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Schimrigk J, Baulig C, Buschmann C, Ehlers J, Kleber C, Knippschild S, Leidel BA, Malysch T, Steinhausen E, Dahmen J. [Indications, procedure and outcome of prehospital emergency resuscitative thoracotomy-a systematic literature search]. Unfallchirurg 2020; 123:711-723. [PMID: 32140814 DOI: 10.1007/s00113-020-00777-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital resuscitative thoracotomy (PHRT) is a controversially discussed measure for the acute treatment of traumatic cardiac arrest (TCA) recommended by the current guidelines of the European Resuscitation Council (ERC). The aim of this work is the comprehensive presentation and summary of the available literature with the underlying hypothesis that the available publications show the feasibility and survival following PHRT in patients with TCA with a good neurological outcome. METHOD A systematic literature search was performed in the databases PubMed, EMBASE, Google Scholar, Springer LINK and Cochrane. The study selection, data extraction and evaluation of bias potential were performed independently by two authors. The outcome of patients with TCA after PHRT was selected as the primary endpoint. RESULTS A total of 4616 publications were found of which 21 publications with a total of 287 patients could be included in the analyses. For a detailed descriptive analysis, 15 publications with a total of 205 patients were suitable. The TCA of these patients was most commonly caused by pericardial tamponade, thoracic vascular injuries and severe extrathoracic multiple injuries. In 24% of the cases TCA occurred in the presence of the emergency physician. Clamshell thoracotomy (53%) was used preclinically more often than anterolateral thoracotomy (47%). Of the PHRT patients after TCA 12% (25/205) left the hospital alive, 9% (n = 19/205) with good neurological outcome and 1% (n = 3/205) with poor neurological outcome (according to the Glasgow outcome scale, GOS). CONCLUSION The prognosis of TCA seems to be much better than has long been assumed. Decisive for the success of resuscitation efforts in TCA seems to be the immediate, partly invasive treatment of all reversible causes. The measures for TCA recommended by the ERC resuscitation guidelines, seem to be poorly implemented, especially in the preclinical setting. A controversy regarding the recommendations of the guidelines is the question of whether a PHRT can be successfully implemented and if the comprehensive introduction in Germany seems to be meaningful. Despite the recommendation of the guidelines, this systematic review and meta-analysis underlines the lack of high-quality evidence on PHRT, whereby a survival probability to hospital discharge of 12% was reported, of which 75% had a good neurological outcome. The risk of bias of the results in individual publications as well as in this review is high. Further systematic research in the field of preclinical trauma resuscitation is particularly necessary also for acceptance of the guidelines.
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Affiliation(s)
- J Schimrigk
- Lehrstuhl für Didaktik und Bildungsforschung im Gesundheitswesen, Department Humanmedizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - C Baulig
- Institut für Medizinische Biometrie und Epidemiologie (IMBE), Department Humanmedizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - C Buschmann
- Institut für Rechtsmedizin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
- AG Trauma, Deutscher Rat für Wiederbelebung - German Resuscitation Council (GRC), Ulm, Deutschland
| | - J Ehlers
- Lehrstuhl für Didaktik und Bildungsforschung im Gesundheitswesen, Department Humanmedizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - C Kleber
- AG Trauma, Deutscher Rat für Wiederbelebung - German Resuscitation Council (GRC), Ulm, Deutschland
- Chirurgische Notaufnahme, Universitätszentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum TU Dresden, Dresden, Deutschland
| | - S Knippschild
- Institut für Medizinische Biometrie und Epidemiologie (IMBE), Department Humanmedizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - B A Leidel
- Zentrale Notaufnahme, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - T Malysch
- Klinik für Anästhesiologie und Intensivtherapie, Klinikum Brandenburg, Medizinische Hochschule Brandenburg, Brandenburg, Deutschland
| | - E Steinhausen
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Duisburg, Deutschland
- Ärztliche Leitung Rettungsdienst Berlin, Fakultät für Gesundheit, Department Humanmedizin, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58455, Witten, Deutschland
| | - J Dahmen
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Duisburg, Deutschland.
- Ärztliche Leitung Rettungsdienst Berlin, Fakultät für Gesundheit, Department Humanmedizin, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58455, Witten, Deutschland.
- Ärztliche Leitung Rettungsdienst, Berliner Feuerwehr, Voltairestraße 2, 10179, Berlin, Deutschland.
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Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma? Eur J Trauma Emerg Surg 2018; 44:811-818. [PMID: 29564472 DOI: 10.1007/s00068-018-0937-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/03/2018] [Indexed: 10/17/2022]
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.
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Corcoran F, Bystrzycki A, Masud S, Mazur SM, Wise D, Harris T. Ultrasound in pre-hospital trauma care. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408615606753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pre-hospital medicine is developing rapidly. Increasingly, specialist pre-hospital medical practitioners are working in this environment and paramedics are advancing their skill base. Tools traditionally associated with hospital care are now used pre-hospital to improve diagnosis and intervention. In this paper, we assess the developing role of ultrasound in improving trauma care in the pre-hospital arena. Focused ultrasound is used to facilitate early diagnosis of pneumothorax and intraperitoneal/pericardial haemorrhage in trauma victims. Ultrasound may have a role in assessing the circulating blood volume, fracture diagnosis and triage in mass casualty scenarios. Information obtained using ultrasound may change diagnoses and consequently alter therapy, as well as patient disposition by highlighting injuries not identified on physical examination. Receiving hospitals can be alerted to injuries requiring intervention upon arrival. Ultrasound is also used to reduce complications and improve performance in numerous procedures such as obtaining vascular and intra-osseous access, paracentesis and tracheal tube placement. There is emerging evidence that ultrasound may be used safely pre-hospital without increasing on-scene times and with results comparable to use in hospital.
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Affiliation(s)
- Frances Corcoran
- South Australian Ambulance Service (SAAS) MedSTAR Emergency Medical Retrieval Service, Australia
- Emergency Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Adam Bystrzycki
- Alfred Emergency & Trauma Centre, Alfred Health, Melbourne, Australia
| | - Syed Masud
- Emergency Department, John Radcliffe Infirmary, Oxford, UK
- Thames Valley Air Ambulance, RAF Benson, UK
| | - Stefan M Mazur
- South Australian Ambulance Service (SAAS) MedSTAR Emergency Medical Retrieval Service, Australia
- Emergency Department, Royal Adelaide Hospital, Adelaide, Australia
| | - David Wise
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - Tim Harris
- Emergency Medicine, Bart's Health NHS Trust, London, UK
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Harrison OJ, Lockey D. Should resuscitative thoracotomy be performed in the pre-hospital phase of care? TRAUMA-ENGLAND 2013. [DOI: 10.1177/1460408613488481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Penetrating thoracic trauma is increasing in the UK and elsewhere and immediate transfer to a Major Trauma Centre with cardio-thoracic expertise is usually optimal management. Pre-hospital traumatic cardiac arrest has an extremely poor prognosis. Performing thoracotomy before arrival in hospital has produced neurologically intact survivors in several case series. The technique described involves rapid clamshell thoracotomy and release of pericardial tamponade. Favourable outcomes appear to be associated with a single stab wound to the heart causing cardiac tamponade. Pre-hospital thoracotomy is described in the current European Resuscitation Guidelines and courses for non-surgeons are now taught at the Royal College of Surgeons of England and at the Surgical Skills Training Centre at Newcastle Freeman Hospital. It is likely that further survivors will be reported as the technique becomes more widely used. Alternatives to pre-hospital thoracotomy in the future for patients with hypovolaemic cardiac arrest may include resuscitative endovascular balloon occlusion of the aorta and pre-hospital extended preservation and resuscitation.
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Affiliation(s)
| | - David Lockey
- North Bristol NHS Trust, Bristol, UK
- Barts Health NHS Trust, UK
- School of Clinical Sciences, University of Bristol, UK
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Lockey DJ, Weaver AE, Davies GE. Practical translation of hemorrhage control techniques to the civilian trauma scene. Transfusion 2013; 53 Suppl 1:17S-22S. [PMID: 23301967 DOI: 10.1111/trf.12031] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article examines how established and innovative techniques in hemorrhage control can be practically applied in a civilian physician-based prehospital trauma service. A "care bundle" of measures to control hemorrhage on scene are described. Interventions discussed include the implementation of a system to achieve simple endpoints such as shorter scene times, appropriate triage, careful patient handling, use of effective splints and measures to control external hemorrhage. More complex interventions include prehospital activation of massive hemorrhage protocols and administration of on-scene tranexamic acid, prothrombin complex concentrate, and red blood cells. Radical resuscitation interventions, such as prehospital thoracotomy for cardiac tamponade, and the potential future role of other interventions are also considered.
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Affiliation(s)
- David J Lockey
- London's Air Ambulance, Royal London Hospital, London, UK.
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Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results. ACTA ACUST UNITED AC 2011; 70:E75-8. [PMID: 21131854 DOI: 10.1097/ta.0b013e3181f6f72f] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital cardiac arrest associated with trauma almost always results in death. A case of survival after prehospital thoracotomy was published in 1994 and several others have followed. This article describes the result of prehospital thoracotomy in a physician-led system for patients with stab wounds to the chest who suffered cardiac arrest on scene. METHODS A 15-year retrospective prehospital trauma database review identified victims of stab wounds to the chest who suffered cardiac arrest on scene and had thoracotomy performed according to local standard operating procedures. RESULTS Overall, 71 patients met inclusion criteria. Thirteen patients (18%) survived to hospital discharge. Neurologic outcome was good in 11 patients and poor in 2. Presenting cardiac rhythm was asystole in four patients, pulseless electrical activity in five, and unrecorded in the remaining four. All survivors had cardiac tamponade. The medical team was present at the time of cardiac arrest for six survivors (good neurologic outcome): arrived in the first 5 minutes after arrest in three patients (all good neurologic outcome), arrived 5 minutes to 10 minutes after arrest in two patients (one poor neurologic outcome), and in one patient (poor neurologic outcome) the period was unknown. Of the survivors, seven thoracotomies were performed by emergency physicians and six by anesthesiologists. CONCLUSIONS Prehospital thoracotomy is a well-established procedure in this physician-led prehospital service. Results from this and other similar systems suggest that when performed for the subgroup of patients described, significant numbers of survivors with good neurologic outcome can be expected.
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Morrison JJ, Mellor A, Midwinter M, Mahoney PF, Clasper JC. Is pre-hospital thoracotomy necessary in the military environment? Injury 2011; 42:469-73. [PMID: 20362287 DOI: 10.1016/j.injury.2010.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 02/12/2010] [Accepted: 03/08/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Exsanguination from penetrating torso injury is a major source of mortality on the battlefield. Advanced Life Support guidelines suggest 'on-scene' thoracotomy for patients in cardiac arrest following penetrating chest trauma. This requires significant resourcing and training. Experience from published series (31 pre-hospital thoracotomies with 3 survivors) suggests that when this manoeuvre is applied to a well selected group it is a significant and life-saving procedure. Can this be applied to military injuries? METHODS Over a 12 month period on Operation Herrick all patients who sustained significant thoracic trauma were retrospectively reviewed. Parameters were recorded to allow detailed analysis of injury pattern and operative management. Our main objective was to determine if an early (pre-hospital) thoracotomy would have influenced the outcome. RESULTS Over the period, 81 patients required operative intervention following thoracic trauma: 8 patients underwent emergency thoracotomy (performed as part of the resuscitation) and 14 underwent urgent thoracotomy (performed after physiology partly restored). There were 9 fatalities--7 undergoing emergency thoracotomy and 2 post-operatively from multi-organ failure. Of the 7 intra-operative deaths 4/7 patients had thoracic injury and 6/7 had additional abdominal injuries. The median predicted survival of fatalities was 2.0% using Trauma Injury Severity Scoring. DISCUSSION Emergency thoracotomy should be performed in cardiac arrest following penetrating trauma as soon as possible. Highest survival rates in both in-hospital and pre-hospital thoracotomy are found in isolated cardiac stab wounds (19.4%). Poorest survival is found in multiply, ballistic injured patients (0.7%). The latter best reflects the injury pattern of military patients who have cardiac arrest following penetrating torso injury. CONCLUSION As our injury pattern suggests, any pre-hospital thoracotomy on military patients is likely to require complex intervention in very challenging environments. Our evidence does not support the notion that earlier thoracotomy could improve survival.
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Affiliation(s)
- J J Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham B15 2SQ, United Kingdom.
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Ho AMH, Graham CA, Ng CS, Yeung JH, Dion PW, Critchley LA, Karmakar MK. Timing of tracheal intubation in traumatic cardiac tamponade: A word of caution. Resuscitation 2009; 80:272-4. [DOI: 10.1016/j.resuscitation.2008.09.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Revised: 09/09/2008] [Accepted: 09/27/2008] [Indexed: 01/05/2023]
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