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FAST Ultrasound Examination As a Predictor of Outcomes After Resuscitative Thoracotomy a Prospective Evaluation

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FAST Ultrasound Examination As a Predictor of Outcomes After Resuscitative Thoracotomy a Prospective Evaluation PAPERS OF THE 135TH ASA ANNUAL MEETING FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy A Prospective Evaluation Kenji Inaba, MD,∗ Konstantinos Chouliaras, MD,∗ Scott Zakaluzny, MD,∗ Stuart Swadron, MD,† Thomas Mailhot, MD,† Dina Seif, MD,† Pedro Teixeira, MD,∗ Emre Sivrikoz, MD,∗ Crystal Ives, MD,∗ Galinos Barmparas, MD,∗ Nikolaos Koronakis, MD,∗ and Demetrios Demetriades, MD∗ providers.2–4 Despite the controversy, RT does yield survivors.5–15 Objective: The objective of this study was to examine the ability of Focused In one of the largest series to date, Rhee reviewed 4620 cases over Assessment Using Sonography for Trauma (FAST) to discriminate between a 25-year period, documenting a survival rate of 7.4% with normal survivors and nonsurvivors undergoing resuscitative thoracotomy (RT). neurologic function in 92.4% of survivors.16 Long-term survival with Background: RT is a high-risk, low-salvage procedure performed in arresting normal cognition and return to normal activity without evidence of trauma patients with poorly defined indications. post-traumatic stress disorder has also been demonstrated.17 In ad- Methods: Patients undergoing RT from 10/2010 to 05/2014 were prospec- dition to survival, organ donation is an important, tangible outcome tively enrolled. A FAST examination including parasternal/subxiphoid cardiac after this procedure,13 with a direct benefit to society. views was performed before or concurrent with RT. The result was captured The ability of both clinical criteria18–22 and laboratory as adequate or inadequate with presence or absence of pericardial fluid and/or findings23 to discriminate between survivors and nonsurvivors has cardiac motion. A sensitivity analysis utilizing the primary outcome measure been examined. As summarized in a recent Western Trauma Asso- of survival to discharge or organ donation was performed. ciation critical decisions review,24 there is a paucity of high quality Results: Overall, 187 patients arrived in traumatic arrest and underwent FAST. data upon which recommendations can be based. As a direct result, Median age 31 (1–84), 84.5% male, 51.3% penetrating. Loss of vital signs despite comprehensive consensus statements by groups such as the occurred at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. NAEMSP-ACSCOT on withholding and terminating resuscitation Emergent left thoracotomy was performed in 77.5% and clamshell thoraco- after traumatic arrest25,26 and guidelines on the initiation of RT by tomy in 22.5%. Sustained cardiac activity was regained in 48.1%.However, the American College of Surgeons,27 universally accepted criteria for overall survival was only 3.2%. An additional 1.6% progressed to organ do- who should and should not undergo this emergent procedure do not nation. FAST was inadequate in 3.7%, 28.9% demonstrated cardiac motion exist at this time. and 8.6% pericardial fluid. Cardiac motion on FAST was 100% sensitive and The Focused Assessment Using Sonography for Trauma 73.7% specific for the identification of survivors and organ donors. (FAST) examination, performed at the bedside by a nonradiologist Conclusions: With a high degree of sensitivity for the detection of potential clinician, has become a standard of care diagnostic procedure in the survivors after traumatic arrest, FAST represents an effective method of sepa- management of injured patients. In penetrating cardiac trauma, for rating those that do not warrant the risk and resource burden of RT from those example, it has been demonstrated to have near perfect sensitivity who may survive. The likelihood of survival if pericardial fluid and cardiac and a very high specificity28 for hemopericardium and is the im- motion were both absent was zero. mediate test of choice for patients at risk for cardiac injury in the Keywords: arrest, injury, resuscitation, trauma, ultrasound resuscitation area. It is often the sole test that is utilized to decide on the operative versus nonoperative management of patients with (Ann Surg 2015;262:512–518) potential cardiac injury. It can be rapidly performed within seconds of arrival and repeated frequently, with little patient preparation or movement required and no radiation burden. Importantly, it can be or patients presenting in traumatic cardiac arrest, a resuscitative performed concurrently with any life saving interventions. Outside of thoracotomy (RT)1 performed in the Emergency Department is F the trauma population, but highly relevant to the current study, point often utilized as a final salvage maneuver. The quantitative yield on of care ultrasound has also been demonstrated to be highly effective this procedure, however, is exceedingly low. Although proponents for visualizing cardiac motion, the absence of which is strongly cor- would argue that there is little to lose as not intervening would invari- related with nonsurvivability in the nontraumatic arrest patient.29,30 ably end in death, there is a collateral impact on society because of The purpose of this study was to examine the ability of the resource utilization and the potential risk of harm to the trauma care bedside FAST examination to discriminate between survivors and nonsurvivors after RT. As organ donation is an important clinical outcome after traumatic arrest, the ability of FAST to identify organ From the ∗Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA; and †Department donors was also assessed. Our hypothesis was that for patients pre- of Emergency Medicine, University of Southern California, Los Angeles, CA. senting in traumatic cardiac arrest, FAST would be able to separate Presented at the 135th Annual Meeting of the American Surgical Association, April survivors and organ donors from those in whom a RT is futile. 23–25, 2015, San Diego, CA. Disclosure: The authors declare no conflict of interest. Reprints: Kenji Inaba, MD, FRCS, FACS, Division of Trauma and Criti- METHODS cal Care, University of Southern California, LAC+USC Medical Cen- After institutional review board approval, all patients undergo- ter, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA 90033. E-mail: ing an RT in the Emergency Department, at the Los Angeles County + [email protected]. University of Southern California (LAC+USC) Medical Center, be- Copyright C 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/15/26203-0512 tween October 2010 and May 2014 were enrolled in a prospective DOI: 10.1097/SLA.0000000000001421 observational trial. The RT was initiated on patients in cardiac arrest r 512 | www.annalsofsurgery.com Annals of Surgery Volume 262, Number 3, September 2015 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. r Annals of Surgery Volume 262, Number 3, September 2015 Ultrasound in Resuscitative Thoracotomy at the discretion of the attending trauma surgeon or in their absence the arrest is a clinically important positive outcome, survival to organ attending emergency medicine physician or the most senior member donation was also analyzed along with overall survival. A sensitivity of the trauma team present. In general, all penetrating trauma patients analysis was performed using the primary outcome (alive or organ with absent vital signs and blunt trauma patients with a loss of vital donor versus dead) as the gold standard in the assessment of the find- signs en route or in the resuscitation bay underwent RT. ings of the FAST results (positive cardiac motion or pericardial fluid Only thoracotomies performed in the Emergency Department, versus no motion and no fluid). Secondary outcomes included Length immediately upon arrival, were analyzed in this study. Patients under- of Stay (LOS) and ICU LOS. going an emergent or urgent thoracotomy in the Operating Room were excluded. Injury and patient demographics, operative details, injury RESULTS burden and clinical outcomes were prospectively documented. The There were 223 cases that underwent an RT between October primary outcome was survival to discharge or organ donation. Other 2010 and May 2014 at the LAC+USC Medical Center after sustaining outcomes of interest included the return of organized cardiac activity a traumatic arrest (Fig. 1). Of the entire study population 187 (83.9%) with spontaneous circulation after RT which was defined as a sponta- had a FAST performed forming our study cohort. In the patient cohort neously beating heart without the need for external cardiac manipu- that was excluded, there were no survivors or organ donors. The lation or the infusion or intermittent dosing of inotropic medications. median age was 31 years (range1–84) with males comprising 84.5% The FAST was performed justbefore, or concurrent with the of the cases (Table 1). 51.3% of the patients sustained penetrating thoracotomy. FAST examinations during the study period were per- trauma, with the most common mechanism being a gunshot wound formed by PGY 2–4 emergency medicine residents under direct fac- (42.2%) followed by pedestrian struck by auto (22.5%), motor vehicle ulty supervision. As part of their standard residency training and collision (17.1%) and stab wound (9.1%). This was a severely injured before participation in the study, all residents completed a 2 day, 16 cohort of patients with a median ISS of 34 (IQR 19). The total injury hour ultrasound course consisting of didactics and hands on training, burden was extensive (Table 2) with 46.5% having an associated
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