Skip to main content
SpringerLink
Log in

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

  • Review Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

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 A UK population reports a single survivor of PHRT following blunt trauma but the case details remain unpublished.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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  3. Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: objectives, indications, and outcomes.” World J Emerg Surg. 2006;1:4.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  5. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma—a review. Injury. 2006;37(1):1–19.

    Article  CAS  Google Scholar 

  6. Ashrafian H, Athanasiou T. Emergency prehospital on-scene thoracotomy: a novel method. Coll Antropol. 2010;34(4):1449–52.

    PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  9. Keogh SP, Wilson AW. Survival following pre-hospital arrest with on-scene thoracotomy for a stabbed heart. Injury 1996;27(7):525–7.

    Article  CAS  Google Scholar 

  10. Deakin CD. From agonal to output: An ECG history of a successful pre-hospital thoracotomy. Resuscitation 2007;75(3):525–9.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  12. Wall MJ, Pepe PE, Mattox KL. Successful roadside resuscitative thoracotomy: case report and literature review. J Trauma. 1994;36(1):131–4.

    Article  Google Scholar 

  13. Craig R, Clarke K, Coats TJ. On scene thoracotomy: a case report. Resuscitation 1999;40(1):45–7.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  19. Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors?” Ann Emerg Med. 2006;48(3):240–4.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  24. Wright K, Murphy K. Cardiac tamponade: a case of kitchen floor thoracotomy. Emerg Med J. 2002;19:587–88.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  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. Harrison OJ, Lockey D. Should resuscitative thoracotomy be performed in the pre-hospital phase of care?” Trauma. 2013;15(2):176–85.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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. 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.

    Article  CAS  Google Scholar 

  33. Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015;108(1):11–6.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

Download references

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.

Author information

Authors and Affiliations

  1. Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK

    Edward J. Nevins, Nicholas T. E. Bird, John V. Taylor & Nikhil Misra

  2. University of Liverpool Medical School, Liverpool, UK

    Parisa L. Moori, John V. Taylor & Nikhil Misra

  3. Department of Anaesthesia, Royal Liverpool University Hospital, Liverpool, UK

    Jonathan Smith-Williams

Authors
  1. Edward J. Nevins
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Parisa L. Moori
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jonathan Smith-Williams
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nicholas T. E. Bird
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. John V. Taylor
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Nikhil Misra
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Edward J. Nevins.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to declare.

Appendix 1

Appendix 1

  1. 1.

    Does your service practice pre-hospital resuscitative thoracotomy?

  2. 2.

    Do you have a standard operating procedure for PHRT?

  3. 3.

    What are your indications for performing PHRT?

  4. 4.

    What are your exclusion criteria for performing PHRT?

  5. 5.

    Do you perform PHRT following blunt trauma?

  6. 6.

    Do you use ultrasound to aid decision-making for PHRT following blunt trauma?

  7. 7.

    Does your service carry pre-hospital blood and blood products?

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nevins, E.J., Moori, P.L., Smith-Williams, J. et al. Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma?. Eur J Trauma Emerg Surg 44, 811–818 (2018). https://doi.org/10.1007/s00068-018-0937-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-018-0937-4

Keywords

Search

Navigation