Lecture on Sustained Thoracotomy for Trauma Cardiac Arrest

Introduction

• Speaker emphasizes the lack of evidence in studies on sustained thoracotomy.
• Focus on data-driven approach to understanding trauma and thoracotomy.
• Importance of differentiating between opinions and observable data.
• Acknowledgment of the team involved in data collection and analysis.

Definition of Traumatic Arrest

• Patient is unconscious, unresponsive, and no measurable cardiac output (no central pulses, blood pressure).
• Different from medical cardiac arrest (heart medically stops, e.g., VF or asystole).

Prevalence and Context

• Traumatic cardiac arrest is a relatively common cause of cardiac arrest, particularly in pre-hospital settings.
• In London, one in ten patients attended by emergency services are in traumatic arrest.
• Majority of traumatic arrests occur outside of hospitals and are often not included in trauma databases.
• An example from 1993 of a successful pre-hospital thoracotomy resulting in patient survival.

Guidelines and Treatment Principles

• European Resuscitation Council's guideline emphasizes treating the cause of traumatic arrest, not the same as medical arrest.
• Four reversible causes: asphyxia (hypoxia), hypovolemia (bleeding), tension pneumothorax, and cardiac tamponade.
• Controversies and uncertainties around the effectiveness and timing of pre-hospital thoracotomy.

Data Analysis

• 21 years of data from London's air ambulance on pre-hospital thoracotomies.
• Primary outcomes: survival to hospital discharge, survival of the event, neurological intactness on survival.
• Techniques: clam shell thoracotomy, opening pericardium, controlling bleeding wounds, open heart massage, and aortic occlusion.

Findings on Cardiac Tamponade

• Survival and timing: Best survival outcomes if thoracotomy performed within 10 minutes of arrest; no survivors beyond 15 minutes.
• ECG rhythms: Narrow complex rhythms associated with higher survival rates.
• Neurological outcomes: Longer arrest times correlate with poorer neurological outcomes.

Findings on Exsanguination

• Shorter survivable window than tamponade; majority arrest within 24 minutes of injury.
• Very low survival rates, no survivors beyond 5 minutes of arrest.
• Survivors had aortic occlusion and received high volumes of blood rapidly.

Decision-Making Factors

• Timing is crucial; immediate action required within a few minutes after arrest.
• ECG reading can guide the decision for performing thoracotomy.
• Sustained thoracotomy is generally not effective for those who bled out (exsanguination) but can be life-saving for cardiac tamponade.

Future Guidelines and Considerations

• Differentiating between tamponade and exsanguination can guide procedural decisions.
• Potential for more detailed guidelines based on data analysis.
• Importance of training and moulage for medical personnel performing these procedures.
• Role of pre-hospital interventions and importance of prompt action.