EMS World

FEB 2017

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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38 FEBRUARY 2017 | EMSWORLD.com report higher survival rates. Some studies reported survival to hospital discharge of 2.6%–4.5% 19,21 and neurologically intact survival of 2.2%–12.8%. 1,14,17,19 Penetrating trauma almost universally had better sur- vival rates. Blunt trauma had reported sur- vival rates between 0%–12.5%, 1,15,18,22,23 and penetrating trauma had a reported survival between 8.8%–22%. 1,15,18,22,23 Some studies even went further to divide penetrating trauma into stab and gunshot wounds, with survival rates of 15.2%–70.9%, and 0%–29.2% respectively. 1,15,16,20,22 With relatively low survival and widely variable rates of traumatic arrest patients undergoing emergency thoracotomy, many studies have focused on which patients benefit from resuscitation after traumatic arrests. As discussed above, blunt trauma is more uniformly fatal compared to penetrat- ing trauma. When looking at penetrating trauma, stabbing victims are much more likely to be successfully resuscitated com- pared to gunshot victims. But with patients in all of the above categories surviving trau- matic arrests after emergency thoracotomy, what other factors inf luence survival in these patients? As can be expected, isolated head injuries suffering traumatic arrests do not survive resuscitation efforts. 24 Location of injury is also a major factor, with thoracic injuries (and specifically cardiac injuries) having the highest survival, followed by abdomi- nal injuries, with multiple injury locations having the lowest survival. 1 Studies also frequently quoted signs of life at the scene or ED as independent predictors of surviv- al. 22,23 Throughout the literature, the general trend was for increasing survival the closer the arrest was to the hospital. 1,15,16,18,19,25,26 Although the above studies cannot answer this question, is the reason for increased survival for those patients who lose vital signs closer to the hospital due to the time-sensitive nature of more definitive intervention, specifically emergency resus- citative thoracotomy? We already know that CPR is not definitive care for these patients, as hypovolemia or tamponade physiology (typically the cause of arrest) prevents sig- nificant blood circulation with chest com- pressions. 27 And for those patients with cardiac tamponade, pericardiocentesis does not typically work due to clotted blood in the pericardial sac. 28 So how do we get these patients to definitive care more rapidly? Prehospital Evidence As emergency thoracotomy is a time-critical intervention for traumatic arrest and periar- rest patients, is bringing this intervention to the field the next step in trauma care in the United States? In places like the United Kingdom, Germany, Japan, Spain and Australia, this intervention is already a part of the prehospital algorithm for trauma victims. The 2003 guidelines for withholding or terminating resuscitation in prehospital traumatic cardiopulmonary arrest by NAEMSP and ACS said, "Thora- cotomy is not a procedure that falls under the purview of prehospital care." 29 This may be true in a paramedic-run EMS system, as thoracotomy should not be a procedure expected to be performed by paramedics. But in certain other countries across the globe, and increasingly in the United States, physicians have become an integral part of EMS systems. The first case report of prehospital tho- racotomy was actually performed in the United States and is the only published account of a prehospital thoracotomy being performed in the U.S. This procedure was performed in 1988 by a senior surgical resi- dent riding with the Houston EMS system. The patient was a left-thorax stabbing vic- tim and lost pulses prior to EMS departure from the scene, with an estimated trans- port time of 15–20 minutes. The resident performed a left-sided thoracotomy using a scalpel from an OB kit, evacuated a large amount of blood and clot from the chest, and applied manual compression of the descending aorta. The patient regained pulses prior to arrival at the hospital and survived neurologically intact. 30 Since this time case reports of successful prehospital thoracotomies have been pub- lished in the U.K., Finland and Austria. 31–35 Additionally, several EMS systems across the globe have adopted protocols that include prehospital thoracotomy for trau- matic arrests. 27,36,37 Although thoracotomy as a prehospital intervention is gaining acceptance outside the United States, the data on who benefits most from this procedure is still somewhat limited. A handful of retrospective studies have been published by EMS systems that now include prehospital thoracotomy as part of their trauma algorithms. A retrospective review from 1993–1999 in London included penetrating trauma patients with cardiac arrest. This time frame saw 39 prehospital thoracotomies performed. Providers obtained ROSC in 59% of patients, 10% survived to hospital discharge, and 75% of those survived neu- rologically intact. All of the long-term sur- vivors in this study were from stab wounds. Of all the stabbing victims, 16% survived. None of the GSW victims survived. All sur- vivors had cardiac tamponade. 38 This study led to the policy of prehospital thoracoto- mies being performed on all trauma arrest patients with more than 10 minutes' hos- pital transport time in the London HEMS system. After the inclusion of prehospital tho- racotomy in the London HEMS system, a 15-year retrospective database review was published using data from 1993–2008. This included all thoracotomies performed for penetrating chest injury with cardiac arrest times less than 10 minutes prior to EMS arrival. This review excluded GSW victims. In this review 18% of patients survived to hospital discharge, 77% of them neuro- logically intact. Additionally, all survivors with arrest times less than five minutes prior to EMS arrival had good neurologic outcomes. 39 A London HEMS study published in 2004 showed a 9.7% survival for prehospital thoracotomies. This retrospective review included both blunt and penetrating trauma victims, although it did not separate them for analysis. This study showed that thora- cotomy was not an independent predictor of death and concluded that this may be a lifesaving procedure for a select group of patients (although it did not define this subset). 40 Is it time to put emergenc y resuscitative thoracotomy into our EMS trauma protocol s a s the ne x t step in trauma care when physicians are available at the scene?

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