Resuscitative thoracotomy in blunt traumatic cardiac arrest,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

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Resuscitative thoracotomy in blunt traumatic cardiac arrest
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine ( IF 3.0 ) Pub Date : 2022-04-25 , DOI: 10.1186/s13049-022-01010-8
Benjamin Stretch ₁ , Denise Gomez ₂

Affiliation

Many thanks to EHAAT for publishing their case series showing consistent delivery of resuscitative thoracotomy (RT) in a wide range of clinical scenarios [1]. Although sadly none of the patients survived, our understanding of traumatic cardiac arrest has been improved by the study. The majority (26/44) of RTs were performed in blunt trauma—a less well recognised indication for RT, with a small number of single case reports of survivors and multiple case series from around the world reporting dismal outcomes [2]. As a result, if there is a survival benefit of RT in blunt traumatic cardiac arrest, the NNT may be more than the 26 RT’s performed. The indications for blunt thoracotomy are poorly characterised as shown by a study from Nevins and colleagues, which showed great variation in standard operating procedures across UK pre-hospital services [2].

European Resuscitation Council (ERC) guidelines [3] recommend RT for relieving tamponade and aortic control in subdiaphragmatic haemorrhage in the context of appropriate Expertise, Equipment, Environment and Elapsed time (Fig. 1). In actively deteriorating trauma patients, particularly in the rural setting, there are limited treatment options for active non-compressible haemorrhage. An important finding from this study is that 15% of patients in blunt traumatic cardiac arrest had evidence of cardiac tamponade on RT, which may represent a reversible cause in some cases – however none of these patients survived and will have suffered more complex injury patterns than isolated tamponade.

The Royal College of Emergency Medicine (RCEM) are more pessimistic, stating that immediate surgical support and an onwards chain of survival are required following RT—otherwise the procedure is likely to be futile [4]. A challenge from this case series is geographical location of the incidents, with long transfer times resulting in only 6 of the 44 patients being stable enough for primary transfer to the major trauma centre. The “Trauma Emergency Thoractomy for Resuscitation In Shock” (TETRIS) study is an ongoing national audit on UK RT practice and may help identify which patients (if any) may benefit. Positive prognostic factors are likely to include on-scene expertise at the time of cardiac arrest with immediate RT; cardiac tamponade rather than exsanguinating haemorrhage; concurrent damage control resuscitation including balanced transfusion and temperature management; short transfer time to the Major Trauma Centre with early targeted surgical intervention; otherwise survivable injuries and absence of traumatic brain injury.

Phillip Almond,
Sarah Morton,
Matthew OMeara &
Neal Durge

Essex and Herts Air Ambulance, Earls Colne, Colchester, CO6 2NS, Essex, UK
Phillip Almond, Sarah Morton, Matthew OMeara & Neal Durge

We are grateful to Stretch and Gomez for their feedback. We agree that the timeline for RT remains a challenge, particularly in our environment. We further agree about the current state of the literature landscape and hence why we wanted to share our findings. The point relating to Number Needed to Treat (NNT) is well made and we would go further in agreement by stating a survival rate of 1.4% would yield an NNT of 71—approximately three times the number in our blunt RT series [5]. In short, you have to kiss a lot of frogs!

Other systems have demonstrated that survival is possible, even in the face of long transfer times where blunt force trauma has resulted in cardiac tamponade [6]. It is perhaps a quirk of the rarity of such procedures which brings difficulty in studying or publishing such success. We wholeheartedly commend, support and contribute to the prospective trainee-led TETRIS STUDY, which is now recruiting.

Not applicable.

EHAAT:: Essex and herts air ambulance trust (Title)
RT:: Resuscitative thoracotomy
ERC:: European resuscitation council
RCEM:: The royal college of emergency medicine
TETRIS:: Trauma emergency thoractomy for resuscitation in shock

Almond P, Morton S, OMeara 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): 1-11
Nevins EJ, Moori PL, Smith-Williams J, et al. Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma? Eur J Trauma Emerg Surg. 2018;44:811–8.
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Lott C, Truhlar A, Alfonzo A, Guidelines ERC, et al. Cardiac arrest in special circumstances. Resuscitation. 2021;161(2021):152–219.
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The Royal College of Emergency Medicine (RCEM). Position statement on resuscitative thoracotomy in trauma units. April 2017
Seamon M, Haut E, Van Arendonk K, et al. An evidence based approach to patient selection for emergency department thoracotomy: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma and Acute Care Surgery. 2015;79:159–73.
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Rogerson T, Efstratiades T, Von Oppell U, Davies G, Curtin R. Survival after pre-hospital emergency clamshell thoracotomy for blunt cardiac rupture. Injury. 2020;51:122–3.
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Queen Mary University London, London, UK
Benjamin Stretch
Barts And The London school of Anaesthesia, London, UK
Denise Gomez

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Article prepared and completed by BS.

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Correspondence to Benjamin Stretch or Sarah Morton.

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Stretch, B., Gomez, D. Resuscitative thoracotomy in blunt traumatic cardiac arrest. Scand J Trauma Resusc Emerg Med 30, 30 (2022). https://doi.org/10.1186/s13049-022-01010-8

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Received: 11 February 2022
Accepted: 11 March 2022
Published: 25 April 2022
DOI: https://doi.org/10.1186/s13049-022-01010-8

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中文翻译：

钝性外伤性心脏骤停的复苏性开胸术

非常感谢 EHAAT 发布了他们的案例系列，展示了在广泛的临床场景中持续提供复苏性开胸 (RT) [1]。尽管遗憾的是没有一个患者幸存下来，但这项研究提高了我们对创伤性心脏骤停的理解。大多数 (26/44) 放疗是在钝性创伤中进行的——这是一个不太为人所知的放疗适应症，少数幸存者的单例病例报告和来自世界各地的多个病例系列报告的结果令人沮丧 [2]。因此，如果 RT 对钝性创伤性心脏骤停有生存益处，则 NNT 可能超过 26 次 RT。Nevins 及其同事的一项研究表明，钝性开胸术的适应症特征很差，该研究表明英国院前服务的标准操作程序存在很大差异 [2]。

欧洲复苏委员会 (ERC) 指南 [3] 在适当的专业知识、设备、环境和经过时间的情况下，推荐 RT 用于缓解膈下出血中的填塞和主动脉控制（图 1）。在积极恶化的创伤患者中，特别是在农村地区，活动性不可压缩性出血的治疗选择有限。这项研究的一个重要发现是，15% 的钝性外伤性心脏骤停患者在放疗时有心脏压塞的证据，这在某些情况下可能是可逆的原因——然而，这些患者都没有幸存下来，并且遭受的损伤模式比孤立的填塞物。

皇家急诊医学学院 (RCEM) 更为悲观，指出 RT 后需要立即进行手术支持和后续的生存链——否则该程序可能是徒劳的 [4]。这个案例系列的一个挑战是事件的地理位置，由于转移时间长，44 名患者中只有 6 名足够稳定，可以初步转移到主要创伤中心。“休克复苏的创伤紧急开胸”（TETRIS）研究是对英国 RT 实践的持续国家审计，可能有助于确定哪些患者（如果有）可能受益。积极的预后因素可能包括心脏骤停时的现场专业知识并立即进行放疗；心脏压塞而不是大出血；同步损伤控制复苏，包括平衡输血和温度管理；转移到主要创伤中心的时间短，早期有针对性的手术干预；否则可幸存的伤害和没有创伤性脑损伤。

菲利普杏仁，
莎拉·莫顿
马修·奥米拉 &
尼尔·德奇

Essex and Herts Air Ambulance, Earls Colne, Colchester, CO6 2NS, Essex, UK
菲利普·杏仁、莎拉·莫顿、马修·奥米拉和尼尔·德奇

我们感谢 Stretch 和 Gomez 的反馈。我们同意 RT 的时间表仍然是一个挑战，尤其是在我们的环境中。我们进一步同意文学景观的现状，因此我们想分享我们的发现。与需要治疗的数量 (NNT) 相关的观点说得很好，我们将进一步同意，指出 1.4% 的存活率将产生 71 的 NNT——大约是我们钝性 RT 系列中数量的三倍 [5]。简而言之，你必须亲吻很多青蛙！

其他系统已经证明，即使在钝力创伤导致心脏压塞的较长转移时间的情况下，生存也是可能的[6]。可能是此类程序的稀有性造成了研究或出版如此成功的困难。我们全心全意地赞扬、支持并为未来的受训者主导的俄罗斯方块研究做出贡献，该研究目前正在招募中。

不适用。

EHAAT：: 埃塞克斯和赫茨空中救护车信托（标题）
转发：: 复苏性开胸
ERC：: 欧洲复苏委员会
RCEM：: 皇家急诊医学学院
俄罗斯方块：: 创伤紧急开胸术在休克中复苏

杏仁 P、莫顿 S、OMeara M 等。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): 1-11
Nevins EJ、Moori PL、Smith-Williams J 等人。院前复苏性开胸手术是否应该仅用于穿透性胸部创伤？Eur J Trauma Emerg Surg。2018；44：811-8。
文章谷歌学术
Lott C、Truhlar A、Alfonzo A、指南 ERC 等。特殊情况下心脏骤停。复苏。2021；161（2021）：152–219。
文章谷歌学术
皇家急诊医学学院 (RCEM)。关于创伤单位复苏性开胸术的立场声明。2017 年 4 月
Seamon M、Haut E、Van Arendonk K 等人。急诊开胸患者选择的循证方法：东部创伤外科协会的实践管理指南。J 创伤和急性护理手术。2015；79:159–73。
文章谷歌学术
Rogerson T、Efstratiades T、Von Oppell U、Davies G、Curtin R. 院前紧急翻盖式开胸手术治疗钝性心脏破裂后的生存。受伤。2020；51：122-3。
CAS 文章谷歌学术

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