急诊医师在活体组织穿透性心脏损伤模型中进行标准左前外侧开胸与改良双侧翻盖开胸的前瞻性随机试验

IF 2.2 3区医学 Q1 EMERGENCY MEDICINE

American Journal of Emergency Medicine Pub Date : 2025-09-11 DOI:10.1016/j.ajem.2025.09.012

Ryan Newberry DO, MPH , Derek Brown MD, MPH , Thomas A. Mitchell MD, MHA , R. Madelaine Paredes PhD , Vincent Nelson MD , Renford Cindass Jr MD , Dylan Rodriguez MSc , Jae Hyek Choi PHD, DVSc , Allyson Arana PhD , Joseph K. Maddry MD

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引用次数: 0

摘要

目的胸腔切开术（RT）是一项关键的、时间敏感的手术，可由急诊医学（EM）医师进行。左前外侧开胸术（LAT）是美国传统上使用的技术。然而，其有限的暴露可能会阻碍有效的干预。改良的双侧翻盖开胸术（MCT）是由伦敦空中救护（LAA）的Barts Health NHS Trust临床医生开发的，它提供了更大的曝光率，可能更适合急诊医生。本研究旨在确定急诊医生的最佳RT技术，同时评估技术挑战、程序问题和提供者偏好。方法来自一级创伤中心的工作人员和住院医师接受MCT和LAT技术的标准化培训后参与。参与者被随机分配到具有新型穿透损伤模型的活组织猪上执行每种技术。成功的定义是心脏从心包囊娩出，心脏出血得到控制，并完全阻断胸主动脉。主要结果是成功完成RT的时间。次要结局包括手术成功率、充分暴露、出血控制、交叉夹持成功、医源性损伤和参与者反馈。结果10名急诊医师完成了研究。成功完成MCT和LAT技术的时间没有显著差异（585秒vs 664.9秒，风险比0.63，可信区间95% 0.27 ~ 1.49）。成功率相似（80% vs 70%，差异- 10%，95% CI - 50.6% ~ 30.6%）。相比于LAT，医生更倾向于MCT （100% vs 0%）。结论虽然参与者对LAT有更多的经验，但MCT表现良好，普遍首选。MCT可能是急诊医生在没有外科医生的情况下，面对胸椎穿透性损伤并无脉搏或四肢瘫痪的理想技术。

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Prospective randomized trial of standard left anterolateral thoracotomy vs modified bilateral clamshell thoracotomy performed by emergency physicians in a live tissue penetrating cardiac injury model

Objective

Resuscitative thoracotomy (RT) is a critical, time-sensitive procedure that may be performed by emergency medicine (EM) physicians. The left anterolateral thoracotomy (LAT) is the technique traditionally used in the United States. However, its limited exposure may hinder effective intervention. The modified bilateral clamshell thoracotomy (MCT), developed by Barts Health NHS Trust clinicians at London's Air Ambulance (LAA), offers greater exposure and may be more suitable for EM physicians. This study aimed to determine the optimal RT technique for EM physicians while also assessing technical challenges, procedural concerns, and provider preferences.

Methods

EM staff and resident physicians from a level one trauma center participated after receiving standardized training on both MCT and LAT techniques. Participants were randomized to perform each technique on live tissue swine with a novel penetrating injury model. Success was defined as heart delivery from the pericardial sac, cardiac hemorrhage control, and full thoracic aorta occlusion. The primary outcome was time to successful RT completion. Secondary outcomes included procedural success rates, adequate exposure, hemorrhage control, cross-clamping success, iatrogenic injuries, and participant feedback.

Results

Ten EM physicians completed the study. There was not a significant difference in time to successful completion of the MCT and LAT techniques (585 s vs 664.9 s, hazard ratio 0.63, CI 95 % 0.27 to 1.49). Success rates were similar (80 % vs 70 %, difference − 10 %, 95 % CI -50.6 % to 30.6 %). Provider procedure preference favored the MCT over the LAT (100 % vs 0 %).

Conclusion

Though participants were more experienced with the LAT, the MCT performed as well and was universally preferred. The MCT may be the ideal technique for EM physicians confronting a penetrating thoracic injury with pulselessness or extremis in the absence of a surgical provider.

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来源期刊

American Journal of Emergency Medicine 医学-急救医学

CiteScore

6.00

自引率

5.60%

发文量

730

审稿时长

42 days

期刊介绍： A distinctive blend of practicality and scholarliness makes the American Journal of Emergency Medicine a key source for information on emergency medical care. Covering all activities concerned with emergency medicine, it is the journal to turn to for information to help increase the ability to understand, recognize and treat emergency conditions. Issues contain clinical articles, case reports, review articles, editorials, international notes, book reviews and more.