Elsevier

Resuscitation

Volume 80, Issue 11, November 2009, Pages 1270-1274
Resuscitation

Clinical paper
Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system

https://doi.org/10.1016/j.resuscitation.2009.08.010Get rights and content

Abstract

Objective

We investigated whether emergency thoracotomy (ET) performed in pre-hospital settings contributed to saving the lives of blunt trauma patients with impending or recent cardiac arrest.

Methods

Eighty-one consecutive cardiac arrest patients with blunt trauma were performed ET before or after arrival at the emergency department (ED). These were reviewed retrospectively and were classified into the following three groups: (1) an emergency field thoracotomy was performed (EFT group, n = 34); (2) a doctor dispatched to the scene, but the thoracotomy was performed in the ED (EDT-a group, n = 10); and (3) no doctor dispatched to the scene, and the thoracotomy was performed in the ED (EDT-b group, n = 37). The patients in the EFT and EDT-a groups were managed within the Japanese helicopter emergency medical service system with a doctor dispatched to the scene.

Result

The time between the arrival of the EMT at the scene and the start of the thoracotomy was significantly shorter in the EFT group than in the EDT-b group (19.2 ± 7.9 min vs. 30.7 ± 6.8 min, p < 0.001). In the EFT group, the “ICU admission” rate was significantly higher among the patients who experienced cardiac arrest after the EMT arrival than among the patients who experienced cardiac arrest before the EMT arrival (70% vs. 8%, p = 0.001). Unfortunately, however, there were no survivors in this series.

Conclusion

These findings indicate that “early access” to a doctor's expertise and the performance of an “emergency field thoracotomy” might be two important factors for improving the possibility of saving the lives of blunt trauma patients with impending or recent cardiac arrest.

Introduction

Saving the life of a patient who suffers cardiac arrest after experiencing a severe blunt trauma is extremely difficult, and this is true throughout the world. In Japan, this difficulty is considered to be partially attributable to the conventional emergency medical service system (EMS). If another EMS scheme for dispatching physicians to the scenes of accidents were to be established, new data and thorough discussions would be required with regard to interventions for pre-hospital trauma management.

In the United States, a resuscitative emergency department thoracotomy (EDT) for cardiac arrest patients who have sustained blunt trauma is only indicated in limited cases because the overall survival of these patients is extremely poor.1, 2 Also, while the helicopter emergency medical service (HEMS) is quite advanced in the US, on-board physicians are rare. Instead, on-scene primary care is provided by paramedics and rapid transport to an emergency care hospital is the main mission. This system differs from the HEMS concept that we are trying to realize in Japan, which resembles the European HEMS system,3, 4, 5, 6 and this difference should be taken into account when assessing emergency care for cardiac arrest patients who have sustained blunt trauma.

The Japanese government is currently promoting a “doctor-helicopter” system.7 In this system, a helicopter that has been specially configured for EMS care and an on-board physician and nurse are rushed to the accident scene. Since 2003, we have been using this HMES system to take a proactive approach to performing emergency thoracotomies at the accident scene when such a procedure is required for the treatment of patients experiencing cardiac arrest after they have sustained blunt trauma; we refer to this procedure as an emergency field thoracotomy (EFT). The aim of the present study was to investigate whether EFT contributes to saving the lives of blunt trauma patients with impending or recent cardiac arrest.

Section snippets

Materials and methods

The HEMS system in Japan is alerted by a direct call from the dispatch center or EMS provider at the accident scene. The Shock and Trauma Center at Chiba Hokusoh Hospital of Nippon Medical School, which is the base hospital of the HEMS system for Chiba prefecture and corresponds to a Level 1 trauma center in the US, has over 700 HEMS missions per year. Our flight crews include one emergency physician and one flight nurse per helicopter. The helicopter is airborne within 3.5 min after the call

Results

The overall survival rate of the patients treated using a resuscitative emergency thoracotomy after sustaining a blunt trauma was 3.2% (3/95), whereas the survival of patients who received an emergency thoracotomy after cardiac arrest was 1.1% (1/90). Of the 81 cases included in the present analysis, 52 cases were in cardiac arrest before the EMT arrived at the accident scene, whereas 29 experienced cardiac arrest after the arrival of the EMT; 5 of these 29 cases experienced cardiac arrest

Discussion

The role and efficacy of emergency thoracotomy as a life-saving procedure is somewhat unclear because of the numerous different situations and patient characteristics that can affect the place or timing of this procedure.8 In a review of 4620 cases from institutions reporting the use of emergency thoracotomy for the treatment of patients with either blunt or penetrating trauma, the overall survival rates ranged from 1.8% to 27.5%.9 In general, an emergency thoracotomy is regarded as an

Conclusions

In conclusion, the time from EMT arrival to the performance of an emergency thoracotomy was significantly shorter in the groups in which doctors were dispatched to the accident scene. The numbers of patients who had meaningful heartbeat restoration and who were admitted to the ICU after the removal of aortic clamping were significantly larger in the group who experienced cardiac arrest after EMT arrival and who underwent an on-scene emergency thoracotomy, compared with the other groups. These

Conflict of interest statement

None to declare.

References (21)

There are more references available in the full text version of this article.

Cited by (44)

  • Emergency Resuscitative Thoracotomy for Civilian Thoracic Trauma in the Field and Emergency Department Settings: A Systematic Review and Meta-Analysis

    2022, Journal of Surgical Research
    Citation Excerpt :

    The quality of evidence was rated as very low (Table 1). Of these, 43 were included in the analysis of RT setting3,8,11,14–36,38–46,51–53,55–59, and 40 were included in the analysis of RT for blunt versus penetrating trauma.8,11,14–18,20–29,31–36,38–46,51–53,55–59 Five studies evaluated PH-RT (eTable 1a).11,15,37,44,58

View all citing articles on Scopus

A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2009.08.010.

View full text