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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. "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. injuries [Subheading] OR trauma[tw] or “major trauma”[tw] OR “severe* injur*”[tw] OR “blunt trauma”[tw] OR “penetrating trauma”[tw]
3. Thoracotomy[Mesh] OR “resuscitative thoracotomy”[tw] OR “prehospital thoracotomy”[tw]
4. Mortality[mesh]
5. #1 AND #2 AND #3 AND #4

Search 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.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
TJ Coats, et al 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
T Athanasiou, et al 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
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
H Matsumoto, et al, 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.
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
M G Van Vledder 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
O J F van Weas, et al 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

Comment(s)

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.

Clinical 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

1. TJ Coats, S Keogh, H Clark, M Neal Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series J Trauma 2001;50(4):670–3
2. 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 Eur J Cardio Thoracic Surg 2004;26(2):377–85
3. D Lockey, K Crewdson, G Davies Traumatic Cardiac Arrest: Who Are the Survivors? Annals of Emergency Medicine 2006; 48(3): 240-244
4. 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. Resuscitation 2009;80(11):1270–4
5. G Davies, D Lockey Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results The Journal of Trauma 2011; 70(5): E75-8
6. 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. Injury 2017;48(9):1865–9
7. 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 Injury 2019, published online
8. 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? J Trauma Emerg Surg 2018 Dec;44(6):811-818