Prehospital Resuscitative Thoracotomy for Traumatic Cardiac Arrest

Abstract

IMPORTANCE: Traumatic cardiac arrest (TCA) presents a critical challenge in trauma care, often occurring rapidly after injury before effective interventions are available.OBJECTIVE: To evaluate the association of prehospital resuscitative thoracotomy with survival outcomes for TCA.DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study examined all cases of prehospital resuscitative thoracotomy for TCA in London from January 1999 to December 2019. Data were analyzed from July 2022 to July 2023.EXPOSURE: Prehospital resuscitative thoracotomy for TCA.MAIN OUTCOMES AND MEASURES: The primary outcome was survival to hospital discharge. Secondary outcomes included survival to hospital admission and neurological status at discharge.RESULTS: Prehospital resuscitative thoracotomy was undertaken in 601 patients with out-of-hospital TCA. The median (IQR) age was 25 (20-37) years; 538 (89.5%) were male and 63 (10.5%) female. A total of 529 patients (88.0%) had a penetrating mechanism of injury. TCA occurred at a median (IQR) of 12 (6-22) minutes after the emergency call, with 491 arrests (81.7%) before the advanced trauma team's arrival. TCA was the result of cardiac tamponade (105 patients, 17.5%), exsanguination (418 patients, 69.6%), and exsanguination combined with cardiac tamponade (72 patients, 12.0%). Thirty patients (5.0%) survived to hospital discharge, with a favorable neurological outcome observed in 23 survivors (76.6%). Survival varied significantly with the cause of TCA: 22 of 105 patients (21%) with cardiac tamponade, 8 of 418 patients (1.9%) with exsanguination, and none of the 72 patients with combined or other pathologies survived. There were no survivors beyond 15 minutes of TCA for cardiac tamponade and 5 minutes after exsanguination. Multivariable analysis revealed that the cause of TCA (adjusted odds ratio [aOR], 21.1; 95% CI, 8.1-54.7; P &lt; .001), duration of TCA (aOR, 20.9; 95% CI, 4.4-100.6, P &lt; .001), and absence of the need for internal cardiac massage (AOR, 0.2; 95% CI, 0.06-0.5; P = .001) were independently associated with survival.CONCLUSIONS AND RELEVANCE: TCA occurs soon after injury, with only a brief window available for effective intervention. This study found that resuscitative thoracotomy is feasible in a mature, physician-led, urban prehospital system and is associated with improved survival for patients with out-of-hospital TCA, particularly when caused by cardiac tamponade, in situations where other treatment options are limited.</p