EBQ:FAST ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy

incomplete Journal Club Article

Inaba K1, Chouliaras K, Zakaluzny S, Swadron S, Mailhot T, Seif D, Teixeira P, Sivrikoz E, Ives C, Barmparas G, Koronakis N, Demetriades D.. "FAST ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy". Ann Surg. 2015. :512-518.
PubMed Full text

Clinical Question

Can Focused Assessment using Sonography for Trauma (FAST) be used to discriminate between survivors and nonsurvivors undergoing resuscitative thoracotomy (RT)?

Conclusion

FAST is an effective method of separating who will have improved survival.

Major Points

• RT can yield survivors with 4620 cases had a 7.4% survival and 92.4% had normal neurological function
• Lack of high quality data published to determine which patients would benefit from RT.
• Point of care ultrasound is used in atraumatic cardiac arrest and the lack of cardiac motion is strongly related to a nonsurvivable outcome.
• FAST exam in penetrating cardiac trauma has near perfect sensitivity and a very high specificity for hemopericardium

Study Design

• Prospective Observational Trial
• RT decided by attending trauma surgeon, or if absent the attending emergency medicine physician or the most senior member of the trauma team
  • Indications for RT
    • Penetrating trauma patients AND absent vital signs
    • Blunt trauma patients with loss of vital signs en route or in the resuscitation bay
• FAST preformed by PGY2-4 emergency medicine residents prior to or during the thoracotomy
  • parasternal and/or subxiphoid views
    • looked for pericardial effusion, cardiac activity and cardiac standstill
    • cardiac motion- organized nonfibrillating contractions of the heart

Population

• All patients presenting to ED at LAC+USC between Oct 2010-May 2014 who had RT

Patient Demographics

• All patients presenting to ED at Los Angeles County + University of Southern California between Oct 2010-May 2014 who had RT
• 187 patients had FAST exam performed forming our study cohort
• Median age is 31 years
• Males 84.5%
• Mechanism of trauma
  • 51.3% of the patients sustained penetrating trauma
  • 22.5 % pedestrian struck by auto
  • 17.1% motor vehicle collision
  • 9.1% stab wound
  • median ISS of 34
• Traumatic Injuries
  • 46.5% associated head injury
  • 12.8% pelvic fracture
  • 29.9% extremity injury
  • 32.6% vascular injury
  • 38% abdominal injury

21 patients had cardiac injury and were taken to the OR with 7 being unstable and arresting on entry to the OR (all survived to discharge)

• penetrating trauma
• pericardial effusion on FAST
• OR for planned sternotomy

Vital signs 48.1% lost at the scene 23.5% en route 28.3% in the ED

Field endotracheal intubation in 48.7% 22.5% bilateral or clamshell thoracotomy with remainder receiving a standard left anterolateral thoracotomy 48.1% regained sustained cardiac motion 3.2% survived 1.6% organ donors

• 28.9% cardiac motion, however all of the survivors had cardiac motion.
• 72.1% no cardiac motion, and none of these patients survived
• 8.6% pericardial fluid and none of these patients survived

• Cardiac motion in predicting survivors or organ donors has a sensitivity of 100% and specificity of 73.7%

Inclusion Criteria

• RT preformed in the emergency department immediately upon arrival

Exclusion Criteria

• Patients who didn't have an adequate FAST exam
• emergent or urgent thoracotomy in the Operating Room

Interventions

• FAST ultrasound with subxiphoid view or/and parasternal view
• Resuscitative Thoracotomy in the ED

Outcomes

Primary Outcome

• survival to discharge
• survival to organ donation

• 28.9% cardiac motion, however all of the survivors had cardiac motion.
• 72.1% no cardiac motion, and none of these patients survived
• 8.6% pericardial fluid and none of these patients survived

• Cardiac motion in predicting survivors or organ donors has a sensitivity of 100% and specificity of 73.7%

Secondary Outcomes

• Return of spontaneous circulation after RT
  • spontaneously beating heart
    • No external cardiac manipulation
    • No infusion or intermittent dosing of inotropic medications
• Length of Stay (LOS)
• ICU LOS

Adverse Events

*Death of patient however RT is a high risk and high resource intensive procedure that is known to produce a low yield in improving patients outcomes. 

Criticisms & Further Discussion

*No common guidelines exist for role of RT

• stab wound to chest went immediately to OR and all survived
• FAST exam to study who will survive if there is cardiac activity and/or pericardial effusion these would be the patients who would benefit from RT

• location of traumatic injury can influence survival, mechanism of injury
• lack of contractile cardiac activity has been shown to predict death with a NPV of nearly 100%
• RT is a rare procedure and might decrease the trauma teams ability to perform this procedure if it is made even less common
• FAST with RT can help the team identify which patients could benefit from an RT versus those patients that RT would use up essential resources, blood, time away from other patients as well as exposing providers to harm.