Recently Scott put up a post on this topic and given it’s infrequent occurrence, we don’t mean to spend lots of time but this editorial/article came up so I couldn’t resist mentioning it once more (plus, let’s be serious emergency thoracotomies are pretty awesome especially given they can be life-saving).
I’m not sure how I feel about the idea of pre-hospital thoracotomy (followed by helicopter transport), especially given the often dismal outcomes and the potential for considerable harm. Nevermind the fact that once you performed the procedure, you then have to pack up the patient who has an open chest and get them via helicopter to the ED (wow…). I have to say I’m not particularly in favor of it, but willing to look at the evidence, which this article presents. The authors review the literature and summarize that among those with penetrating trauma (a key distinction), that there’s a survival rate of 11%. Looking at this superficially, that means that there’s a bunch of people that were actually dead who were subsequently saved. What we don’t know is much about the potential for harm (e.g needlestick injuries to healthcare provides, prolonged ICU stays without benefit). In summary, the authors cite the successes from London HEMS and they are clear supporters of this procedure but correctly address the minimal role in blunt trauma. Furthermore they suggest that additional research is needed…realistically, probably hard to gather much more than case series unfortunately. I won’t hold my breath for a large randomized trial in the New England Journal.
An editorial critique follows the article by Dr. Ken Mattox (the world renowed surgeon from Houston of permissive hypotension fame). In looking at both sides he uses the Altemeier axiom “sometimes a solution to a problem creates 4 times as many problems” and I think that definitely could be applied to this procedure. However, he doesn’t exclude the possibility that pre-hospital thoracotomies might have a role in the correct circumstances. He mentions the following overriding principles that would have to be applied
- Protocol overseen by established trauma program and approved by IRB
- Adequate training and appropriate instruments and equipment
- Ability to have communication with the trauma center and trauma surgeon in case of any “surprises”
- All cases must be carefully reviewed by the trauma program for quality assurance
So while it remains controversial, there’s some new discussion among the leaders in trauma resuscitation about pre-hospital thoracotomy. As Scott, has pointed out that it unlikely has much role in Auckland, its definitely interesting to see what’s being discussed.
Source: Roberton and Bulstrode, Emergency department thoracotomies: Is it time we took them to the field? J Trauma vol 73 (no 5): 1070.
Full text pdf is available here (secure area limited to ADHB staff only – ADHB has subscription access for staff to these journals through the Philson Library at the University of Auckland School Of Medicine)
Thanks for the post, Andrew! I was interested to see that the one of the authors of the paper is based in Edinburgh. Scotland has a major problem with knife culture and penetrating trauma – the first and only ED thoracotomy I have been involved with was during my time at the New Royal Infirmary of Edinburgh (cardiothoracic service waiting for the patient in resus, 22 units of red cells, unsuccessful). One of my most vivid memories from that time was seeing what pathology presented to ED when the first bus of the day arrived after a hard night’s drinking (the New Royal is some distance out of the city centre). Facial fracture, boxer’s fracture, scalp laceration, …. what? Three parasternal stab wounds?!? “Och, I had a few too many bevvies, and I dunno what happened, eh pal!”
For a region with a high incidence of penetrating trauma establishing a formal audited pre-hospital thoracotomy program is clearly achievable, as the London HEMS have demonstrated. In our setting, with a low incidence of penetrating trauma, it would take many decades to achieve enough numbers to demonstrate whether it is a useful intervention that we could deliver (especially if we consider that under the best ED circumstances, the majority of these patients will die anyway).
In the New Zealand setting (in my experience) practical training has been limited to surgical trainees. During the surgical portion of the EMST course I did a few years ago, the thoracotomy section of the course, involving performing elements of the procedure on an anaesthetised animal, was limited to the surgeons (ED people like myself got to do the surgical airway). I suspect in most Australasian settings, most ED people have not had much hands-on training in emergency thoracotomy (with a few exceptions like this – http://www.ncbi.nlm.nih.gov/pubmed/20629696 )
One of the most interesting things about the London HEMS case series was that of the 13 survivors, seven were performed by ED doctors and six by anaesthetics doctors. To me, this suggests that with the right training ED doctors can achieve prehospital outcomes that are comparable with ED thoracotomy outcomes reported in the literature.
The second half of this clip shows part of the London HEMS training package for thoracotomy:
If someone from our service is faced with the decision of whether to perform a thoracotomy or not on someone who has arrested in from of them from penetrating trauma, I think that:
a) For our setting, there is no clear answer from the literature
b) We are unlikely to be faced with this often enough to EVER be able to generate sufficient data to remedy a)
c) I think the clinician involved would be open to criticism whether they decided to do the procedure or not
Personally I would attempt it if the indication was there, but I would not be in a hurry to criticise someone else who elected not to do the procedure under the same prehospital circumstances.
It is hard to know how much training time we should devote to this. Given the nature of the jobs we attend, we are far more likely to save lives by focusing on core tasks like RSI and brain-oriented intensive care, and more likely to generate poor outcomes if we fail in our core tasks because we have ‘overcooked’ training in more unusual/unlikely areas, like thoracotomy
Thanks for a very balanced reply Scott. I think this is a very practical approach and I completely agree that emphasis on rarely performed procedures should not detract at all from the training for the core tasks we need to be experts at.
There is a training day for thoracotomy run through the Emergency Department at the Alfred Hospital in Melbourne. The Alfred is the main trauma centre in Melbourne. I was fortunate enough to attend one of these and I was really impressed by their common sense approach and the algorithm they apply. They base their decision to perform a thoracotomy on mechanism (penetrating vs. blunt trauma) + loss of output within 10 minutes + ultrasound evidence of tamponnade (and personally I think this is the latter is thekey so there is documented evidence of the indication for the procedure). They have a kit ready to go in the ED and their staff have clearly defined roles for this procedure. It is very well organised.
Most people with penetrating trauma to the chest that survive until you get there will have wounds to the right side of the heart which fills the pericardium more gradually. In the HEMS video they talk about delivering the heart through the pericardium (and scooping out the clot). Once you have done that, it is relatively easy to apply pressure or a staple to a right sided wound as it is under lower pressure. The tricky thing in some ways is that if you do restore circulation they patient will wake up so you need to make sure you have intubated them in the meantime and there is sedation and analgesia on board.
If anyone is interested in the day programme at the Alfred I will see if it is possible for our docs to attend. Whilst it is a procedure I will probably never do given our culture of blunt more than penetrating trauma, I certainly feel more comfortable having done the course. Or I would… if there was a gigli saw in the pack…….