Does temporary chest wall closure with or without chest packing improve survival for trauma patients in shock after emergent thoracotomy?

Jennifer L. Lang, Richard P. Gonzalez, Kim N. Aldy, Elizabeth A. Carroll, Alexander L. Eastman, Cassandra Q. White, Geoffrey A. Funk, Herb A. Phelan

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

Background: Many surgeons avoid the damage-control techniques of intrathoracic packing and temporary chest wall closure after thoracotomy for trauma because of concerns about packing's effects on intrathoracic pressure and infectious risks. We hypothesized that temporary chest closure with or without intrathoracic packing (TCC-P) as a method of thoracic damage control would yield higher than expected survival rates for trauma thoracotomy patients with metabolic exhaustion, whereas traditional definitive chest closure (DEF) would exhibit predicted survival rates. Methods: This was a retrospective cohort study by two urban Level I trauma centers on patients who (1) underwent emergent thoracotomy for trauma, (2) received ≥10 units (U) packed red blood cells and/or sustained a cardiac arrest before starting chest closure, and (3) survived to intensive care unit arrival. Demographic/physiologic data, chest closure method, and thoracic complications were gathered. Trauma injury severity scores (TRISS) were used to calculate survival probability for TCC-P and DEF. Nonparametric statistics were used for all comparisons. All values are expressed as medians and interquartile ranges (IQR). Results: Sixty-one patients met inclusion criteria. Both TCC-P (n = 17) and DEF (n = 44) were severely injured (ISS = 35 [IQR, 25-42] vs. 29 [IQR 19-45] and packed red blood cells = 16.5 U [IQR, 12.3-25.5 U] vs. 15 U [IQR, 11-23 U], respectively; p = ns). Patient demographics were similar except for the findings that the TCC-P cohort had higher rates of cardiac arrest before starting chest closure (TCC-P 82% vs. DEF 48%, p = 0.04), significantly more severe abdominal injuries, and less severe head injuries than the DEF group. No significant differences were observed in survival of the overall samples (TCC-P = 47% vs. DEF = 57%), nor for observed:expected (O:E) survival ratio in 13 patients with TCC-P and 30 with DEF meeting criteria for TRISS calculation (TCC-P O:E, 46%:39%; DEF O:E, 53%:57%). No significant differences were found for TCC-P and DEF thoracic infectious (24% vs. 25%) or hemorrhagic (18% vs. 14%) complications. Surprisingly, peak inspiratory pressures on intensive care unit arrival were markedly better after TCC-P (20 cm H2O [IQR, 18-31 cm H2O]) than after DEF (32.5 cm H2O [IQR, 28-37.5 cm H2O], p = 0.003). Conclusion: Concerns about TCC-P are not borne out as thoracic infection rates are unaffected and peak pressures are actually lower, possibly due to greater pleural volume from an open chest wall and skin-only closure. However, no significant survival benefit was seen with TCC-P.

Original languageEnglish (US)
Pages (from-to)705-709
Number of pages5
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume70
Issue number3
DOIs
StatePublished - Mar 1 2011
Externally publishedYes

Fingerprint

Thoracic Wall
Thoracotomy
Shock
Thorax
Survival
Wounds and Injuries
Injury Severity Score
Heart Arrest
Pressure
Intensive Care Units
Survival Rate
Erythrocytes
Demography
butyl phosphorotrithioate
Abdominal Injuries
Trauma Centers
Nonparametric Statistics
Craniocerebral Trauma
Cohort Studies
Retrospective Studies

Keywords

  • Chest closure
  • Damage control
  • Thoracic trauma

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Does temporary chest wall closure with or without chest packing improve survival for trauma patients in shock after emergent thoracotomy? / Lang, Jennifer L.; Gonzalez, Richard P.; Aldy, Kim N.; Carroll, Elizabeth A.; Eastman, Alexander L.; White, Cassandra Q.; Funk, Geoffrey A.; Phelan, Herb A.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 70, No. 3, 01.03.2011, p. 705-709.

Research output: Contribution to journalArticle

Lang, Jennifer L. ; Gonzalez, Richard P. ; Aldy, Kim N. ; Carroll, Elizabeth A. ; Eastman, Alexander L. ; White, Cassandra Q. ; Funk, Geoffrey A. ; Phelan, Herb A. / Does temporary chest wall closure with or without chest packing improve survival for trauma patients in shock after emergent thoracotomy?. In: Journal of Trauma - Injury, Infection and Critical Care. 2011 ; Vol. 70, No. 3. pp. 705-709.
@article{7027048d52ca4be6a12ba72fc3a15a49,
title = "Does temporary chest wall closure with or without chest packing improve survival for trauma patients in shock after emergent thoracotomy?",
abstract = "Background: Many surgeons avoid the damage-control techniques of intrathoracic packing and temporary chest wall closure after thoracotomy for trauma because of concerns about packing's effects on intrathoracic pressure and infectious risks. We hypothesized that temporary chest closure with or without intrathoracic packing (TCC-P) as a method of thoracic damage control would yield higher than expected survival rates for trauma thoracotomy patients with metabolic exhaustion, whereas traditional definitive chest closure (DEF) would exhibit predicted survival rates. Methods: This was a retrospective cohort study by two urban Level I trauma centers on patients who (1) underwent emergent thoracotomy for trauma, (2) received ≥10 units (U) packed red blood cells and/or sustained a cardiac arrest before starting chest closure, and (3) survived to intensive care unit arrival. Demographic/physiologic data, chest closure method, and thoracic complications were gathered. Trauma injury severity scores (TRISS) were used to calculate survival probability for TCC-P and DEF. Nonparametric statistics were used for all comparisons. All values are expressed as medians and interquartile ranges (IQR). Results: Sixty-one patients met inclusion criteria. Both TCC-P (n = 17) and DEF (n = 44) were severely injured (ISS = 35 [IQR, 25-42] vs. 29 [IQR 19-45] and packed red blood cells = 16.5 U [IQR, 12.3-25.5 U] vs. 15 U [IQR, 11-23 U], respectively; p = ns). Patient demographics were similar except for the findings that the TCC-P cohort had higher rates of cardiac arrest before starting chest closure (TCC-P 82{\%} vs. DEF 48{\%}, p = 0.04), significantly more severe abdominal injuries, and less severe head injuries than the DEF group. No significant differences were observed in survival of the overall samples (TCC-P = 47{\%} vs. DEF = 57{\%}), nor for observed:expected (O:E) survival ratio in 13 patients with TCC-P and 30 with DEF meeting criteria for TRISS calculation (TCC-P O:E, 46{\%}:39{\%}; DEF O:E, 53{\%}:57{\%}). No significant differences were found for TCC-P and DEF thoracic infectious (24{\%} vs. 25{\%}) or hemorrhagic (18{\%} vs. 14{\%}) complications. Surprisingly, peak inspiratory pressures on intensive care unit arrival were markedly better after TCC-P (20 cm H2O [IQR, 18-31 cm H2O]) than after DEF (32.5 cm H2O [IQR, 28-37.5 cm H2O], p = 0.003). Conclusion: Concerns about TCC-P are not borne out as thoracic infection rates are unaffected and peak pressures are actually lower, possibly due to greater pleural volume from an open chest wall and skin-only closure. However, no significant survival benefit was seen with TCC-P.",
keywords = "Chest closure, Damage control, Thoracic trauma",
author = "Lang, {Jennifer L.} and Gonzalez, {Richard P.} and Aldy, {Kim N.} and Carroll, {Elizabeth A.} and Eastman, {Alexander L.} and White, {Cassandra Q.} and Funk, {Geoffrey A.} and Phelan, {Herb A.}",
year = "2011",
month = "3",
day = "1",
doi = "10.1097/TA.0b013e31820e89f1",
language = "English (US)",
volume = "70",
pages = "705--709",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",
number = "3",

}

TY - JOUR

T1 - Does temporary chest wall closure with or without chest packing improve survival for trauma patients in shock after emergent thoracotomy?

AU - Lang, Jennifer L.

AU - Gonzalez, Richard P.

AU - Aldy, Kim N.

AU - Carroll, Elizabeth A.

AU - Eastman, Alexander L.

AU - White, Cassandra Q.

AU - Funk, Geoffrey A.

AU - Phelan, Herb A.

PY - 2011/3/1

Y1 - 2011/3/1

N2 - Background: Many surgeons avoid the damage-control techniques of intrathoracic packing and temporary chest wall closure after thoracotomy for trauma because of concerns about packing's effects on intrathoracic pressure and infectious risks. We hypothesized that temporary chest closure with or without intrathoracic packing (TCC-P) as a method of thoracic damage control would yield higher than expected survival rates for trauma thoracotomy patients with metabolic exhaustion, whereas traditional definitive chest closure (DEF) would exhibit predicted survival rates. Methods: This was a retrospective cohort study by two urban Level I trauma centers on patients who (1) underwent emergent thoracotomy for trauma, (2) received ≥10 units (U) packed red blood cells and/or sustained a cardiac arrest before starting chest closure, and (3) survived to intensive care unit arrival. Demographic/physiologic data, chest closure method, and thoracic complications were gathered. Trauma injury severity scores (TRISS) were used to calculate survival probability for TCC-P and DEF. Nonparametric statistics were used for all comparisons. All values are expressed as medians and interquartile ranges (IQR). Results: Sixty-one patients met inclusion criteria. Both TCC-P (n = 17) and DEF (n = 44) were severely injured (ISS = 35 [IQR, 25-42] vs. 29 [IQR 19-45] and packed red blood cells = 16.5 U [IQR, 12.3-25.5 U] vs. 15 U [IQR, 11-23 U], respectively; p = ns). Patient demographics were similar except for the findings that the TCC-P cohort had higher rates of cardiac arrest before starting chest closure (TCC-P 82% vs. DEF 48%, p = 0.04), significantly more severe abdominal injuries, and less severe head injuries than the DEF group. No significant differences were observed in survival of the overall samples (TCC-P = 47% vs. DEF = 57%), nor for observed:expected (O:E) survival ratio in 13 patients with TCC-P and 30 with DEF meeting criteria for TRISS calculation (TCC-P O:E, 46%:39%; DEF O:E, 53%:57%). No significant differences were found for TCC-P and DEF thoracic infectious (24% vs. 25%) or hemorrhagic (18% vs. 14%) complications. Surprisingly, peak inspiratory pressures on intensive care unit arrival were markedly better after TCC-P (20 cm H2O [IQR, 18-31 cm H2O]) than after DEF (32.5 cm H2O [IQR, 28-37.5 cm H2O], p = 0.003). Conclusion: Concerns about TCC-P are not borne out as thoracic infection rates are unaffected and peak pressures are actually lower, possibly due to greater pleural volume from an open chest wall and skin-only closure. However, no significant survival benefit was seen with TCC-P.

AB - Background: Many surgeons avoid the damage-control techniques of intrathoracic packing and temporary chest wall closure after thoracotomy for trauma because of concerns about packing's effects on intrathoracic pressure and infectious risks. We hypothesized that temporary chest closure with or without intrathoracic packing (TCC-P) as a method of thoracic damage control would yield higher than expected survival rates for trauma thoracotomy patients with metabolic exhaustion, whereas traditional definitive chest closure (DEF) would exhibit predicted survival rates. Methods: This was a retrospective cohort study by two urban Level I trauma centers on patients who (1) underwent emergent thoracotomy for trauma, (2) received ≥10 units (U) packed red blood cells and/or sustained a cardiac arrest before starting chest closure, and (3) survived to intensive care unit arrival. Demographic/physiologic data, chest closure method, and thoracic complications were gathered. Trauma injury severity scores (TRISS) were used to calculate survival probability for TCC-P and DEF. Nonparametric statistics were used for all comparisons. All values are expressed as medians and interquartile ranges (IQR). Results: Sixty-one patients met inclusion criteria. Both TCC-P (n = 17) and DEF (n = 44) were severely injured (ISS = 35 [IQR, 25-42] vs. 29 [IQR 19-45] and packed red blood cells = 16.5 U [IQR, 12.3-25.5 U] vs. 15 U [IQR, 11-23 U], respectively; p = ns). Patient demographics were similar except for the findings that the TCC-P cohort had higher rates of cardiac arrest before starting chest closure (TCC-P 82% vs. DEF 48%, p = 0.04), significantly more severe abdominal injuries, and less severe head injuries than the DEF group. No significant differences were observed in survival of the overall samples (TCC-P = 47% vs. DEF = 57%), nor for observed:expected (O:E) survival ratio in 13 patients with TCC-P and 30 with DEF meeting criteria for TRISS calculation (TCC-P O:E, 46%:39%; DEF O:E, 53%:57%). No significant differences were found for TCC-P and DEF thoracic infectious (24% vs. 25%) or hemorrhagic (18% vs. 14%) complications. Surprisingly, peak inspiratory pressures on intensive care unit arrival were markedly better after TCC-P (20 cm H2O [IQR, 18-31 cm H2O]) than after DEF (32.5 cm H2O [IQR, 28-37.5 cm H2O], p = 0.003). Conclusion: Concerns about TCC-P are not borne out as thoracic infection rates are unaffected and peak pressures are actually lower, possibly due to greater pleural volume from an open chest wall and skin-only closure. However, no significant survival benefit was seen with TCC-P.

KW - Chest closure

KW - Damage control

KW - Thoracic trauma

UR - http://www.scopus.com/inward/record.url?scp=79952796429&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=79952796429&partnerID=8YFLogxK

U2 - 10.1097/TA.0b013e31820e89f1

DO - 10.1097/TA.0b013e31820e89f1

M3 - Article

C2 - 21610362

AN - SCOPUS:79952796429

VL - 70

SP - 705

EP - 709

JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

IS - 3

ER -