Prehospital resuscitative thoracotomy in trauma patients
Date First Published:
March 22, 2021
Last Updated:
March 22, 2021
Report by:
Dr Thomas Shanahan, ST1 emergency medicine and NIHR Academic Clinical Fellow (Manchester University NHS Foundation Trust)
Search checked by:
Dr Peter Hulme, Manchester University NHS Foundation Trust
Three-Part Question:
[In trauma patients] does [prehospital resuscitative thoracotomy] improve [survival]?
Clinical Scenario:
30 year old male has been involved in a road traffic collision and sustained penetrating injuries to the chest. You arrive on scene and the patient loses his pulse and goes into traumatic cardiac arrest. You wonder whether a prehospital resuscitative thoracotomy (PHRT) would improve his chances of survival?
Search Strategy:
We searched Medline using the PubMed interface using the following terms:
1.t"Emergency Medical Services"[Mesh] OR prehospital[tw] OR pre-hospital[tw] OR “emergency care, prehospital”[tw] OR “prehospital emergency care”[tw] OR “out-of-hospital”[tw]
2.tinjuries [Subheading] OR trauma[tw] or “major trauma”[tw] OR “severe* injur*”[tw] OR “blunt trauma”[tw] OR “penetrating trauma”[tw]
3.tThoracotomy[Mesh] OR “resuscitative thoracotomy”[tw] OR “prehospital thoracotomy”[tw]
4.tMortality[mesh]
5.t#1 AND #2 AND #3 AND #4
1.t"Emergency Medical Services"[Mesh] OR prehospital[tw] OR pre-hospital[tw] OR “emergency care, prehospital”[tw] OR “prehospital emergency care”[tw] OR “out-of-hospital”[tw]
2.tinjuries [Subheading] OR trauma[tw] or “major trauma”[tw] OR “severe* injur*”[tw] OR “blunt trauma”[tw] OR “penetrating trauma”[tw]
3.tThoracotomy[Mesh] OR “resuscitative thoracotomy”[tw] OR “prehospital thoracotomy”[tw]
4.tMortality[mesh]
5.t#1 AND #2 AND #3 AND #4
Outcome:
The search resulted in 79 papers. Six of them were found to be relevant to the question. Four were excluded. One was an editorial, which provided no new data. Two were case reports. One was a review, the results of which have been incorporated into this BestBET and referenced (Nevins, et al, 2018).
We also did a reference review of the original six papers and found five additional studies. This resulted in a total of seven papers.
We also did a reference review of the original six papers and found five additional studies. This resulted in a total of seven papers.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series TJ Coats, S Keogh, H Clark, M Neal 2001 UK | 39 prehospital thoracotomies over six years (1993 to 1999) |
Retrospective case review Level 4 |
Survival to hospital discharge and neurological status | 4 (10%) survivors with one with long-term disability | Retrospective and observational and unclear if patients are included in other studies |
| Emergency thoracotomy in the pre-hospital setting: a procedure requiring clarification T Athanasiou, G Krasopoulos, P Nambiar, T Coats, M Petrou, P Magee, R Uppal 2004 UK | 670 consecutive patients; 31 (58%) were prehospital thoracotomies | Retrospective & multivariable regression analysis Level 4 |
Emergency thoracotomy as an independent predictor of mortality following chest trauma | Emergency thoracotomy was not an independent predictor of mortality (OR = 1.93, 95% CI 0.61 – 6.1) | No mortality data for prehospital thoracotomy; incomplete prehospital data; small sample size |
| Traumatic Cardiac Arrest: Who Are the Survivors? D Lockey, K Crewdson, G Davies 2006 UK | 909 patients; 93 prehospital thoracotomies. 10 year retrospective database (July 1994 – July 2004) | Retrospective case series Level 4 |
Survival to hospital discharge and neurological status | 8 survived (8.6%); 5 with good neurological status (62.5%) | Retrospective and observational and unsure if patients are included in other studies; small sample size |
| Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system. H Matsumoto, K Mashiko, Y Hara, N Kutsukata, Y Sakamoto, K Takei, K Kanemaru, Y Tomita, N Saito, T Yagi, S Tetsu, H Lida, Y Masuda, H Koami, H Yokota 2009 Japan | 95 consecutive cases; 34 prehospital thoracotomies; January 2003 – July 2008 | Retrospective case review Level 4 |
Rates of heartbeat restoration & ICU admission | No survivors; 27 (80%) had heartbeat restoration in cardiac arrest after EMT arrival with 24 (70%) admission to ICU; 2 (8%) had heartbeat restoration in cardiac arrest before EMT arrival with 2 (8%) admission to ICU | Retrospective, small sample size, no agreed protocol for when to perform a prehospital thoracotomy. No use of the same outcome measures in other studies of prehospital thoracotomy to compare with. |
| Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results G Davies, D Lockey 2011 UK | 71 patients with penetrating chest trauma; 15 years (1993 – 2008) | Retrospective case review Level 4 |
Survival to hospital discharge and neurological status | 13 (18%) survived to hospital discharge; neurological outcome was good in 11 (85%) and poor in 2 (15%) | Retrospective and observational and unsure if patients are included in other studies; small sample size |
| Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma. MG Van Vledder, OFJ Van Waes, FO Kooij, JH Peters, EMM Van Lieshout, MHJ Verhofstad 2017 The Netherlands | 33 pre-hospital thoracotomies; 5 years (September 2011 – September 2016) | Retrospective case review Level 4 |
Primary: ROSC; secondary: survival to hospital discharge | 9 (27%) had ROSC; 1 survivor (3%) | Retrospective and observational; small sample size |
| Evaluation of out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma; Three years after our first report O J F van Weas, AM Leemeyer, FO Kooij, N Hoogerwerf, MG Van Vledder 2019 The Netherlands | 71 pre-hospital thoracotomies (37 added to the above M G Van Vledder paper); 8 years (September 2011 – August 2019) |
Retrospective case review as a letter to the editor Level 4 |
Survival to hospital discharge | 5 (7%) survived to hospital discharge | Retrospective and observational & cross-over in patients with another study |
Author Commentary:
The search and reference review resulted in eight case reports, which provided information on survivors only. They provide useful discussions of the indications for prehospital thoracotomy, how the procedure was performed and outcomes. However, as they do not provide a denominator (total number of prehospital thoracotomies performed) they are of limited value to assess the efficacy of prehospital thoracotomy in penetrating or blunt trauma and have thus been excluded.
The remaining seven studies are all retrospective clinical case series. Thoracotomies were performed in the UK, Dutch and Japanese prehospital systems. Cardiac tamponade following a penetrating injury was the primary pathology in these papers. The predominant outcome was survival to hospital discharge. Survival to hospital discharge varied from 0% to 18%.
Four papers came from London ambulance service. There are cross-over in terms of dates, and quite possibly patients. The case reviews suggest improved survival over time in the London system.
The remaining seven studies are all retrospective clinical case series. Thoracotomies were performed in the UK, Dutch and Japanese prehospital systems. Cardiac tamponade following a penetrating injury was the primary pathology in these papers. The predominant outcome was survival to hospital discharge. Survival to hospital discharge varied from 0% to 18%.
Four papers came from London ambulance service. There are cross-over in terms of dates, and quite possibly patients. The case reviews suggest improved survival over time in the London system.
Bottom Line:
Prehospital thoracotomy in a carefully selected group of patients might have a role. From these papers the patients most likely to survive had penetrating thoracic injuries, which resulted in cardiac tamponade and had the thoracotomy performed within 10 minutes of cardiac arrest.
References:
- TJ Coats, S Keogh, H Clark, M Neal. Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series
- T Athanasiou, G Krasopoulos, P Nambiar, T Coats, M Petrou, P Magee, R Uppal. Emergency thoracotomy in the pre-hospital setting: a procedure requiring clarification
- D Lockey, K Crewdson, G Davies. Traumatic Cardiac Arrest: Who Are the Survivors?
- H Matsumoto, K Mashiko, Y Hara, N Kutsukata, Y Sakamoto, K Takei, K Kanemaru, Y Tomita, N Saito, T Yagi, S Tetsu, H Lida, Y Masuda, H Koami, H Yokota. Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system.
- G Davies, D Lockey. Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results
- MG Van Vledder, OFJ Van Waes, FO Kooij, JH Peters, EMM Van Lieshout, MHJ Verhofstad. Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma.
- O J F van Weas, AM Leemeyer, FO Kooij, N Hoogerwerf, MG Van Vledder. Evaluation of out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma; Three years after our first report
- EJ Nevins, PL Moori, J Smith-Williams, NTE Bird, JV Taylor, N Misra. Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma?