Paediatric Thoracic Damage Control Resuscitation for Ballistic Injury: A Case Report

Is pre-hospital thoracotomy necessary in the military environment?

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.

Anaesthetic and critical care management of thoracic injuries

Thoracic wounding has been a relatively common presentation of military wounds throughout modern conflict. When civilian casualties are included the incidence has remained constant at around 10%, although the frequency and severity of wounds to combatants has been altered by modern body armour. Whilst thoracic injury has a high initial mortality on the battlefield, those surviving to reach hospital frequently have injuries that only require simple management. In addition to penetrating ballistic injury, blunt chest trauma frequently occurs on operations as a result of road traffic collisions or tertiary blast injury. The physiological impact of thoracic wounds, however, is often great and survivors often require intensive care management and, where available, complex strategies to ensure oxygenation and carbon dioxide removal. This review examines the incidence and patterns of thoracic trauma and looks at therapeutic options for managing these complex cases.