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”,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

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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”
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine ( IF 3.3 ) Pub Date : 2022-03-21 , DOI: 10.1186/s13049-022-01011-7
E Ter Avest ₁ , L Carenzo ₂

Affiliation

Dear editor

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.

The authors describe a thoracotomy case series of 44 patients seen by a HEMS service. ROSC was achieved in 11/44 (25%) of the patients attended, but none of the patients survived to hospital discharge. Although the authors mention several factors that could potentially have contributed to their findings, we hypothesize that several other factors may have played a role as well.

First, performing a RT in patients who had signs of life (palpable pulses, respiratory effort) on arrival of the first EMS crew is likely more successful then performing a RT in patients in whom the time of arrest is not confirmed [2]. In this cohort, RT was performed in 17 patients (38%) who had lost signs of life before the arrival of the first EMS crew (on average 9.7 min after the 999 call). HEMS arrived on average 29 [range 15–44] minutes after 999 call. By this time the chances of success of resuscitation efforts would have dropped dramatically, which is reflected by the low ROSC rate in this group (3/17). Therefore, although not absolute, recent guidelines recommend a cut-off of 10–15 min no flow time [3].

Second, in 18 patients the procedure was performed to gain aortic control. Aortic control is not only provided to control bleeding (as mentioned by the authors), but also to facilitate resuscitation of the heart by increasing afterload and thereby coronary perfusion and oxygen delivery to the heart. However, this is only helpful when at the same time oxygenated blood is provided to the coronary arteries by rapid transfusion of packed red blood cells (PRBC’s). As blood products were introduced into the service in 2019, the majority of RT’s (29/44) were performed in a time where mainly crystalloids were available to increase preload. Although crystalloids may help to achieve this, they have no oxygen carrying capacity, and hence their administration under circumstances of traumatic cardiac arrest is unlikely to contribute to ROSC.

Finally, the authors mention that 4/26 RT’s for blunt trauma had a tamponade. Although a tamponade is usually regarded as a treatable cause of arrest, it is important to look at the etiology of the tamponade too. In this study one patient had an aortic arch rupture, one had an LAD-graft rupture, one had a tamponade secondary to abdominal injuries, whilst for the last patient the etiology of the tamponade was not mentioned. These injuries are not treatable in the prehospital setting, and therefore when encountered non-survivable. The relatively high incidence of tamponade by itself should therefore not be regarded as a justification to lower the threshold for RT in blunt trauma patients.

Above all, this very interesting study demonstrates that careful patient selection remains of utmost importance when this procedure is carried out in the prehospital setting. Larger cohort studies are needed to refine indications and contra-indications for this advanced procedure, in particular regarding timelines.

Not applicable.

(H)EMS:: (Helicopter) emergency medical service
(P)RBC:: Packed red blood cells
ROSC:: Return of spontaneous circulation
RT:: Resuscitative thoracotomy

Almond P, Morton S, Oeara M, et al. 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. Scand J Trauma Resusc Emerg Med. 2022;30:8. https://doi.org/10.1186/s13049-022-00997-4.
Article PubMed PubMed Central Google Scholar
Athanasiou T, Krasopoulos G, Nambiar P, Coats T, Petrou M, Magee P, et al. Emergency thoracotomy in the pre-hospital setting: a procedure requiring clarification. Eur J Cardiothorac Surg. 2004;26:377–86.
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Lott C, Truhlar A, Alfonzo A, Barelli A, Gonzalez-Salvado V, Hinkelbein J, Nolan JP, European Resuscitation Council Guidelines. Cardiac arrest in special circumstances. Resuscitation. 2021;161:152–219.
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Affiliations

Department of Emergency Medicine, University Medical Center Groningen, University of Groningen, PO Box 9713 GZ, Groningen, The Netherlands
E. ter Avest
Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
L. Carenzo

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E. ter AvestView author publications
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L. CarenzoView author publications
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EtA and LC drafted the letter and both authors read and approved the final manuscript.

Corresponding author

Correspondence to E. ter Avest.

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The authors declare that they have no competing interests.

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ter Avest, E., Carenzo, L. 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”. Scand J Trauma Resusc Emerg Med 30, 21 (2022). https://doi.org/10.1186/s13049-022-01011-7

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Received: 15 February 2022
Accepted: 11 March 2022
Published: 21 March 2022
DOI: https://doi.org/10.1186/s13049-022-01011-7

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中文翻译：

致编辑的信，回应“由直升机紧急医疗服务在城乡混合地区实施的 6 年复苏性开胸病例系列，比较钝性创伤与穿透性创伤”

亲爱的编辑

我们感兴趣地阅读了 Almond 等人的出版物。其中作者描述了由直升机紧急医疗服务 (HEMS) 在英国城乡混合地区实施的 6 年复苏性开胸 (RT) 病例系列 [1]。我们要赞扬作者发表了他们的（基本上是负面的）发现，这表明存在一个非常完善的治理体系。

作者描述了由 HEMS 服务机构看到的 44 名患者的开胸病例系列。11/44 (25%) 的患者实现了 ROSC，但没有患者存活至出院。尽管作者提到了几个可能促成他们的发现的因素，但我们假设其他几个因素也可能发挥了作用。

首先，在第一批 EMS 工作人员到达时对有生命迹象（可触及脉搏、呼吸困难）的患者进行 RT 可能比在未确认逮捕时间的患者中进行 RT 更成功 [2]。在该队列中，有 17 名患者 (38%) 在第一批 EMS 工作人员到达之前（平均在 999 呼叫后 9.7 分钟）就失去了生命迹象，他们接受了 RT。HEMS 在拨打 999 后平均 29 [范围 15-44] 分钟到达。到此时，复苏努力成功的机会将急剧下降，这反映在该组的低 ROSC 率 (3/17)。因此，尽管不是绝对的，但最近的指南推荐 10-15 分钟的无流动时间截止 [3]。

其次，在 18 名患者中进行了手术以获得主动脉控制。主动脉控制不仅用于控制出血（如作者所提到的），而且还通过增加后负荷来促进心脏复苏，从而使冠状动脉灌注和氧气输送到心脏。然而，这仅在通过快速输注浓缩红细胞 (PRBC's) 向冠状动脉提供含氧血液时才有用。随着血液制品于 2019 年投入使用，大多数 RT (29/44) 是在主要晶体液可用于增加预负荷的时期进行的。尽管晶体液可能有助于实现这一目标，但它们没有携氧能力，因此在创伤性心脏骤停的情况下给药不太可能有助于 ROSC。

最后，作者提到用于钝性创伤的 4/26 RT 有填塞物。尽管填塞物通常被认为是可治疗的逮捕原因，但了解填塞物的病因也很重要。在这项研究中，一名患者出现主动脉弓破裂，一名患者出现 LAD 移植物破裂，一名患者出现继发于腹部损伤的填塞物，而最后一名患者未提及填塞物的病因。这些伤害在院前环境中是无法治疗的，因此在遇到无法生存时。因此，相对较高的填塞发生率本身不应被视为降低钝性创伤患者 RT 阈值的理由。

最重要的是，这项非常有趣的研究表明，在院前环境中进行该程序时，仔细选择患者仍然至关重要。需要更大规模的队列研究来完善这种先进程序的适应症和禁忌症，特别是关于时间表。

不适用。

(H)EMS：: （直升机）紧急医疗服务
(P)红细胞：: 包装红细胞
罗斯科：: 自主循环恢复
转发：: 复苏性开胸

杏仁 P、莫顿 S、奥埃拉 M 等人。由直升机紧急医疗服务在城乡混合地区实施的 6 年复苏性开胸病例系列，比较钝性创伤和穿透性创伤。Scand J Trauma Resusc Emerg Med。2022；30:8。https://doi.org/10.1186/s13049-022-00997-4。
文章 PubMed PubMed Central Google Scholar
Athanasiou T、Krasopoulos G、Nambiar P、Coats T、Petrou M、Magee P 等。院前紧急开胸手术：需要澄清的程序。Eur J 心胸外科杂志。2004；26:377–86。
文章谷歌学术
Lott C、Truhlar A、Alfonzo A、Barelli A、Gonzalez-Salvado V、Hinkelbein J、Nolan JP，欧洲复苏委员会指南。特殊情况下心脏骤停。复苏。2021；161：152–219。
文章谷歌学术

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格罗宁根大学医学中心急诊医学系，格罗宁根大学，邮政信箱 9713 GZ，格罗宁根，荷兰
E. ter Avest
意大利米兰罗扎诺 IRCCS Humanitas 研究医院麻醉和重症监护医学部
L.卡伦佐

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EtA 和 LC 起草了这封信，两位作者都阅读并批准了最终手稿。

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ter Avest, E., Carenzo, L. 致编辑的信，回应“由直升机紧急医疗服务在城乡混合地区实施的 6 年复苏性开胸病例系列，比较钝性创伤与穿透性创伤” . Scand J Trauma Resusc Emerg Med 30, 21 (2022)。https://doi.org/10.1186/s13049-022-01011-7

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