title: Is pre-hospital thoracotomy necessary in the military environment?
abstract: BACKGROUND
  Exsanguination from penetrating torso injury is a major source of mortality on the battlefield. Advanced Life Support guidelines suggest 'on-scene' thoracotomy for patients in cardiac arrest following penetrating chest trauma. This requires significant resourcing and training. Experience from published series (31 pre-hospital thoracotomies with 3 survivors) suggests that when this manoeuvre is applied to a well selected group it is a significant and life-saving procedure. Can this be applied to military injuries?
  
  
  METHODS
  Over a 12 month period on Operation Herrick all patients who sustained significant thoracic trauma were retrospectively reviewed. Parameters were recorded to allow detailed analysis of injury pattern and operative management. Our main objective was to determine if an early (pre-hospital) thoracotomy would have influenced the outcome.
  
  
  RESULTS
  Over the period, 81 patients required operative intervention following thoracic trauma: 8 patients underwent emergency thoracotomy (performed as part of the resuscitation) and 14 underwent urgent thoracotomy (performed after physiology partly restored). There were 9 fatalities--7 undergoing emergency thoracotomy and 2 post-operatively from multi-organ failure. Of the 7 intra-operative deaths 4/7 patients had thoracic injury and 6/7 had additional abdominal injuries. The median predicted survival of fatalities was 2.0% using Trauma Injury Severity Scoring.
  
  
  CONCLUSIONS
  Emergency thoracotomy should be performed in cardiac arrest following penetrating trauma as soon as possible. Highest survival rates in both in-hospital and pre-hospital thoracotomy are found in isolated cardiac stab wounds (19.4%). Poorest survival is found in multiply, ballistic injured patients (0.7%). The latter best reflects the injury pattern of military patients who have cardiac arrest following penetrating torso injury.
  
  
  CONCLUSIONS
  As our injury pattern suggests, any pre-hospital thoracotomy on military patients is likely to require complex intervention in very challenging environments. Our evidence does not support the notion that earlier thoracotomy could improve survival.
authors.affiliation: Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham B15 2SQ, United Kingdom. jonny_morrison@doctors.org.uk
authors.forename: J J
authors.initials: JJ
authors.lastname: Morrison
authors.forename: A
authors.initials: A
authors.lastname: Mellor
authors.forename: M
authors.initials: M
authors.lastname: Midwinter
authors.forename: P F
authors.initials: PF
authors.lastname: Mahoney
authors.forename: J C
authors.initials: JC
authors.lastname: Clasper
mesh_terms: D000328:Adult; D016887:Cardiopulmonary Resuscitation / Q000379:methods / Q000401:mortality; D004632:Emergency Medical Services / Q000379:methods*; D058734:Exsanguination / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008887:Military Medicine / Q000379:methods*; D008889:Military Personnel; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013898:Thoracic Injuries / Q000401:mortality / Q000601:surgery*; D013908:Thoracotomy / Q000379:methods* / Q000401:mortality; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000401:mortality / Q000601:surgery