Advertisement

Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma?

  • Edward J. Nevins
  • Parisa L. Moori
  • Jonathan Smith-Williams
  • Nicholas T. E. Bird
  • John V. Taylor
  • Nikhil Misra
Review Article

Abstract

Purpose

The indications for pre-hospital resuscitative thoracotomy (PHRT) remain undefined. The aim of this paper is to explore the variation in practice for PHRT in the UK, and review the published literature.

Methods

MEDLINE and PUBMED search engines were used to identify all relevant articles and 22 UK Air Ambulance Services were sent an electronic questionnaire to assess their PHRT practice.

Results

Four European publications report PHRT survival rates of 9.7, 18.3, 10.3 and 3.0% in 31, 71, 39 and 33 patients, respectively. All patients sustained penetrating chest injury. Six case reports also detail survivors of PHRT, again all had sustained penetrating thoracic injury. One Japanese paper presents 34 cases of PHRT following blunt trauma, of which 26.4% survived to the intensive therapy unit but none survived to discharge. A UK population reports a single survivor of PHRT following blunt trauma but the case details remain unpublished. Ten (45%) air ambulance services responded, each service reported different indications for PHRT. All perform PHRT for penetrating chest trauma, however, length of allowed pre-procedure down time varied, ranging from 10 to 20 min. Seventy percent perform PHRT for blunt traumatic cardiac arrest, a procedure which is likely to require aggressive concurrent circulatory support, despite this only 5/10 services carry pre-hospital blood products.

Conclusions

Current indications for PHRT vary amongst different geographical locations, across the UK, and worldwide. Survivors are likely to have sustained penetrating chest injury with short down time. There is only one published survivor of PHRT following blunt trauma, despite this, PHRT is still being performed in the UK for this indication.

Keywords

Pre-hospital Resuscitative thoracotomy Traumatic cardiac arrest Penetrating chest trauma Blunt chest trauma 

Notes

Acknowledgements

The authors would like to acknowledge Clint Jones for survey design, help in distribution of survey and proof reading the manuscript. The authors would also like to acknowledge Sarah J. Fadden for proof reading the manuscript.

Funding

The authors received no funding for the production of this manuscript.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest to declare.

References

  1. 1.
    Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190(3):288–98.CrossRefPubMedGoogle Scholar
  2. 2.
    “Practice management guidelines for emergency department thoracotomy. Working group, Ad Hoc subcommittee on outcomes, American College of Surgeons-Committee on Trauma. J Am Coll Surg. 2001;193(3):303–9.CrossRefGoogle Scholar
  3. 3.
    Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: objectives, indications, and outcomes.” World J Emerg Surg. 2006;1:4.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, Fox N, Jawa RS, Khwaja K, Lee JK, Magnotti LJ,, Rowell S, To KB, Falck-Ytter Y, Rhee P, Mayglothling JA, McDonald AA. 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(1):159–73.CrossRefPubMedGoogle Scholar
  5. 5.
    Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma—a review. Injury. 2006;37(1):1–19.CrossRefPubMedGoogle Scholar
  6. 6.
    Ashrafian H, Athanasiou T. Emergency prehospital on-scene thoracotomy: a novel method. Coll Antropol. 2010;34(4):1449–52.PubMedGoogle Scholar
  7. 7.
    Athanasiou T, Krasopoulos G, Nambiar P, Coats T, Petrou M, Magee P, Uppal R. Emergency thoracotomy in the pre-hospital setting: a procedure requiring clarification. Eur J Cardio Thoracic Surg. 2004;26(2):377–85.CrossRefGoogle Scholar
  8. 8.
    Hopson LR, Hirsh E, Delgado J, Domeier RM, McSwain NE, Krohmer J, Weldon C, Friel M, Hoyt DB. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. J Am Coll Surg. 2003;196(3):475–81.CrossRefPubMedGoogle Scholar
  9. 9.
    Keogh SP, Wilson AW. Survival following pre-hospital arrest with on-scene thoracotomy for a stabbed heart. Injury 1996;27(7):525–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Deakin CD. From agonal to output: An ECG history of a successful pre-hospital thoracotomy. Resuscitation 2007;75(3):525–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Corral E, Silva J, Suarez RM, Nunez J, Cuesta C. A successful emergency thoracotomy performed in the field. Resuscitation 2007;75(3):530–3.CrossRefPubMedGoogle Scholar
  12. 12.
    Wall MJ, Pepe PE, Mattox KL. Successful roadside resuscitative thoracotomy: case report and literature review. J Trauma. 1994;36(1):131–4.CrossRefPubMedGoogle Scholar
  13. 13.
    Craig R, Clarke K, Coats TJ. On scene thoracotomy: a case report. Resuscitation 1999;40(1):45–7.CrossRefPubMedGoogle Scholar
  14. 14.
    Coats TJ, Keogh S, Clark H, Neal M. Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series. J Trauma. 2001;50(4):670–3.CrossRefPubMedGoogle Scholar
  15. 15.
    Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results. J Trauma. 2011;70(5):E75–E78.CrossRefPubMedGoogle Scholar
  16. 16.
    Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A. Emergency thoracotomy: ‘how to do it’. Emerg Med J. 2005;22(1):22–4.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Van Vledder MG, Van Waes OJF, Kooij FO, Peters JH, Van Lieshout EMM, Verhofstad MHJ. Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma. Injury. 2017;48(9):1865–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Matsumoto H, Mashiko K, Hara Y, Kutsukata N, Sakamoto Y, Takei K, Kanemaru K, Tomita Y, Saito N, Yagi T, Tetsu S, Iida H, Masuda Y, Koami H, Yokota H. Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system. Resuscitation. 2009;80(11):1270–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors?” Ann Emerg Med. 2006;48(3):240–4.CrossRefPubMedGoogle Scholar
  20. 20.
    Ivatury RR, Nallathambi MN, Roberge RJ, Rohman M, Stahl W. Penetrating thoracic injuries: in-field stabilization vs. prompt transport. J Trauma. 1987;27(9):1066–73.CrossRefPubMedGoogle Scholar
  21. 21.
    Durham LA, Richardson RJ, Wall MJ, Pepe PE, Mattox KL. Emergency center thoracotomy: impact of prehospital resuscitation. J Trauma. 1992;32(6):775–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Schwab CW, Adcock OT, Max MH. Emergency department of thoracotomy (EDT). A 26-month experience using an ‘agonal’ protocol. Am Surg. 1986;52(1):20–9.PubMedGoogle Scholar
  23. 23.
    Luna GK, Pavlin EG, Kirkman T, Copass MK, Rice CL. Hemodynamic effects of external cardiac massage in trauma shock. J Trauma. 1989;29(10):1430–3.CrossRefPubMedGoogle Scholar
  24. 24.
    Wright K, Murphy K. Cardiac tamponade: a case of kitchen floor thoracotomy. Emerg Med J. 2002;19:587–88.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Crewdson K, Lockey D, Weaver A, Davies GE. Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service Injury. 2009;40(5):560–3.CrossRefPubMedGoogle Scholar
  26. 26.
    Dayama A, Sugano D, Spielman D, Stone ME, Kaban J, Mahmoud A, Mcnelis J. Basic data underlying clinical decision-making and outcomes in emergency department thoracotomy: tabular review. ANZ J Surg. 2016;86(1–2):21–6.CrossRefPubMedGoogle Scholar
  27. 27.
    The Royal College of Surgeons of England, Pre-hospital and emergency department resuscitative thoracotomy (PERT). 2017. https://www.rcseng.ac.uk/education-and-exams/courses/search/prehospital-and-emergency-department-resuscitative-thoracotomy-pert/. Accessed 28 Dec 2017.
  28. 28.
    Harrison OJ, Lockey D. Should resuscitative thoracotomy be performed in the pre-hospital phase of care?” Trauma. 2013;15(2):176–85.CrossRefGoogle Scholar
  29. 29.
    Powell DW, Moore EE, Cothren CC, Ciesla DJ, Burch JM, Moore JB, Johnson JL. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg. 2004;199(2):211–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Sherren P, Reid C, Habig K. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staf ed helicopter emergency medical service. Crit Care. 2013;17:S105–6.CrossRefGoogle Scholar
  31. 31.
    Clinical Quality and Patient Saftey Unit, Clinical practice procedures: trauma/thoracotomy. 2016. https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_Thoracotomy.pdf. Accessed 28 Dec 2017.
  32. 32.
    Lockey DJ, Brohi K. Pre-hospital thoracotomy and the evolution of pre-hospital critical care for victims of trauma. Injury. 2017;48(9):1863–4.CrossRefPubMedGoogle Scholar
  33. 33.
    Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015;108(1):11–6.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Inaba K, 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;262(3):512–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Edward J. Nevins
    • 1
  • Parisa L. Moori
    • 2
  • Jonathan Smith-Williams
    • 3
  • Nicholas T. E. Bird
    • 1
  • John V. Taylor
    • 1
    • 2
  • Nikhil Misra
    • 1
    • 2
  1. 1.Emergency General Surgery and Trauma UnitUniversity Hospital AintreeLiverpoolUK
  2. 2.University of Liverpool Medical SchoolLiverpoolUK
  3. 3.Department of AnaesthesiaRoyal Liverpool University HospitalLiverpoolUK

Personalised recommendations