Pre-Hospital Resuscitative Thoracotomy

Resuscitative thoracotomy involves opening the chest cavity in someone who is critically injured in order to help deal with any abnormality with the heart, lungs, or major blood vessels. It is a major operation, and is performed on the roadside in London, on average approximately three times per week.

Resuscitative thoracotomy for trauma in the pre-hospital phase was first described in Alabama in 1902, where it was performed on a kitchen table on a 13-year-old boy, but there was no system in the world where the team was equipped to carry out this procedure. In 1988, we recognised that there was a group of patients who could only survive if the thoracotomy procedure was carried out on scene, and that patients would die if they didn’t get the procedure if they had to wait until they arrived at hospital.

Over subsequent years we performed resuscitative thoracotomy more frequently, developed Standard Operating Procedures for the intervention, and published a practical guide on how to perform it. In conjunction with the Royal College of Surgeons of England, The London’s Air Ambulance team helps deliver a course for clinicians on the theoretical and practical elements of performing this procedure. It has also been adopted by various services across the UK and internationally for use in the pre-hospital phase of care. There are now international case reports published of the successful procedure.

Traditionally, survivors of thoracotomy in the pre-hospital phase of care were largely those who had an isolated cardiac tamponade injury, where there is clotted blood abnormally collected in the sac around the heart. In 2018, we saw two survivors in a new and important group of patients. One patient had exsanguinating pelvic haemorrhage, and one severe intrathoracic haemorrhage. These cases are currently being considered for publication.

We recognise that we need to do more for those who do not survive even the most invasive of procedures such as thoracotomy. REBOA was introduced to help those patients who we learned through our experience, would not be helped by carrying out thoracotomy.