Elsevier

Injury

Volume 48, Issue 9, September 2017, Pages 1865-1869
Injury

Full length article
Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma

https://doi.org/10.1016/j.injury.2017.04.002Get rights and content

Abstract

Introduction

Emergency department thoracotomy is an established procedure for cardiac arrest in patients suffering from penetrating thoracic trauma and yields relatively high survival rates (up to 21%) in patients with cardiac tamponade. To minimize the delay between arrest and thoracotomy, some have advocated thoracotomy on the accident scene. The aim of this study was to determine the proportion of patients with return of spontaneous circulation and subsequent survival after out of hospital thoracotomy in the Netherlands.

Methods

A retrospective analysis of data collected on all out of hospital thoracotomies performed in the Netherlands after penetrating trauma between April 1st, 2011 and September 30th, 2016 was performed. Data on patient characteristics, trauma mechanism and outcome were collected and analyzed. Primary outcome measure was return of spontaneous circulation after the intervention. Survival to hospital discharge was the secondary outcome variable.

Results

Thirty-three prehospital emergency thoracotomies were performed. Ten patients (30%) had gunshot wounds and 23 patients (70%) had stab wounds. Nine patients (27%) had return of spontaneous circulation and were presented to the hospital. Of these, one patient survived until discharge without neurological damage. Five died in the emergency department or operating room and three died in ICU.

Conclusion

Return of spontaneous circulation after out of hospital thoracotomy for cardiac arrest due to penetrating thoracic injury is achievable, but a substantial number of patients die during the in hospital resuscitation phase. However, neurologic intact survival can be achieved.

Introduction

Traditional cardiopulmonary resuscitation for out of hospital traumatic cardiac arrest is associated with poor survival [1]. For patients with cardiac arrest resulting from cardiac tamponade after penetrating thoracic injury, emergency thoracotomy with decompression of the pericardial sac may offer a significant chance of survival. Emergency department series have reported survival rates up to 21% [1].

Emergency department thoracotomy has been included in the guidelines of the European resuscitation council as a resuscitative procedure for patients suspected of having circulatory arrest and cardiac tamponade [2]. Emergency room thoracotomy has been an established procedure in Dutch trauma centers for many years with favorable results [3]. Longer transportation times to the hospital may be associated with poor outcome in these patients; Ideally thoracotomy should be performed within 10 min after circulatory arrest, which is very hard to achieve when arrest occurs in an out of hospital setting1. Davies et al. reported on prehospital thoracotomies performed by the physician-led London Helicopter Emergency Medical Service (HEMS) in patients suffering from cardiac arrest after sustaining a stab wound to the chest. Thirteen out of 71 patients survived to hospital discharge after out of hospital emergency thoracotomy [4]. Therefore, it was hypothesized that adding this procedure to the armamentarium of Dutch HEMS personnel may lead to increased odds of survival in selected patients.

The aim of this retrospective case-series was to determine the proportion of patients with return of spontaneous circulation and subsequent survival after out of hospital thoracotomy. Furthermore, we describe the introduction and implementation of this procedure in the Dutch physician staffed Helicopter Emergency Medical Service (HEMS).

Section snippets

Dutch HEMS operation

The Netherlands covers approximately 41,000 square kilometers and holds about 17 million inhabitants. Prehospital emergency medical services are mostly provided by ground ambulance crews staffed with paramedics, trained in prehospital trauma life support (PHTLS) and a background in intensive care or emergency medicine. Ground emergency medical services (EMS) are supplemented by four physician-led HEMS operations across the country. A HEMS team consists of a board-certified anesthesiologist or

Results

A total of 33 out of hospital thoracotomies were performed. Fourteen thoracotomies (42%) were performed by five trauma surgeons and 19 thoracotomies (58%) were performed by eleven anesthesiologists. Patient characteristics and outcome are presented in Table 1, stratified by trauma-mechanism.

Zero out of ten patients with gunshot wounds had return of spontaneous circulation. Nine out of 23 patients with stab wounds (39%) had return of spontaneous circulation after thoracotomy on-scene and were

Discussion

This paper describes the introduction of prehospital emergency thoracotomy in the Dutch HEMS operation. A total of 33 prehospital emergency thoracotomies were performed in patients suffering cardiac arrest after sustaining penetrating thoracic injury. Nine patients had ROSC and one patient survived to hospital discharge. Since 59% of thoracotomies were performed by anesthesiologists (among which the only surviving patient in this series), we believe this procedure can be successfully taught to

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