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We were interested to the read case report by Wright and Murphy of a prehospital thoracotomy.1 We use a rather different interpretation of the evidence to guide our approach to this problem.
We differ on a number of points. If an immediate prehospital thorocotomy is indicated we have learned from the nine survivors that have been achieved within the London HEMS system, that asystole is not an indicator of an unsurvivable injury. We would also disagree with the time limits given for this intervention, and would only recommend a prehospital thorocotomy when the “downtime” is less than 10 minutes—30 minutes of zero cardiac output makes this, or any other intervention, futile.2 It is also incorrect that all survivors of this procedure are neurologically intact—it should be expected that there will be a level of brain injury associated with “near death”. There is insufficient evidence to be definite about the incidence of disability in survivors but current evidence would suggest that prehospital thorocotomy has about the same long term disability as emergency room thorocotomy (around 10%).
I thank Davies and colleagues for their interest and comments. I should like to address some of their questions.
This was a case report.1 It did not attempt to lay down protocols for use based on such a limited evidence base. The important learning points from this case should be:
(1) The simple technique and the lack of specific cardiothoracic instruments or expertise.
(2) The fact that spontaneous motor activity and evidence of cerebration may occur in these patients once cardiac output is restored.
(3) Patients should be triaged to this procedure as a large number of non-survivors will lead to a lack of confidence in the procedure—we should aim not to exclude any cardiac tamponades.
I agree with the authors that 30 minutes is a long time to be without cardiac output. The ideal of 10 minutes from time of arrest is certainly where we should aim but response times and lack of reliable timing of arrest in some circumstances may make this an unobtainable goal. Asystole is not a uniform predictor of death/disability but its presence is certainly associated with a significantly worse outcome and thoracotomy in this group will lead to a large number of non-survivors.2 Evidence in this area is very limited. Initially evidence from the HEMS group said there was no value in prehospital thoracotomy,3 this view point has now changed.4 We must keep an open mind and continue to consider how penetrating injury is best managed.
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