On scene thoracotomy: a case report

[Emergency thoracotomy in a severely injured patient after hemorrhagic shock in traumatic pelvic bleeding : Case report]

A case of in-hospital thoracotomy with subsequent open chest cardiopulmonary resuscitation of a polytraumatized patient is reported. Emergency thoracotomies are rare interventions in challenging situations. Up to now there are only few standards or uniform education and training concepts. The indications are often a borderline decision. The aim of thoracotomy and open resuscitation in combination with a reduction in circulation, for example by cross-clamping the aorta, is to save time to address reversible causes of the hemorrhage, redirect the blood volume into the vital cerebral and coronary circulation and minimize bleeding from subdiaphragmatic bleeding sources. Ultimately, in case of doubt, the thoracotomy can be performed for the patient's benefit with the appropriate indications.

[Indications, procedure and outcome of prehospital emergency resuscitative thoracotomy-a systematic literature search]

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.

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

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.

Reflections on Twenty Years of Prehospital Care

Although Accident and Emergency staff may feel that prehospital care is the province of the ambulance service alone, their interest in this area is important. Both A&E doctors and nurses have an important role to play in the training of paramedics, and in some circumstances in the direct provision of prehospital care. Physician involvement in routine prehospital care, whether by land or helicopter transport, is still controversial. This paper reviews some of the issues involved in prehospital care over the last twenty years, in addition to a personal perspective from the author. In the absence of a firm evidence base to lead the way to future development in Hong Kong, more research will be needed by doctors, nurses and ambulance staff.

[Successful preclinical thoracotomy in a 17-year-old man]

We report the case of a 17-year-old man who sustained multiple stab wounds after a knife attack. After arrival of the emergency medical team the patient suffered a cardiac arrest caused by cardiac tamponade. After emergency thoracotomy and open heart massage the patient developed ROSC and could be discharged 13 days later without neurological deficits. Prehospital thoracotomy is rarely performed in Austria but is the only realistic chance for survival in cases of hematopericardium and tamponade. Better training of emergency physicians in Austria concerning surgical resuscitation could increase survival rates especially after penetrating thoracic trauma.

Should prehospital resuscitative thoracotomy be incorporated in advanced life support after traumatic cardiac arrest?

The survival of traumatic cardiac arrest patients poses a challenge for Emergency Medical Services initiating advanced life support on-scene, especially with regard to having to decide immediately whether to initiate prehospital emergency thoracotomy. Although the necessity for carrying out the procedure remains a cause for debate, it can be life-saving when performed with the correct indications and approaches.

Should resuscitative thoracotomy be performed in the pre-hospital phase of care?

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.

[Emergency thoracotomy. Indications, surgical technique and results]

Emergency thoracotomy is a surgical technique that has been extended in the last few years, and is currently included in advanced cardiopulmonary resuscitation protocols. Despite its proven use in patients with penetrating heart wounds, it is often not used due to lack of knowledge of the technique. Currently, the increase in chest wounds due to violence, traffic accidents, crashes or suicides, and advances in extra-hospital medical care systems, has currently awakened new interest in this technique. A review of emergency thoracotomy is presented in this article: indications, surgical technique, results, and its usefulness in the extra-hospital setting.

[Open chest cardiopulmonary resuscitation: is there an interest in France?]

OBJECTIVE

To expose and clarify indications, techniques, results, complications and cost for open chest cardiopulmonary resuscitation manoeuvres (OCCRM) in traumatic or nontraumatic cardiac arrest.

DATA SOURCES

References were obtained from Pubmed data bank using the following keywords: "emergency thoracotomy", "resuscitative thoracotomy".

STUDY SELECTION

We focused on publications in English language, from 2000 to 2007.

DATA SYNTHESIS

OCCRM are useful especially in case of traumatic cardiac arrest, penetrating trauma, but also in blunt trauma. Time between cardiac arrest and realisation of the thoracotomy seems to be the most important factor for the prognosis.

CONCLUSION

According to the French "physician in ambulance" prehospital system, OCCRM might be promising in France, because this system favours the fastness of care and therefore would minimize the time factor.

A successful emergency thoracotomy performed in the field

An emergency thoracotomy (ET) is a surgical procedure rarely practiced outside a hospital. However, it can be the only way to resuscitate a patient who has suffered cardiac arrest due to penetrating chest trauma. SAMUR-Protección Civil is a two-tier Emergency Medical Service of Madrid, with Advance Life Support teams led by Emergency Physicians, Emergency Nurses and Paramedics. Over the last 3 years, medical teams from SAMUR have performed ET in six cases, after a short period of cardiac arrest, restoring cardiac output in two cases, and one patient with a normal neurological outcome. The following SAMUR protocol describes these emergency situations and details the case of the patient who was treated and discharged from hospital without any repercussions.

Emergency thoracotomy in trauma: rationale, risks, and realities

Emergency department thoracotomy (EDT) may serve as a life-saving tool when performed for the right indications, in selected patients, and in the hands of a trained surgeon. Critically injured patients 'in extremis' arrive at an increasing rate in the trauma bay, as an effect of improved pre-hospital trauma systems and rapid transport. Any patient in near, or full cardiovascular shock prompts the trauma surgeon to rapidly perform a thoracotomy. The EDT procedure is managed best by surgeons familiar with, and experienced in, penetrating cardiothoracic injuries. However, the geographical differences in trauma epidemiology lends no, or only scarce, experience with this procedure in most European trauma centres. Consequently, mandatory training is imperative for success. The rationale for performing an EDT is to: (I) resuscitate the agonal patient with penetrating cardiothoracic injuries; (II) release cardiac tamponade by evacuation of pericardial blood; (III) immediately control hemorrhage and repair cardiac or pulmonary injury; (IV) perform open cardiac massage; and (V) place a thoracic aortic cross-clamp to redistribute the remaining blood volume, and perfuse the carotids and coronary arteries. The prevalence rates of blood-borne viruses reported in critically injured patients in the USA (10-20%) exceed the prevalence in the Nordic countries (HIV prevalence < 1% in general population). However, risk is not negligible and mandated universal precautions are needed. The literature is rich in series describing the use of EDT, however, the best evidence is derived from a few prospective trials. EDT saves about one in every five patients with isolated penetrating cardiac injury, while > 98% die after blunt injury. Based on an updated review of the current available literature, this paper presents the current evidence regarding the rationale, risk, and outcomes for employing EDT in the field of trauma surgery.

Resuscitative emergency thoracotomy in a Scandinavian trauma hospital--is it justified?

OBJECTIVE

Resuscitative emergency thoracotomy (ET) is of value in selected (penetrating) trauma patients. Current survival-estimates and recommended guidelines are based on data from the United States. However, reports from European trauma centres are lacking. We report the current experience from a Scandinavian trauma hospital.

METHODS

Identification of all consecutive ETs performed during a 5-year period. Data on demographics, and injury severity score (ISS), mechanism and location were recorded. Physiological status on admission (revised trauma score, RTS) and probability of survival (Ps) were calculated. Signs of life (SOL) and need for closed-chest cardiopulmonary resuscitation (CC-CPR) were recorded through the post-injury phase.

RESULTS

Ten patients underwent ET with no survivors. The annual incidence of ET was 0.7 per 100,000 inhabitants during the study period, with an increasing trend during the last years (r=0.74, p=0.014). ETs were performed in 0.7% of all trauma admissions, and in 2.5% of all severely injured patients (ISS>or=16). Blunt mechanism dominated; only three had penetrating injuries. Most frequent location of major injury was "multiple" (n=4) and "thoracic" (n=4). The male to female ratio was 7:3. Median age was 51 years (range 21-77). Median ISS was 34.5 (range 26-75), indicating severely injured patients, with seriously deranged physiology (median RTS of 0.0, range 0-6.1) with poor chance of survival (median Ps of 4.4%, range 0-89.5%). Males had significantly lower RTS and Ps (p=0.007 and 0.03, respectively) than females. Eight patients had signs of life at some time post-injury, but only four in the emergency room. Six patients had both pre- and in-hospital CC-CPR. Four patients had additional surgery to ET. Two possible preventable deaths were identified (Ps) of 51 and 89%), one in a third trimester pregnancy.

CONCLUSION

Emergency thoracotomy is a rarely performed procedure in a rather busy Scandinavian trauma hospital, and outcome is dismal. Reevaluation of our decision-making process concerning the use of emergency thoracotomy is needed. How survival data and clinical experience in Europe compare to current figures from North America deserves further attention.

Open-chest CPR improves survival and neurologic outcome following cardiac arrest

STUDY OBJECTIVE

To determine if 15 min of open-chest cardiac massage (OC-CPR) versus closed-chest compressions (CC-CPR) improves 72-h survival and neurologic outcome (behavioral and histologic) after 5 min of untreated cardiac arrest.

METHODS

Mongrel dogs were anesthetized and instrumented. Cardiac arrest was induced by KCl injection and after a 5-min period of non-intervention, dogs were randomized to receive either CC-CPR (N = 7) or OC-CPR (N = 5) performed for 15 min. The dogs were then resuscitated and physiologic data was recorded. Surviving dogs were scored at 72 h using canine neurodeficit score of Safar et al. (NDS; 0 = behaviorally normal, 500 = brain death). Dogs that could not be resuscitated or died before 72 h were assigned a score of 500. Brain histology was performed on all survivors.

RESULTS

All OC-CPR dogs were successfully resuscitated and were behaviorally normal at 72 h (NDS = 0). Histology in OC-CPR dogs showed little to no injury. Only three out of the seven CC-CPR dogs survived to 72 h. Of the survivors, one dog exhibited minor ataxia (NDS = 15), and two had incapacitating deficits (both NDS = 180). Two dogs died within 24 h after extubation, and one could not be resuscitated and the other could not be weaned from the ventilator (each NDS = 500). Histology of the CC-CPR survivors revealed moderate to severe lesions. NDS between groups was statistically significant (p < 0.0079).

CONCLUSION

In our canine model of cardiac arrest, OC-CPR significantly improved 72-h survival and neurologic outcome when compared to CC-CPR.