cardiac arrest at the ED.
During this period, 117 ED thoracotomies were performed at our emergency room, most in the setting of blunt force trauma. Of this group, eleven children received ED thoracotomies, with a mean age of 7.8 years
Discussion
Due to the distinct improvement in pre-hospital care and the rapid transport of trauma victims in recent years, severely injured children that once would have succumbed to their injuries in the field are now brought to the trauma center, often while being resuscitated, presenting every physician with a major challenge. Nevertheless the established resuscitation guidelines and specific protocols for management of pediatric trauma, selective criteria for ED thoracotomy in children are not clearly
Conclusion
Similar to previous studies, our data confirm the rapid and uniformly fatal outcomes of open-chest cardiopulmonary resuscitation following cardiac arrest in children, especially after blunt trauma. The decision to perform ED thoracotomy involves careful evaluation of the ethical, social and economic issues to avoid unnecessary thoracotomies in children that are destined not to survive. Based on our experience and from critical review of other experiences with pediatric patients, we have drawn
Conflict of interest statement
No conflict of interest declared.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.09.475.