Abstract
BackgroundResuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade however Its role in resuscitation of patients with abdominal exsanguination is uncertain.ObjectiveThe primary objective of this systematic review was to estimate mortality based on survival to discharge in patients with exsanguinating haemorrhage from abdominal trauma in cardiac arrest or a peri arrest clinical condition following a resuscitative thoracotomy.MethodsA systematic literature search was performed to identify original research that reported outcomes in resuscitative thoracotomy either in the emergency department or pre-hospital environment in patients suffering or suspected of suffering from intra-abdominal injuries. The primary outcome was to assess survival to discharge. The secondary outcomes assessed were neurological function post procedure and the role of timing of intervention on survival.ResultsSeventeen retrospective case series were reviewed by a single author which described 584 patients with isolated abdominal trauma and an additional 1745 suffering from polytrauma including abdominal injuries. Isolated abdominal trauma survival to discharge ranged from 0 to 18% with polytrauma survival of 0–9.7% with the majority below 1%. Survival following a thoracotomy for abdominal trauma varied between studies and with no comparison non-intervention group no definitive conclusions could be drawn.Timing of thoracotomy was important with improved mortality in patients not in cardiac arrest or having the procedure performed just after a loss of signs of life. Normal neurological function at discharge ranged from 100 to 28.5% with the presence of a head injury having a negative impact on both survival and long-term morbidity.ConclusionsPre-theatre thoracotomy may have a role in peri-arrest or arrested patient with abdominal trauma. The best outcomes are achieved with patients not in cardiac arrest or who have recently arrested and with no head injury present. The earlier the intervention can be performed, the better the outcome for patients, with survival figures of up to 18% following a resuscitative thoracotomy. More high-quality evidence is required to demonstrate a definitive mortality benefit for patients.
Highlights
Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade Its role in resuscitation of patients with abdominal exsanguination is uncertain
The earlier the intervention can be performed, the better the outcome for patients, with survival figures of up to 18% following a resuscitative thoracotomy
A thoracotomy is referred to by a variety of names in periarrest or arrested patients depending on the physical location it is performed and the physiological status of the patient [4, 5]
Summary
Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade Its role in resuscitation of patients with abdominal exsanguination is uncertain. The procedure is included in the European resuscitation council guidelines for traumatic cardiac arrest for both penetrating and blunt trauma with survival rates of 6–7% reported by several studies for those suffering from penetrating chest injuries, demonstrating the best outcomes [6,7,8].Cross-clamping of the thoracic aorta in order to arrest bleeding and improve blood flow proximal to the clamp is a recognised part of the procedure [9] This is a manoeuvre used both in and out of the operating theatre and is applied to those with intrabdominal trauma in some circumstances, gaining proximal control of arterial bleeding via the chest cavity [9]. This theory has been reinforced by reports that traumatic cardiac arrest is a “low flow state” rather than a cessation of cardiac activity suggesting that rapid intervention to control haemorrhage may be of benefit [10]
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