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Three Part Question

[In patients in traumatic cardiac arrest after abdominal trauma] does [emergency thoracotomy] [improve survival]?

Clinical Scenario

A young patient has been stabbed in the right lower abdomen and is in PEA cardaic arrest. You wonder whether emergency thoracotomy would improve his chances of survival?

Search Strategy

1. abdominal trauma.mp.
2. resucitative thoracotomy.mp.
3. emergency thoracotomy.mp.
4. thoracotomy.mp.
5. 2 OR 3 OR 4
6. 5 AND 1
210 papers

Search Outcome

1 paper was relevant to the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hughes M.; Perkins Z. 6/2/2020 United Kingdom	Seventeen retrospective case series including 584 patients with isolated abdominal trauma and an additional 1745 suffering from polytrauma including abdominal injuries.	Systematic literature review	Isolated abdominal trauma survival to discharge	0-18%	Retrospective data. Different definitions of cardiac arrest used between papers. Neurological status at discharge only stated in 3/17 papers. Only 6/17 papers commented on timing of thoracotomy.
			Polytrauma survival to discharge	0–9.7% with the majority below 1%
			Neurological outcome of survivors	Of the three papers that commented on neurological deficit the first study showed 100% (4 patients) had no neurological deficit, the second paper showed 25% (1 patient) had no neurological deficit and the third paper including 106 patients showed 68% had no permanent neurological deficit, 12% had a mild neurological deficit and the remaining 20% were in a persistent vegetative state.

Comment(s)

The studies included in this paper were of differing quality but showed a range of survival to discharge of 0–16%, increased to 18% if it was an isolated iliac injury was present. Mortality was better in isolated abdominal trauma. Mortality was improved in patients whose cardiac arrest was witnessed or occurred within the emergency department. PEA was associated with improved survival. Ongoing CPR was a negative predictor of survival in both penetrating and blunt trauma.

Clinical Bottom Line

In patients with abdominal trauma who have recently arrested or are in PEA, emergency thoracotomy may improve survival in traumatic cardiac arrest. Further research should be performed to assess this and ascertain which patients would benefit the most from the intervention.

References

1. Hughes M.; Perkins Z. Outcomes following resuscitative thoracotomy for abdominal exsanguination, a systematic review. Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2020 Feb 6;28(1):9. doi: 10.1186/s13049-020-0705-4