Resuscitative Thoracotomy

[LondonMedic]

I read this at work last week, thought some of the more trauma oriented of you might find it interesting.

http://www.ncbi.nlm.nih.gov/pubmed/21131854

In essence, London HEMS did 71 thoracotomies in cardiac arrest following penetrating trauma to the chest and 13 of those patients survived to discharge, giving a success rate of around 18%.

There's nothing particularly new in the survival factors - penetrating trauma, cardiac tamponade, cut early, etc. But I don't recall the success rate ever being advertised as so high.

 

[mycrofft]

More more more

(Apologies to Billy Idol).
What were the inlcusion criteria, out of how big a general population of similar cases; what was the survival rate at 24 hrs, 72 hrs, and one week-post? What was the type of thoracotomy (which just means putting a hole in the chest; someone's already DONE that).

18% "survival" is not a lot, but if the prior level was zero, it's certainly more.

 

[LondonMedic]

(Apologies to Billy Idol).
What were the inlcusion criteria, out of how big a general population of similar cases; what was the survival rate at 24 hrs, 72 hrs, and one week-post? What was the type of thoracotomy (which just means putting a hole in the chest; someone's already DONE that).

18% "survival" is not a lot, but if the prior level was zero, it's certainly more.

The inclusion criteria were cardiac arrest in the presence penetrating chest or epigastric trauma from a knife. This is very specific and excludes a lot of thoracotomies done by this service for blunt and penetrating trauma from GSW which have a far lower success rate.

The technique was clamshell (interestingly, despite employing surgeons, all the survivors were operated on by an anaesthetist or emergency physician).

18% isn't a lot, but previously it was thought to be around 3%.

 

[mycrofft]

Tantalizing.

In light of the ongoing ALS section debate about epinephrine making little change in ROSC/cardiac arrest, length of survival becomes the next big question. (Example: Roux-en-Y patients were cited as having a survival rate postoperatively of "X", but the study was by the manufacturers of the hardware for the op and was very short; when the survival distance postop was doubled, the survival rate dropped significantly, almost incriminatingly.

If I were the responder, I would be thinking about whether this was direct trauma to the pericardial region, or say a major vessel were opened.

This decade's new MD field procedure can become next decade's ALS procedure.

 

[LondonMedic]

In light of the ongoing ALS section debate about epinephrine making little change in ROSC/cardiac arrest, length of survival becomes the next big question. (Example: Roux-en-Y patients were cited as having a survival rate postoperatively of "X", but the study was by the manufacturers of the hardware for the op and was very short; when the survival distance postop was doubled, the survival rate dropped significantly, almost incriminatingly.

If I were the responder, I would be thinking about whether this was direct trauma to the pericardial region, or say a major vessel were opened.

This decade's new MD field procedure can become next decade's ALS procedure.

This particular study does not follow these patients past discharge, I can't see any particular reason why you would in trauma patients.

 

[mycrofft]

Why follow resuscitation patients?

As discussed in the thread about epinephrine not being the wonderdrug it was cracked up to be, the reason is that simply delivering the pt to the emergency department is not enough, when the goal is for them to recover.

Imaginary example: post field thoracotomy, there is a heightened "to-door" survival rate, but they invariably succumb to one or two complications. Suggestes something intrinsically wrong in that procedure's basis, or in its execution.

Post-admission, and admission-to-discharge survival rates help spell the difference between "Good Job!" and "Thanks for playing, next contestant please".

 

[LondonMedic]

Err, this study is explicitly about survival to discharge and neurological outcomes up to that point.

So whilst it may not be able to tell us that these 18% have a shorter life expectancy (which they may) or the likelyhood of them going on to develop heart failure in later life (which may be quite high), it's some of the best data on what is a relatively new and unvalidated procedure.