Resuscitation 40 (1999) 45–47

Case report

On scene thoracotomy: a case report

Richard Craig a, Kevin Clarke b, Timothy John Coats a,*a The London Helicopter Emergency Medical Ser6ice, Royal London Hospital, Whitechapel Road, London, E1 1BB, UK

b London Ambulance Ser6ice, Headquarters Building, Waterloo, London, UK

Received 1 July 1998; received in revised form 14 July 1998; accepted 9 December 1998

Abstract

We report a case of on scene resuscitative thoracotomy performed by an anaesthetist on a patient in cardiac arrest followinga stab wound to the chest. The patient made a good recovery and was discharged from hospital within 2 weeks. The rationalefor performing resuscitative thoracotomy and who should perform this procedure are discussed. © 1999 Elsevier Science IrelandLtd. All rights reserved.

Keywords: Pre-hospital care; Thoracotomy; Chest injury

1. Introduction

The survival of patients following penetratinginjury to the heart is extremely poor (B1%) ifthere are no signs of life prior to departure fromscene by the emergency services [1–3]. This is incontrast to survival rates of over 60% in patientswho arrive in hospital with signs of life [2–4]. Astudy by Durham et al. showed the average timeof pre-hospital CPR for survivors was 5.1 mincompared with 9.1 min for non-survivors [5]. Cur-rent American in-hospital protocols recommendthat resuscitation room thoracotomy should notbe performed on patients with no signs of life onthe initial pre-hospital assessment [5] or patientswho have a period of more than 10 min withoutcardiac output [6]. Doctors of The London Hospi-tal Helicopter Emergency Medical Service

(HEMS) perform on scene resuscitative thoraco-tomy for patients who are in cardiac arrest from apenetrating wound to the chest, where the timefrom arrest to arrival in hospital is estimated to bemore than 10 min. This case report illustrates thetreatment of a patient who was stabbed and suf-fered a cardiac arrest before the arrival of theemergency services.

2. Case report

London Ambulance Service received a 999 callat 10:19 reporting a stabbing. Following telephonetriage HEMS was despatched at 10:26. The firstemergency personnel on scene were police officerswho diagnosed cardiac arrest and commencedCPR with mouth to mask ventilation and externalchest compressions. A paramedic arrived on sceneat 10.30, attached the patient to a monitor, intu-bated him and began to obtain intravenous access.External chest compressions were continued

* Corresponding author. Present address: Accident and EmergencyDepartment, Royal London Hospital, Whitechapel, E1 1BB, UK.Tel.: +44-171-3777728; fax: +44-171-3777014; e-mail:t.j.coats@mds.qmw.ac.uk.

0300-9572/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved.PII: S 0 3 0 0 -9572 (98 )00151 -8

R. Craig et al. / Resuscitation 40 (1999) 45–4746

throughout this stage of resuscitation. A doctorarrived on scene at 10.33 to find an adult malewho was intubated, ventilated with 100% oxygenand receiving external chest compressions. TheECG showed a severe bradyarrythmia with abnor-mal complexes but no palpable pulse. The pa-tient’s pupils were fixed and dilated and there wasno movement to painful stimulus.

A thoracotomy was performed while the ambu-lance service were establishing intravenous accessand giving intravenous fluid. The approach usedby HEMS involves an incision in the fourth/fifthintercostal space from the mid-axillary line on theright round the front of the chest to the mid-axil-lary line on the left. A Gigli saw is then passedunder the sternum and once the bone is cutthrough the upper part of the chest can be lifted togive a good view of both lungs and the peri-cardium. The pericardium was opened and a largevolume of blood and clot was evacuated. Follow-ing evacuation of the clot the empty heart beganto fill and internal cardiac massage was com-menced, while the patient was given a 1-mg bolusof adrenaline. Once filled, the heart was noted tobe in ventricular fibrillation but reverted to sinusrhythm with a good output following externaldefibrillation via the ambulance ECG/defibrillatorthat was already attached. At this point a 2-cmlaceration in the right ventricle became apparentand this was sutured to prevent excessive bloodloss. Following suturing the patient had a furthershort episode of VF again terminated by an exter-nal DC shock. The patient was then packaged andrapidly conveyed to hospital by air, departingscene at 10.53 and arriving at the hospital at 10.55.During loading and transfer the patient received afurther 0.5 mg of adrenaline and 1000 ml ofcolloid.

Throughout transfer the patient maintained agood cardiac rhythm and had a strong carotidpulse. On loading the patient’s pupils were notedto have reduced in size and during the flight hebegan to take some breaths and moved his upperlimbs. He was sedated with morphine and midazo-lam and paralysed with pancuronium.

On arrival in the A & E department the patientwas handed over to the care of the hospitaltrauma team. His chest was closed by a cardiotho-racic surgeon in the A & E department, followingwhich he was transferred to the intensive care unit.Broad spectrum antibiotic prophylaxis was given.

He was ventilated for 24 h for cerebral protection,but was then slow to wake and so was ventilatedfor a further 24 h before extubation, and wastransferred to the ward the following day. He wasdischarged home 11 days post injury. There wasno apparent neurological damage and no evidenceof wound infection.

3. Discussion

Cardiac stab wounds causing rapid cardiac ar-rest from tamponade are uncommon in the UK.Survival following such an injury depends on thetime between the cardiac arrest and the surgicalintervention. There will be few survivors if thedelay between cardiac arrest and surgery is morethan 5 min (10 min if intubated as part of pre-hos-pital CPR) [6]. If survivors are to be achieved,accident and emergency doctors or general surgerytrainees must therefore be prepared to performresuscitative thoracotomy rather than wait for thearrival of cardiothoracic surgeons. If the underly-ing pathology is any more complex than a tam-ponade from a simple ventricular wound thenon-specialist may be unable to correct the situa-tion and the patient will die. This must be ac-cepted in the situation where without resuscitativethoracotomy the patient will certainly die.

The thoracotomy procedure described in thiscase report is relatively simple to perform, evenwith inexperienced (in this case anaesthetic) hands,and provides an excellent view of the pericardiumwith good access to the heart and both hila.Pericardial aspiration could be considered but thisintervention delays definitive treatment, does notcorrect the underlying pathology and, as in thiscase, is ineffective when blood is clotted in thepericardium.

The procedure described is rapid. The total timespent at the patient’s side was between 10 and 12min, and the pericardium was opened within 5 minof the doctor’s arrival on scene. Resuscitative tho-racotomy is indicated in victims of penetratingtrauma who suffer a cardiac arrest in the emer-gency room. If the skills available in the emer-gency room are moved into the pre-hospital phaseall doctors who may find themselves in this situa-tion should be capable of responding. In this casethe doctor performing the procedure had receiveda thorough briefing on how and when to perform

R. Craig et al. / Resuscitation 40 (1999) 45–47 47

a thoracotomy (by an emergency physician) dur-ing his initial training. Furthermore as an anaes-thetist he was used to observing cardiac filling andrhythm during cardiac surgery, which assisted inthe resuscitation of this patient.

The wisdom of a non-surgeon operating can bequestioned. However, when the operation maysave the patient and the alternative is to terminateresuscitation, intervention is certainly indicated. Inthe London HEMS system over the past 10 yearsthere have been three long-term survivors amongstthe 44 patients who required a pre-hospital thora-cotomy for stab wounds. A controlled trial of thistreatment would not be ethical as one of thetreatment arms would result in certain death.

This patient survived the cardiac arrest neuro-logically intact because his cardiac output wasrapidly restored by resuscitative thoracotomy. Asequence of ascending levels of medical treatmentwas essential. Initial basic life support (BLS) fromthe police officers, followed by advanced life sup-port (ALS) from the paramedic, followed by surgi-cal intervention from an appropriately trained

doctor illustrates the tiered response that is nowbecoming possible in the emergency service reac-tion to a severe injury.

References

[1] Kavolius J, Golocovsky M, Champion HR. Predictors ofoutcome in patients who have sustained trauma and whoundergo emergency thoracotomy. Arch Surg1993;128:1158–62.

[2] Jurkovich GJ, Esposito TJ, Maier RV. Resuscitative tho-racotomy performed in the operating room. Am J Surg1992;163:463–8.

[3] Boyd M, Vanek VW, Bourguet CC. Emergency roomthoracotomy: when is it indicated? J Trauma1992;33:714–21.

[4] Velmahos GC, Degiannis E, Souter I, Saadia R. Penetrat-ing trauma to the heart: a relatively innocent injury.Surgery 1994;115:694–7.

[5] Lorenz HP, Steinmetz B, Lieberman J, Schecter P, MachoJR. Emergency thoracotomy: survival correlates withphysiologic status. J Trauma 1992;32:780–5.

[6] Durham LA, Richardson RJ, Wall MJ, Pepe PE, MattoxKL. Emergency centre thoracotomy: impact of pre-hospi-tal resuscitation. J Trauma 1992;32:775–8.

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