Vol.:(0123456789) 1 3 European Journal of Trauma and Emergency Surgery https://doi.org/10.1007/s00068-018-0937-4 REVIEW ARTICLE Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma? Edward J. Nevins 1  · Parisa L. Moori 2  · Jonathan Smith‑Williams 3  · Nicholas T. E. Bird 1  · John V. Taylor 1,2  · Nikhil Misra 1,2 Received: 24 January 2018 / Accepted: 3 March 2018 © Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract Purpose The indications for pre-hospital resuscitative thoracotomy (PHRT) remain undefned. The aim of this paper is to explore the variation in practice for PHRT in the UK, and review the published literature. Methods MEDLINE and PUBMED search engines were used to identify all relevant articles and 22 UK Air Ambulance Services were sent an electronic questionnaire to assess their PHRT practice. Results Four European publications report PHRT survival rates of 9.7, 18.3, 10.3 and 3.0% in 31, 71, 39 and 33 patients, respectively. All patients sustained penetrating chest injury. Six case reports also detail survivors of PHRT, again all had sustained penetrating thoracic injury. One Japanese paper presents 34 cases of PHRT following blunt trauma, of which 26.4% survived to the intensive therapy unit but none survived to discharge. A UK population reports a single survivor of PHRT following blunt trauma but the case details remain unpublished. Ten (45%) air ambulance services responded, each service reported diferent indications for PHRT. All perform PHRT for penetrating chest trauma, however, length of allowed pre-procedure down time varied, ranging from 10 to 20 min. Seventy percent perform PHRT for blunt traumatic cardiac arrest, a procedure which is likely to require aggressive concurrent circulatory support, despite this only 5/10 services carry pre-hospital blood products. Conclusions Current indications for PHRT vary amongst diferent geographical locations, across the UK, and worldwide. Survivors are likely to have sustained penetrating chest injury with short down time. There is only one published survivor of PHRT following blunt trauma, despite this, PHRT is still being performed in the UK for this indication. Keywords Pre-hospital · Resuscitative thoracotomy · Traumatic cardiac arrest · Penetrating chest trauma · Blunt chest trauma Introduction Resuscitative thoracotomy (RT) is now a recognized pro- cedure for patients who are in extremis following traumatic cardiac arrest [1–4]. The primary objective of RT is to con- trol and maintain perfusion to the cardio-respiratory and central nervous system. This can be achieved by the relief of tension pneumothorax, pericardiotomy for the relief of tamponade and cessation of cardiac haemorrhage, control of thoracic exsanguination, open cardiac massage, expulsion of massive air embolism, and temporary occlusion of the descending thoracic aorta for control of sub-diaphragmatic haemorrhage and redistribution of blood to supra-diaphrag- matic organs [1, 3, 5]. Typically, this is performed in the emergency depart- ment (emergency department thoracotomy, EDT) as soon as possible after the patient arrives, as prognosis strongly correlates with the time between loss of cardiac output and commencement of this procedure [2]. In light of this, a num- ber of authors have advocated that RT should not be per- formed if the patient has been in cardiac arrest for prolonged lengths of time [1–4]. Given that, advanced surgical skill and equipment is not always required for RT [6], pre-hospital resuscitative thoracotomy (PHRT) has, therefore, been con- sidered as a viable option for patients who have arrested * Edward J. Nevins dr.e.nevins@gmail.com 1 Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK 2 University of Liverpool Medical School, Liverpool, UK 3 Department of Anaesthesia, Royal Liverpool University Hospital, Liverpool, UK