University of Southern California Dissertations and Theses

Resuscitative thoracotomy for traumatic cardiac arrest: impact of the COVID-19 pandemic on resource utilization and outcomes

(USC Thesis Other)

Resuscitative thoracotomy for traumatic cardiac arrest: impact of the COVID-19 pandemic on resource utilization and outcomes

PDF

Download

Open document

Flip pages

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content

Resuscitative Thoracotomy for Traumatic Cardiac Arrest: Impact of the COVID-19 Pandemic on
Resource Utilization and Outcomes
By
Brandon John Nakashima

A THESIS PRESENTED TO THE
FACULTY OF THE USC DEPARTMENT OF POPULATION AND PUBLIC HEALTH
SCIENCES
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CLINICAL, BIOMEDICAL, AND TRANSLATIONAL INVESTIGATIONS)

May 2023

Copyright 2023 Brandon John Nakashima

ii

Acknowledgements
First and foremost, I would like to thank my amazing mentor, Dr. Morgan Schellenberg,
for her guidance in conceiving and completing this study. Her unrelenting work ethic in both her
clinical work and research work serves as inspiration for the surgeon and researcher I hope to be
in my career. Certainly, I could not have accomplished this project without her help.
I am also very appreciative of the support I have received from the Division of Acute
Care Surgery at LAC+USC Medical Center. From access to their outstanding trauma registry, to
feedback and reviewing of the content for this thesis, I owe the attending surgeons and staff a
sincere thank you.
Thank you also to my thesis committee members, Dr. Morgan Schellenberg, Dr. Wendy
Mack, and my committee chair, Dr. Joseph Wiemels, for taking the time to review and provide
feedback on my thesis.
Finally, I would like to thank the Provost’s Postdoctoral Scholars Program and Keck
School of Medicine Faculty Affairs for the financial support to pursue this master’s degree.

iii

Table of Contents
Acknowledgements…………………………………………………………………...…….....….ii
List of Tables.…..……………………………………………………………………...………....iv
Abstract………………………….………………………………………………………………...v
Chapter 1: Background……..……………………………………………………………………..1
Chapter 2: Methods……………………………………………………………..……………...….2
Chapter 3: Results…………………………………………………………………………............5
Chapter 4: Discussion……………………………………………………………………………..7
References………………………………………………………………………………………..10

iv

List of Tables
Table 1. Patient Demographics, Clinical Data, and Injury Data………………………………12
Table 2. Blood Product Usage and Outcomes…………………………………………………13
Table 3. Blood product use during the COVID-19 pandemic vs. pre-pandemic for patients
undergoing RT, overall and stratified by mechanism of injury………………………………..14

v

Abstract

Introduction: Resuscitative thoracotomy (RT) in the setting of traumatic arrest serves as a vital,
but resource-intensive, intervention. The COVID-19 pandemic created critical shortages,
sharpening the focus on efficient resource utilization. This study aims to compare RT
performance and blood product utilization before and after the onset of the COVID-19 pandemic
for patients in traumatic cardiac arrest.
Methods: All patients undergoing RT for traumatic cardiac arrest in the emergency department
at our ACS-verified Level 1 trauma center (08/01/2017-07/31/2022) were included in this
retrospective observational study. Study groups were dichotomized into Pre-COVID vs. COVID
periods based on patient arrival date (before vs. after 03/10/2020). Demographics, clinical/injury
data, and outcomes were collected. The primary outcome was blood product use by 4 hours after
presentation.
Results: 445 RTs (2% of 23,488 trauma encounters) were performed over the study period: Pre-
COVID, n=209 (2%) vs. COVID, n=236 (2%) (p=0.70). Survival to discharge was equivalent
Pre-COVID vs. COVID (n=22, 11% vs. n=21, 9%, p=0.56). RT patients during COVID
consumed a median of 1 unit less packed red blood cells (pRBC) at the 4 hour measurement (3.9
units [IQR: 8.0] vs. 3.0 units [IQR: 5.1], p=0.012) and 1 unit less of platelet at the 4 hour
measurement (5.7 units [11.5] vs. 4.3 units [7.4], p=0.012) compared to pre-COVID. These
findings were persistent after performing multivariable negative binomial regression adjusting
for clinically relevant factors.

vi

Conclusion: Rates of RT and survival after RT remained consistent during the pandemic.
Despite comparable RT frequency, pRBC and platelet transfusions were reduced, likely
reflecting resource expenditure minimization during the severe blood shortages that occurred. RT
performance for patients in traumatic arrest may therefore be feasible during global pandemics at
pre-pandemic frequencies as long as particular attention is paid to resource expenditure.

1

Chapter 1: Background
Resuscitative thoracotomy (RT) is a critical surgical procedure in the armamentarium of
acute care surgeons for the management of traumatic cardiac arrest. However, RT for traumatic
arrest remains controversial. Physicians and surgeons are tasked with caring for and considering
not only the singular patient in front of them, but also society at large. The issue of resource
limitation has come into focus during the last few years in the face of the global COVID-19
pandemic. In particular, the scarcity of vital blood products came into focus leading to the
announcement of the Red Cross’s first ever blood crisis in January 2022. The United States saw a
critical number of blood drives cancelled and an estimated 19% reduction in the eligible blood
donor pool at the onset of the COVID-19 pandemic, leading to re-evaluation of transfusion
practices.
1, 2
These strategies included extension of blood product shelf life, re-assessment of RBC
transfusion thresholds, and maximization of the use of alternatives to RBC transfusions.
3, 4

Fundamentally, resuscitation of a patient in traumatic arrest necessitates restoration of adequate
end organ perfusion. Thus, inherent to the RT procedure is not only intervention to increase
cerebral and cardiac perfusion with aortic cross-clamping and cardiac massage, but also, almost
universally, the expansion of the intervascular volume by way of blood transfusion.
Our study sought to assess the impact of resource constraints during the COVID-19
pandemic on RT performance for traumatic arrest at an American College of Surgeons (ACS)-
verified Level 1 trauma center. Our hypothesis was that there would be a reduction in RT use
during the COVID-19 pandemic compared to prior to the pandemic, especially for cardiac arrest
secondary to blunt trauma, and that blood product transfusion volumes during RT would be
decreased in response to nationwide blood product shortages.

2

Chapter 2: Methods
All trauma patients presenting to our ACS-verified Level 1 trauma center were screened
for inclusion in this single-center retrospective study (08/01/2017-07/31/2022). Patients were
identified via the institutional trauma registry, with full review of the electronic medical record
subsequently undertaken for complete data capture of study patients. Patients undergoing RT
outside of the ED were excluded. Institutional Review Board approval was obtained and
exemption was granted with a waiver of informed consent due to the observational nature of the
study. The STROBE guideline was used for proper reporting of methods, results, and discussion
(Supplemental Digital Content 1).
Variables included in study analyses were patient demographics (age, sex); clinical data
(field and first ED vital signs and Glasgow Coma Scale [GCS] score); injury data (scene time
(defined as difference between unit arrival time and left scene time), mechanism of injury,
prehospital arrest, signs of life on arrival to ED (defined as having no organized ECG rhythm,
pupillary responses, spontaneous respiratory effort, unassisted blood pressure) , injury severity
score (ISS), abbreviated injury scale (AIS) by body region); blood product transfusion data (use
of massive transfusion, defined as the transfusion of >10 packed red blood cell (pRBC) units in
the first 24 hours; number of pRBC, fresh frozen plasma (FFP), and platelet units transfused
within 4 hours, 24 hours, and over the total hospital stay); and outcomes (survival out of the ED,
hospital length of stay [LOS in days], ICU LOS, survival to hospital discharge, discharge
destination). The primary outcome was amount of blood product use (in units of pRBC) by 4
hours after presentation.

3

Study groups were delineated into Pre-COVID patients vs. COVID patients based on date
of RT, with Pre-COVID patients defined as those who underwent RT before March 10, 2020 and
COVID patients defined as those who underwent RT on or after March 10, 2020. This date was
selected as the cut-off date to define the eras based on the WHO declaration of the COVID-19
pandemic.
5

Descriptive data analysis of patient demographics, clinical data, injury data, blood
transfusions, and outcomes were compared between Pre-COVID vs. COVID groups. There were
no missing data of key study variables. Continuous variables are given as median (interquartile
range, IQR) and statistical comparisons used Mann-Whitney U test. Categorical variables are
compared with the Pearson’s chi-squared test.
Poisson regression analyses were performed to detect differences in blood product
transfusion by study group. All models controlled for clinically relevant predictors and
confounders including: mechanism of injury, age, sex, presence of signs of life on arrival,
prehospital arrest, survival to discharge, and length of stay. Pearson chi-square goodness of fit
tests were performed for each of the analyses, revealing statistically significant departure from
goodness-of-fit in all analyses (all p<0.0001). To address poor model fit and overdispersion of
the data, analyses for pRBC, FFP, and platelet use were run using negative binomial regression.
Negative binomial regression without a zero inflation component was used to evaluate the
relationship between units transfused at 4 hours and during the entire hospital stay. Results from
the negative binomial regression analyses are represented as incidence rate ratios with 95%
confidence intervals (CIs), estimating the ratio of mean transfusion units COVID compared to
Pre-COVID-19 patients.

4

Multiple logistic regression analysis was used to evaluate the association between timing
of RT and in-hospital survival. Predictor variables and confounding variables included in the
analysis were selected based on clinical relevance and included: mechanism of injury, age, sex,
presence of signs of life on arrival, prehospital arrest, and total number of transfused units of
RBC, FFP, and platelets.
Additional multiple logistic regression analysis was utilized to evaluate the association
between massive transfusion and time period. Predictor variables and confounding variables
included in the analysis were again selected based on clinical relevance and included:
mechanism of injury, age, sex, race, presence of signs of life on arrival, prehospital arrest, and
survival to discharge. Results from multiple logistic regression analyses are expressed as log
odds ratio with 95% CIs. Statistical significance was defined as 2-sided p <0.05. Data were
collected and analyzed using Stata version 17.0 (StataCrop LLC) and RStudio (version
2022.12.0, R version 4.2.1).

5

Chapter 3: Results
A total of 23,488 trauma patients were seen at our institution over the study period. Of
these, 36 patients (8%) underwent RT outside of the ED and were therefore excluded, leaving
445 patients (92%) for analysis. Of the 445 study patients, 209 RTs occurred Pre-COVID (47%)
and 236 occurred during COVID (53%). Baseline characteristics of the Pre-COVID and COVID
cohorts were similar in terms of median age (Pre-COVID: 35 years [IQR=26.0] vs. COVID: 34
years [IQR=22.0], p=0.899) and sex (Pre-COVID: n= 176, 84% male vs COVID: n=200, 85%
male (p=0.876) (Table 1). There were no differences between groups in proportion of
prehospital arrest (Pre-COVID: n= 129, 62% vs. COVID: n= 127, 54%, p = 0.092) or signs of
life on arrival to the ED (Pre-COVID: n=68, 33% vs. COVID: n=81, 34%, p = 0.69).
No difference in rate of RT performed per total trauma encounters (Pre-COVID: n=209,
2% vs. COVID: n=236, 2%, p=0.697) was observed. However, a significant increase in the
proportion of RT patients with penetrating trauma between the Pre-COVID and COVID was
noted (Pre-COVID: n=92, 44% vs. COVID: n=134, 57%, p=0.007), owing mainly to an increase
in gunshot wounds (30% vs. 42%).
Outcomes for pre-COVID and COVID RT patients are presented in Table 2. Survival
beyond the ED (Pre-COVID: 51.2% vs. COVID: 42.8%, p=0.08) and to discharge ( Pre-COVID:
22 (11%) vs. COVID: 21 (9%), p=0.56) remained comparable. This persisted on multivariable
logistic regression analysis, which showed no significant difference in odds of survival for
patients undergoing RT during the COVID era compared to the Pre-COVID era (OR 1.04, 95%
CI: (0.25, 4.31), adj p = 0.961). For RT patients who survived beyond the ED, median hospital
days did not significantly differ in Pre-COVID compared to during COVID (Pre-COVID: 0 days
[IQR:5] vs. COVID: 0 days (IQR: 4), p=0.892]. Those patients who survived to the ICU showed

6

no difference in median length of stay Pre-COVID compared to during COVID (3.5 days [6.5]
vs. 2 days [4], p=0.562).
In terms of blood product utilization, unadjusted blood product usage by 4 hours from
presentation and total during stay are displayed in Table 2. RT patients during COVID consumed
a median of 1 unit less pRBC (Pre-COVID: 3.9 units [8.0] vs. COVID: 3.0 units [5.1], p=0.012)
and 1 unit less platelet (Pre-COVID: 5.7 units [11.5] vs. COVID: 4.3 units [7.4], p=0.012) by the
4 hours from presentation mark. Additionally, there was 1 unit reduction in total hospital stay
pRBC (Pre-COVID: 4.0 units [8.9] vs. 3.0 units [5.2], p =0.006) and platelet (Pre-COVID: 5.8
units [12.9] vs COVID: 4.3 units [7.5], p=0.006) use for COVID RT patients. Use of massive
transfusion was assessed by multivariable logistic regression. The odds of massive transfusion
for RT patients during COVID compared to pre-COVID were significantly decreased [OR 0.48,
95% CI: (0.30, 0.78), adj p = 0.003].
Negative binomial regression was used to further investigate the impact of RT timing on
blood product use. RT during COVID was associated with an over 20% reduction in units of
pRBC (Pre-COVID: IRR 0.776 (95% CI: 0.638, 0.943, adj p = 0.011) and platelets (Pre-COVID:
IRR 0.779 (95% CI: 0.645, 0.945, adj p = 0.011) used by 4 hours after controlling for clinical
factors. After stratifying data by Blunt vs. Penetrating mechanism, Blunt trauma patients during
COVID demonstrated a persistent reduction in RBC [4 hour: IRR 0.716 (0.552, 0.927), adj p:
0.011; total: IRR 0.728, 95% CI: (0.552, 0.961, adj p=0.025)] and platelet consumption [4 hour:
IRR 0.719, 95% CI: (0.557, 0.928), adj p=0.001; total: IRR 0.0.734, 95% CI: (0.558, 0.965)]
compared to Pre-COVID patients (Table 3).

7

Chapter 4: Discussion
In this study, we examined the impact of resource limitations imposed by the COVID-19
pandemic on resuscitative thoracotomy use in traumatic arrest and blood product utilization for
these patients. Although RT performance occurred with similar frequency during the pandemic
as compared to the pre-pandemic period, we demonstrated the compelling finding of a reduction
in RBC and platelet usage during the pandemic. This is likely reflective of blood product
shortages during that time.
1-3
Importantly, despite reducing blood product transfusion during RT
performance, the rate of survival to hospital discharge after RT during the pandemic was
comparable to pre-pandemic levels. The survival rate of 10% after RT reported here is
commensurate with previously published outcome data
6, 7
, though more recent examination of
ACS-TQIP trauma data suggests an overall survival approaching 20%.
8
This consistency in
survival during the pandemic compared to pre-pandemic was affirmed after controlling for a
number of clinical predictors and confounders. Discrepancy between more contemporary
survival estimates and the current study may be attributed to a more liberal approach to
resuscitative thoracotomy at our institution.
During the pandemic, focus on the use of resource-intensive, minimally-beneficial
procedures has sharpened. Patients experiencing arrest in the context of blunt trauma have been
shown to have significantly lower survival after RT compared to their penetrating traumatic arrest
counterparts. Consequently, major trauma society guidelines for RT performance distinguish
between blunt and penetrating traumatic arrests. In fact, the 2015 Eastern Association for the
Surgery of Trauma guidelines on emergency department (ED) thoracotomy conditionally
recommend against performing RT in blunt trauma patients presenting without a pulse.
9
Balance
must be struck when weighing the potential lives saved and the occupational exposure risks,

8

personnel utilization, operating room space , and consumption of disposable supplies such as blood
products.
10, 11
.
Despite concerns that RT frequency may need to be reduced based on limited blood
availability, many centers such as ours were able to maintain consistent RT rates during the
pandemic. Regionally in Southern California, the use of invasive ED interventions, including RT,
continued during the COVID-19 at similar rates to the pre-pandemic years.
12
Interestingly,
selection of patients undergoing RT seemed to shift during the COVID-19 pandemic at our
institution. While pre-pandemic a majority of RT patients experienced blunt trauma, during the
pandemic RT was performed more often on penetrating trauma patients. This may have been
driven by a change to a more restrictive RT selection approach by the trauma team after weighing
the resource-intensive nature of RT and knowledge that penetrating trauma RT tends to have
higher survival rates compared to blunt trauma
6-8
,
Since the onset of the COVID-19 pandemic, discussion around resource conservation and
allocation, including blood products, has been a vital part of the global response.
3, 4, 13
Despite a
consistent RT frequency during the COVID-19 pandemic, we witnessed a significant decrease in
the median number of RBC and platelet use for RT patients, while plasma use was unchanged.
At both 4 hours from presentation and across the entire hospitalization time, the rates of RBC
and platelets used per patient were reduced by over 20%. Blood product conservation was
additionally supported by the fact that odds of massive RBC transfusion in the first 24 hours was
significantly lower in the pandemic cohort compared to the pre-pandemic cohort. During the
pandemic study period, there was no institutional policy change to the massive transfusion
protocol nor use of blood products in trauma patients. Thus, it was incumbent upon the trauma
team to decide the when and how much blood product to transfuse. Influences on these decisions

9

were likely multifactorial, with possibilities including advisement from administration, personal
awareness of resource limitations, and change in patient complement based on mechanism of
injury.
However, this study is not without limitations. This was a single-center retrospective
observational study where selection of patients undergoing RT was not protocolized and was at
the discretion of the attending trauma surgeon. As mentioned previously, our institutional
approach to indications for performing RT may be less restrictive than other institutions. These
factors contribute to limiting the external validity of our findings. Additionally, no specific
intervention to blood product use was applied during the study period, and thus the determination
of a conscious blood product use reduction is difficult to assess. Analysis of multicenter or
national database data would provide increased power to evaluate our findings and would allow
for greater generalizability of these conclusions.
To conclude, the usage of RBC and platelet products for patients undergoing ERT during
the COVID-19 pandemic was significantly reduced. In a time of limited resources affecting the
global community at large, our institution saw a reduction in blood product without notable
impact on survival to discharge for a population that demands significant resources. This study
may provide the impetus to further examine the approach to blood product transfusion in
traumatic arrest patients. Performing additional multicenter studies could help further delineate
the minimal transfusion thresholds and influence institutional policy.

10

References

1. Riley W, Love K and McCullough J. Public Policy Impact of the COVID-19 Pandemic
on Blood Supply in the United States. Am J Public Health. 2021;111:860-866.

2. Ngo A, Masel D, Cahill C, Blumberg N and Refaai MA. Blood Banking and Transfusion
Medicine Challenges During the COVID-19 Pandemic. Clin Lab Med. 2020;40:587-601.

3. Stanworth SJ, New HV, Apelseth TO, Brunskill S, Cardigan R, Doree C, Germain M,
Goldman M, Massey E, Prati D, Shehata N, So-Osman C and Thachil J. Effects of the COVID-
19 pandemic on supply and use of blood for transfusion. Lancet Haematol. 2020;7:e756-e764.

4. Al-Riyami AZ, Burnouf T, Wood EM, Devine DV, Oreh A, Apelseth TO, Goel R, Bloch
EM, van Den Berg K, Getshen M, Louw V, Ang AL, Lee CK, Rahimi-Levene N, Stramer SL,
Vassallo R, Schulze TJ, Patidar GK, Pandey HC, Dubey R, Badawi M, Hindawi S, Meshi A,
Matsushita T, Sorrentino E, Grubovic Rastvorceva RM, Bazin R, Vermeulen M, Nahirniak S,
Tsang HC, Vrielink H, Triyono T, Addas-Carvalho M, Hecimovic A, Torres OW, Mutindu SM,
Bengtsson J, Dominguez D, Sayedahmed A, Hanisa Musa R, Gautam B, Herczenik E, So-Osman
C and Group IC-CPW. International Society of Blood Transfusion survey of experiences of
blood banks and transfusion services during the COVID-19 pandemic. Vox Sang. 2022;117:822-
830.

5. Organization WH. WHO Director-General’s opening remarks at the media briefing on
COVID19 -March 2020. 2020.

6. Seamon MJ, Chovanes J, Fox N, Green R, Manis G, Tsiotsias G, Warta M and Ross SE.
The use of emergency department thoracotomy for traumatic cardiopulmonary arrest. Injury.
2012;43:1355-61.

7. Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M and Rich N. Survival after
emergency department thoracotomy: review of published data from the past 25 years. J Am Coll
Surg. 2000;190:288-98.

8. Panossian VS, Nederpelt CJ, El Hechi MW, Chang DC, Mendoza AE, Saillant NN,
Velmahos GC and Kaafarani HMA. Emergency Resuscitative Thoracotomy: A Nationwide
Analysis of Outcomes and Predictors of Futility. J Surg Res. 2020;255:486-494.

9. Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, Fox N, Jawa
RS, Khwaja K, Lee JK, Magnotti LJ, Mayglothling JA, McDonald AA, Rowell S, To KB, Falck-
Ytter Y and Rhee P. An evidence-based approach to patient selection for emergency department
thoracotomy: A practice management guideline from the Eastern Association for the Surgery of
Trauma. J Trauma Acute Care Surg. 2015;79:159-73.

10. Nunn A, Prakash P, Inaba K, Escalante A, Maher Z, Yamaguchi S, Kim DY, Maciel J,
Chiu WC, Drumheller B, Hazelton JP, Mukherjee K, Luo-Owen X, Nygaard RM, Marek AP,
Morse BC, Fitzgerald CA, Bosarge PL, Jawa RS, Rowell SE, Magnotti LJ, Ong AW,

11

Brahmbhatt TS, Grossman MD and Seamon MJ. Occupational exposure during emergency
department thoracotomy: A prospective, multi-institution study. J Trauma Acute Care Surg.
2018;85:78-84.

11. Passos EM, Engels PT, Doyle JD, Beckett A, Nascimento B, Jr., Rizoli SB and Tien HC.
Societal costs of inappropriate emergency department thoracotomy. J Am Coll Surg.
2012;214:18-25.

12. Ghafil C, Matsushima K, Ding L, Henry R and Inaba K. Trends in Trauma Admissions
During the COVID-19 Pandemic in Los Angeles County, California. JAMA Netw Open.
2021;4:e211320.

13. Haldane V, De Foo C, Abdalla SM, Jung AS, Tan M, Wu S, Chua A, Verma M, Shrestha
P, Singh S, Perez T, Tan SM, Bartos M, Mabuchi S, Bonk M, McNab C, Werner GK, Panjabi R,
Nordstrom A and Legido-Quigley H. Health systems resilience in managing the COVID-19
pandemic: lessons from 28 countries. Nat Med. 2021;27:964-980.

12

Table 1. Patient Demographics, Clinical Data, and Injury Data.

Continuous variables presented as median (interquartile range, IQR). Categorical variables presented as number
(percentage, %). SBP, systolic blood pressure (mmHg). HR, heart rate (beats per minute). GCS, Glasgow Coma
Scale score. GSW, gunshot wound. SW, stab wound. MVC, motor vehicle crash. MCC, motorcycle crash. AVP, auto
vs. pedestrian. AIS, Abbreviated Injury Scale. ISS, injury severity score

Total RTs
(n=445)
Pre-COVID RTs
(n=209, 47%)
COVID RTs
(n=236, 53%)
p-value
Characteristics

ERTs per Trauma Encounters 445 (2%) 209 (2%) 236 (2%) 0.697
Median Age 34.0 (23) 35.0 (26.0) 34.0 (22.0) 0.899
Gender

0.876
Male 376 (84%) 176 (84%) 200 (85%)

Female 69 (16%) 33 (16%) 36 (15%)

Field Vital Signs
Median Heart Rate 64.0 (101.0) 67.5 (102.0) 60.0 (100.0) 0.318
HR >120 bpm 45 (11%) 22 (11%) 23 (11%) 0.893
Median SBP mmHg 60.0 (117.0) 72.5 (110.0) 37.0 (124) 0.777
SBP<90 mmHg 325 (73%) 146 (70%) 179 (76%) 0.155
Median Total GCS 3.0 (1.0) 3.0 (1.0) 3.0 (1.0) 0.927
Prehospital Arrest 256 (58%) 129 (62%) 127 (54%) 0.092
Scene time, minutes 9 (7) 9 (7) 8 (6) 0.106
ED Vitals

Median Heart Rate 0.0 (66.0) 0 (84) 0 (47) 0.158
HR >120 bpm 48 (11%) 27 (13%) 21 (9%) 0.188
Median SBP mmHg 0.0 (96.8) 0.0 (111.0) 0.0 (70.0) 0.163
SBP<90 mmHg 325.0 (73%) 146.0 (70%) 179 (76%) 0.155
Median Total GCS 3 (0) 3.0 (0.0) 3.0 (0.0) 0.255
Signs of Life on Arrival 149 (34%) 68 (33%) 81 (34%) 0.690
Injury Data

Mechanism of Injury

0.007
Penetrating 226 (51%) 92 (44%) 134 (57%)

GSW 171 (37%) 65 (30%) 106 (42%)
SW 53 (11%) 26 (12%) 27 (10%)
Blunt 219 (49%) 117 (56%) 102 (43%)
MVC 56 (12%) 30 (14%) 26 (10%)
MCC 28 (6%) 13 (6%) 15 (3%)
AVP 85 (18%) 51 (24%) 34 (14%)
Fall 37 (8%) 19 (9%) 18 (7%)
Assault 23 (5%) 5 (2%) 18 (7%)
Other 12 (3%) 6 (3%) 6 (2%)
Median AIS by Body Part
Head 4 (2) 4 (2) 3 (2) 0.281
Face 2 (1) 2 (1) 1 (1) 0.140
Neck 4 (2) 4 (2) 4 (2) 0.756
Thorax 3 (2) 3 (1.25) 3 (2) 0.073
Abdomen 3 (1) 3 (1) 3 (1) 0.890
Spine 1 (0) 1 (0) 1 (0) 0.113
Median ISS 26 (26) 29 (25) 26 (26) <0.001

13

Total RTs
(n=445)
Pre-COVID RTs
(n=209, 47%)
COVID RTs
(n=236, 53%)
p-value
Blood Product Use (Units)
pRBC

4 hours from presentation 3.8 (6.9) 3.9 (8.0) 3.0 (5.1) 0.012
During total hospital stay 3.9 (7.7) 4.0 (8.9) 3.0 (5.2) 0.006
FFP

4 hours from presentation 0 (5.3) 0 (7.0) 0 (2.9) 0.059
During total hospital stay 0 (5.8) 0 (7.6) 0 (3.5) 0.091
Platelets

4 hours from presentation 5.4 (9.9) 5.7 (11.5) 4.3 (7.4) 0.012
During total hospital stay 5.6 (11.2) 5.8 (12.9) 4.3 (7.5) 0.006
Outcomes
ED Survival 208 (47%) 107 (51%) 101 (43%) 0.076
Post-ED Location

0.117
ICU 12 (3%) 3 (1%) 9 (4%)

Interventional Radiology 4 (1%) 2 (1%) 0 (0%)

OR 189 (43%) 102 (49%) 87 (37%)

PICU 1 (0.2%) 0 (0%) 1 (0.4%)

Ward 1 (0.2%) 0 (0%) 1 (0.4%)

Deceased 237 (53%) 102 (49%) 136 (58%)

Median Hospital Days* 0 (4) 0 (5) 0 (4)

Median ICU** 3 (5) 3.5 (6.5) 2 (4) 0.892
Survival to Discharge 43 (10%) 22 (11%) 21 (9%) 0.302
Discharge Location

0.562
Acute Care Facility 6 (14%) 3 (14%) 3 (14%) 0.361
Against Medical Advice 1 (2%) 1 (5%) 0 (0%)

Home Without Services 22 (51%) 11 (50%) 11 (52%)

Home with Services 1 (2%) 0 (0%) 1 (4%)

Jail 1 (2%) 1 (5%) 0 (0%)

Recooperative Care 1 (2%) 0 (0%) 1 (4%)

Rehabilitation Center 5 (12%) 1 (5%) 4 (19%)

Skilled Nursing Facility 4 (9%) 3 (14%) 1 (5%)

Subacute Care 2 (5%) 2 (9%) 0 (0%)

Table 2. Blood Product Usage and Outcomes

Continuous variables presented as median (interquartile range, IQR). Categorical variables presented as number
(percentage, %). pRBC, packed red blood cells. FFP, fresh frozen plasma. ED, emergency department. ICU,
intensive care unit. OR, operating room. PICU, pediatric intensive care unit. RBC, packed red blood cells, FFP,
fresh frozen plasma

*Only patients who survived ED were included
**Only patients with ICU stay included

14

Table 3. Blood product use during the COVID-19 pandemic vs. pre-pandemic for patients
undergoing RT, overall and stratified by mechanism of injury.

IRR, Incidence rate ratio.
Regression analyses adjusted for age, sex, presence of signs of life on arrival, blunt or penetrating mechanism,
occurrence of prehospital arrest, length of stay, survival to discharge.

4 Hour Consumption

Overall Blunt Trauma Penetrating Trauma

IRR (95% CI) p-value IRR (95% CI) p-value IRR (95% CI) p-value
RBC 0.776 (0.638, 0.943) 0.011 0.716 (0.552, 0.927) 0.011 0.844 (0.630, 1.131) 0.256
Plasma 0.830 (0.507, 1.357) 0.457 0.691 (0.362, 1.317) 0.261 1.057 (0.473, 2.366) 0.892
Platelets 0.779 (0.642, 0.945) 0.011 0.719 (0.557, 0.928) 0.011 0.846 (0.634, 1.130) 0.257

Total Consumption

Overall Blunt Trauma Penetrating Trauma

IRR (95%CI) p-value IRR (95% CI) p-value IRR (95% CI) p-value
RBC 0.777 (0.631, 0.956) 0.017 0.728 (0.552, 0.961) 0.025 0.830 (0.606, 1.131) 0.235
Plasma 0.844(0.514, 1.387) 0.504 0.731 (0.381, 1.402) 0.346 0.932 (0.423, 2.055) 0.862
Platelets 0.779 (0.635, 0.957) 0.017 0.734 (0.558, 0.965) 0.027 0.828 (0.609, 1.127) 0.231

15

Figures

Figure 1. Flow diagram of resuscitative thoracotomy cases

Trauma activations (2017-2022)
n=23,488
Resuscitative thoracotomy (RT)
n=480
RT outside of ED
n=35
ED RT
n=445
Pre-COVID RT
(08/01/2017-03/09/2020)
n=209, 47%
COVID RT
(03/10/2020-07/31/2022)
n=236, 53%

Abstract (if available)

Abstract Introduction: Resuscitative thoracotomy (RT) in the setting of traumatic arrest serves as a vital, but resource-intensive, intervention. The COVID-19 pandemic created critical shortages, sharpening the focus on efficient resource utilization. This study aims to compare RT performance and blood product utilization before and after the onset of the COVID-19 pandemic for patients in traumatic cardiac arrest.

Methods: All patients undergoing RT for traumatic cardiac arrest in the emergency department at our ACS-verified Level 1 trauma center (08/01/2017-07/31/2022) were included in this retrospective observational study. Study groups were dichotomized into Pre-COVID vs. COVID periods based on patient arrival date (before vs. after 03/10/2020). Demographics, clinical/injury data, and outcomes were collected. The primary outcome was blood product use by 4 hours after presentation.

Results: 445 RTs (2% of 23,488 trauma encounters) were performed over the study period: Pre-COVID, n=209 (2%) vs. COVID, n=236 (2%) (p=0.70). Survival to discharge was equivalent Pre-COVID vs. COVID (n=22, 11% vs. n=21, 9%, p=0.56). RT patients during COVID consumed a median of 1 unit less packed red blood cells (pRBC) at the 4 hour measurement (3.9 units [IQR: 8.0] vs. 3.0 units [IQR: 5.1], p=0.012) and 1 unit less of platelet at the 4 hour measurement (5.7 units [11.5] vs. 4.3 units [7.4], p=0.012) compared to pre-COVID. These findings were persistent after performing multivariable negative binomial regression adjusting for clinically relevant factors.

Conclusion: Rates of RT and survival after RT remained consistent during the pandemic. Despite comparable RT frequency, pRBC and platelet transfusions were reduced, likely reflecting resource expenditure minimization during the severe blood shortages that occurred. RT performance for patients in traumatic arrest may therefore be feasible during global pandemics at pre-pandemic frequencies as long as particular attention is paid to resource expenditure.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Characteristics associated with emergency medical services for cardiac arrest pre- and during COVID-19 in Los Angeles, CA

PDF

The impact of the COVID-19 pandemic on cancer care delivery

PDF

The impact of virtual clinical education during the COVID-19 pandemic on nursing graduates in the hospital setting

PDF

Assessing the utility of wearable fitness trackers for objective capture and quantification of activity levels among patients undergoing radical cystectomy

PDF

The impact of COVID-19 and how teachers can intervene to improve student learning

PDF

The effect of cytomegalovirus on gene expression of pediatric acute lymphoblastic leukemia

PDF

Validation of the pancreatitis activity scoring system in a large prospective cohort

PDF

The impact of childhood trauma on substance use and mental health during the SARS-CoV-2 pandemic among young adults

PDF

Cardiac function in children and young adults treated with MEK inhibitors: a retrospective cohort study of routinely collected health data

PDF

Pregnancy in the time of COVID-19: effects on perinatal mental health, birth, and infant development

PDF

Association of Pediatric Early Warning Score with early intensive care unit readmission

PDF

Relationship of blood pressure and antihypertensive medications to cognitive change in the BVAIT, WISH, and ELITE clinical trials

PDF

Using mobile health to improve social support for low-income Latino patients with diabetes: a randomized mixed methods feasibility trial of TExT-MED FANS

PDF

The impact of the COVID-19 pandemic on K-12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals

PDF

The impact of the COVID-19 pandemic on physician burnout in LA County Hospital settings

PDF

COVID-19 pandemic: the impact on the Napa Valley wine industry workers

PDF

The Filipino family initiative: preliminary effects of an evidence-based parenting intervention offered in churches on parent and child outcomes

PDF

Integrated management of atrial fibrillation in women in an underserved, safety-net health care system: a multicenter, single health system randomized control efficacy trial protocol

PDF

A cross-sectional study of the association of PTH on bone quality across levels of propionic acid among adult patients with uremia

PDF

The impact of the COVID-19 pandemic on K–12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals

Asset Metadata

Creator Nakashima, Brandon John (author)

Core Title Resuscitative thoracotomy for traumatic cardiac arrest: impact of the COVID-19 pandemic on resource utilization and outcomes

Contributor Electronically uploaded by the author (provenance)

School Keck School of Medicine

Degree Master of Science

Degree Program Clinical, Biomedical and Translational Investigations

Degree Conferral Date 2023-05

Publication Date 03/29/2025

Defense Date 03/29/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag COVID-19 pandemic,OAI-PMH Harvest,resuscitative thoracotomy,traumatic arrest

Format theses (aat)

Language English

Advisor Wiemels, Joseph (committee chair), Mack, Wendy (committee member), Schellenberg, Morgan (committee member)

Creator Email b.naka04@gmail.com,brandon.nakashima@med.usc.edu

Unique identifier UC112850384

Identifier etd-NakashimaB-11539.pdf (filename)

Legacy Identifier etd-NakashimaB-11539

Document Type Thesis

Format theses (aat)

Rights Nakashima, Brandon

Internet Media Type application/pdf

Type texts

Source 20230330-usctheses-batch-1013 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu