Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma?

PURPOSE: The indications for pre-hospital resuscitative thoracotomy (PHRT) remain undefined. The aim of this paper is to explore the variation in practice for PHRT in the UK, and review the published literature. METHODS: MEDLINE and PUBMED search engines were used to identify all relevant articles and 22 UK Air Ambulance Services were sent an electronic questionnaire to assess their PHRT practice. RESULTS: Four European publications report PHRT survival rates of 9.7, 18.3, 10.3 and 3.0% in 31, 71, 39 and 33 patients, respectively. All patients sustained penetrating chest injury. Six case reports also detail survivors of PHRT, again all had sustained penetrating thoracic injury. One Japanese paper presents 34 cases of PHRT following blunt trauma, of which 26.4% survived to the intensive therapy unit but none survived to discharge. A UK population reports a single survivor of PHRT following blunt trauma but the case details remain unpublished. Ten (45%) air ambulance services responded, each service reported different indications for PHRT. All perform PHRT for penetrating chest trauma, however, length of allowed pre-procedure down time varied, ranging from 10 to 20 min. Seventy percent perform PHRT for blunt traumatic cardiac arrest, a procedure which is likely to require aggressive concurrent circulatory support, despite this only 5/10 services carry pre-hospital blood products. CONCLUSIONS: Current indications for PHRT vary amongst different geographical locations, across the UK, and worldwide. Survivors are likely to have sustained penetrating chest injury with short down time. There is only one published survivor of PHRT following blunt trauma, despite this, PHRT is still being performed in the UK for this indication.

'Less may be best'-Pediatric parapneumonic effusion and empyema management: Lessons from a UK center.

BACKGROUND: Children with empyema are managed at our center using a protocol-driven clinical care pathway. Chemical fibrinolysis is deployed as first-line management for significant pleural disease. We therefore examined clinical outcome(s) to benchmark standards of care while analyzing disease severity with introduction of the pneumococcal conjugate vaccine. METHODS: Medical case-records of children managed at a UK pediatric center were surveyed from Jan 2006 to Dec 2012. Binary logistic regression was utilized to study failure of fibrinolytic therapy. The effects of age, comorbidity, number of days of intravenous antibiotics prior to drainage and whether initial imaging showed evidence of necrotizing disease were also studied. RESULTS: A total of 239 children were treated [age range 4months-19years; median 4years]. A decreasing number of patients presenting year-on-year since 2006 with complicated pleural infections was observed. The majority of children were successfully managed without surgery using antibiotics alone (27%) or a fine-bore chest-drain and urokinase (71%). Only 2% of cases required primary thoracotomy. 14.7% cases failed fibrinolysis and required a second intervention. The only factor predictive of failure and need for surgery was suspicion of necrotizing disease on initial imaging (P=0.002, OR 8.69). CONCLUSION: Pediatric patients with pleural empyema have good outcomes when clinical care is led by a multidisciplinary team and protocol driven care pathway. Using a 'less is best' approach few children require surgery.