Predictors of survival in trauma patients requiring resuscitative thoracotomy: A scoping review

Introduction

Traumatic injuries are one of the leading contributors to disease burden worldwide. ¹ As trauma systems advance and management in prehospital and in-hospital settings evolve, an increasing number of studies are evaluating factors implicated in survival, with a goal of further optimizing trauma care. Although blunt and penetrating thoracic injuries make up approximately 25–50% of traumas, only 10–15% require resuscitative thoracotomy (RT) as part of the initial resuscitation.^2,3 Previous studies have identified overall poor outcomes following RT, particularly in the context of blunt injuries when compared to penetrating trauma.^4–8 Additionally, several factors have been linked to lower likelihoods of survival, including the performance of RT more than 30 min after hospital arrival, RT in the context of traumatic cardiac arrest (TCA), the patient's clinical status on emergency department (ED) arrival, RT procedure duration, heart rate (HR) at the end of the procedure, absence of signs of life (SOL) on-scene or in the ED, and cardiopulmonary resuscitation (CPR) duration.^9–13 However, to date, data have primarily focused on in-hospital and injury-specific variables and literature that synthesizes what we know about outcome predictors in the trauma population following RT is lacking. Additionally, there is a scarcity of studies that provide a breakdown of data based on different care settings (i.e., prehospital and in-hospital). Therefore, this review aims to highlight key outcome predictors following RT in both care settings that have been identified in existing literature, while concurrently evaluating the breadth of data that exists in this area.

Methods

A literature review was conducted using the EMBASE database, with further review of included papers’ reference lists to extract additional studies that meet inclusion criteria. The following search terms were applied: [exp. Thoracotomy] AND [Trauma.mp] AND [exp. Survival OR exp. Mortality]. The search was limited to full-text articles in the English language and publications released up to February 27, 2022. We included all primary research studies that qualitatively or quantitatively evaluated the predictive value of one or more prehospital, in-hospital, patient or injury-specific characteristics in survival, mortality or return of spontaneous circulation (ROSC) of trauma patients post-RT. The following exclusion criteria were applied: (1) Inability to access the full-text article and (2) systematic reviews, meta-analyses, case reports, animal-based studies, conference proceedings, and letters to editors.

All titles and abstracts were reviewed by two authors (N.R. and R.W.) and included based on the above criteria. Full-text review was subsequently undertaken individually by N.R. and R.W. to extract the following data: publication year, publication country, publication type, whether TCA was an inclusion or exclusion criteria, prehospital variables (prehospital systolic blood pressure [SBP], diastolic blood pressure [DBP], HR, SOL [defined as organized electrical activity, pupillary response, spontaneous respiratory attempts or movement], HR, SBP, or respiratory rate [RR]^12,14), in-hospital variables, patient characteristics and injury characteristics. For all identified characteristics, we extracted the following associated statistical values: sensitivity, specificity, odds ratio, relative risk, and area under the receiver operating curve (AUROC) with 95% confidence interval (CI) or p values.

Results

Study selection and demographic characteristics

After applying the search strategy and limitations, we retrieved a total of 204 articles (Figure 1). A total of 37 studies were included in this scoping review. A detailed list of study demographics is shown in Table 1.

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Figure 1.

PRISMA flow diagram of study screening and selection. ¹⁵

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Table 1.

Study characteristics.

Country of Publication, n (%)		Study population, n (%)
United States	30 (81)	Age ≥15 years	2 (5)
United Kingdom	2 (5)	Age ≥16 years	1 (3)
Australia	1 (3)	Age ≥17 years	0 (0)
Israel	1 (3)	Age ≥18 years	4 (11)
Iran	1 (3)	Adult population NOS	6 (16)
Norway	1 (3)	Pediatric population NOS	7 (19)
Singapore	1 (3)	All ages	17 (46)
Study type, n (%)		Type of predictors, n (%)
Retrospective cohort	29 (78)	Patient-specific	5 (7)
Prospective cohort	6 (16)	Injury-specific	21 (28)
Retrospective and prospective cohort	2 (5)	Prehospital	17 (22)
		In-hospital	33 (43)
Year of Publication, n (%)		Proportion of studies evaluating the following number and type of predictors, n (%)
1980–1989	6 (16)	Single individual variable	2 (5)
1990–1999	8 (22)	Multiple individual variables	33 (89)
2000–2009	6 (16)	Single score variable	5 (14)
2010–2019	12 (32)	Multiple score variables	4 (11)
2020–20222	5 (14)

Discussion

Our study highlights the disparity of data available when contrasting demographic variables with prehospital and in-hospital outcome predictors, which is even more pronounced in the prehospital setting. Existing data predominantly focus on injury and patient variables, and most studies do not explicitly look at the TCA population.

The use of thoracotomies for resuscitation of trauma patients with penetrating or blunt traumatic injuries continues to be controversial, owing to a high amount of material and personnel resource utilization, low overall survival rates, and potential exposure of staff to bloodborne pathogens.^20,21 Despite this, RT can be lifesaving with excellent long-term outcomes, particularly for patients with penetrating mechanisms of injury presenting to the ED with SOL or vital signs. As such, the Western Trauma Association and the Eastern Association for the Surgery of Trauma advocate for the performance of RT when specific—and slightly varying—indications are met. ²² Based on our scoping review of existing literature, we can conclude three major findings in the context of RT: (1) RTs performed in the setting of blunt trauma have a worse prognosis compared to patients undergoing RT for penetrating injuries, (2) procedures that have the potential to delay patient transport to hospital, such as intubation, may significantly increase the risk of mortality (Prehospital intubation, survival to hospital discharge: OR < 0.001, 95% CI: <0.01–0.05 ¹⁶ ; number of prehospital procedures, survival to hospital discharge: OR 0.38, 95% CI: 0.18–0.79 ¹⁶ ), and (3) the presence of SOL or hemodynamic stability in the prehospital or in-hospital setting are positive survival predictors in the setting of RT (In-hospital SOL, survival to hospital discharge: OR 13.32, 95% CI: 9.27–19.15) ¹⁴ ; prehospital HR < 60 bpm, mortality: OR 3.43, 95% CI: 1.73–6.79 ²³ ; in-hospital pediatric hypotension (based on SBP), mortality: OR 2.10, 95% CI: 1.10–4.00. ¹⁸

The most recently published systematic review on survival predictors following RT that was identified through our literature search was limited to independent patient- and injury-specific factors and did not look at multiple factors in the context of various clinical settings (i.e., whether vital signs or SOL were lost in the field vs. in-hospital, field interventions). ²² Additionally, a major portion of studies that met inclusion criteria in the present review provided only qualitative analyses of factors contributing to the survival or mortality of trauma patients following RT. In combination, the capacity of these studies to inform future clinical guidelines on the use of RT in different settings, including prehospital management for emergency medical services (EMS) personnel, and more precisely defining RT indications for trauma teams, is limited. This scoping review summarizes existing data in the form of quantitative predictive abilities of variables, while concurrently delineating findings based on prehospital, in-hospital, patient-specific, and injury-specific outcome measures.

Conclusion

In summary, our study has highlighted the limits of current data regarding outcome predictors in the trauma patient requiring RT. We identify many patient-specific, mechanism of injury, and management variables that may impact survival from RT. Further studies defining outcomes or predictors of survival from RT could better inform clinical decision tools and develop prehospital management guidelines to improve overall survival.

Declaration

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