A 6-year case series of resuscitative thoracotomies performed by a helicopter emergency medical service in a mixed urban and rural area with a comparison of blunt versus penetrating trauma

Abstract

Background Resuscitative thoracotomy (RT) is an intervention that can be performed in the prehospital setting for relieving cardiac tamponade and/or obtaining vascular control of suspected sub-diaphragmatic haemorrhage in patients in traumatic cardiac arrest. The aim of this retrospective case study is to compare the rates of return of spontaneous circulation (ROSC) in RTs performed for both penetrating and blunt trauma over 6 years in a mixed urban and rural environment. Methods The electronic records of a single helicopter emergency medical service were reviewed between 1st June 2015 and 31st May 2021 for RTs. Anonymised data including demographics were extracted for relevant cases. Data were analysed with independent t-tests and Χ2 tests. A p value < 0.05 was considered statistically significant. Results Forty-four RTs were preformed within the 6 years (26 for blunt trauma). Eleven ROSCs were achieved (nine blunt, two penetrating) but no patient survived to discharge. In contrast to RTs for penetrating trauma, twelve of the RTs for blunt trauma had a cardiac output present on arrival of the prehospital team (p = 0.01). Two patients had an RT performed in a helicopter (one ROSC) and two on a helipad (both achieving ROSC), likely due to the longer transfer times seen in a more rural setting. Four of the RTs for blunt trauma (15%) were found to have a cardiac tamponade versus seven (39%) of the penetrating trauma RTs. Conclusion Prehospital RT remains a procedure with low rates of survival but may facilitate a ROSC to allow patients to reach hospital and surgery, particularly when distances to hospitals are greater. A higher-than-expected rate of cardiac tamponade was seen in RTs for blunt trauma, although not caused by a right ventricular wound but instead due to underlying vessel damage.

Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries

“…In these patients, swift decision-making is warranted and a low threshold to perform a RT could be justified. Although the overall mortality of patients with a pre-hospital RT is high as a prolonged no-flow time, aortic cross-clamping and hypothermia often result in irreversible trauma-induced coagulopathy and/or multi-organ failure [ 32 , 33 ], the survival in patients who have a cardiac tamponade and a short TCA duration approaches 20% [ 12 ].…”

Outcomes of the resuscitative and emergency thoracotomy at a Dutch level-one trauma center: are there predictive factors for survival?

“…Both are part of the damage control surgery arsenal and are usually performed in the emergency department (ED) or the operating room (OR) [ 1 – 3 ]. Furthermore, especially resuscitative thoracotomies are increasingly applied in the field by Helicopter Emergency Medical Services (HEMS) [ 4 – 6 ]. While the objective of a damage control thoracotomy is undisputed, the indications remain a topic of debate and are closely related to the chance of survival.…”

“…For patients with penetrating thoracic injuries, the indication is stretched to cardiac arrest < 15 min prior to arrival and witnessed arrest [ 11 , 12 ]. As a result of the importance of elapsed time after cardiac arrest and the trauma mechanism, the decision to perform a resuscitative or emergency thoracotomy will highly depend on geographic circumstances and pre-hospital logistics [ 6 , 13 , 14 ]. For example, within the Netherlands, resuscitative or emergency thoracotomies by the HEMS are rare since the Netherlands has 11 level I trauma centers, enabling relatively short transport times to level I trauma centers[ 5 ].…”

Letter to the editor in response to “A 6-year case series of resuscitative thoracotomies performed by a helicopter emergency medical service in a mixed urban and rural area with a comparison of blunt versus penetrating trauma”

“…With interest we read the publication of Almond et al wherein the authors describe a 6-year case series of resuscitative thoracotomies (RT) performed by a helicopter emergency medical service (HEMS) in a mixed urban and rural area in the UK [ 1 ]. We’d like to compliment the authors for publication of their (essentially negative) findings, which demonstrates the presence of a very well established governance system.…”