by Justin Jackson, Medical Xpress

Credit: Unsplash/CC0 Public Domain

Researchers from an international collaborative team have found that prehospital resuscitative thoracotomy (RT) is feasible and associated with improved survival for traumatic cardiac arrest (TCA) patients when performed in a structured physician-led emergency response system.

Findings show that RT is most beneficial for patients experiencing TCA due to cardiac tamponade, an injury where blood accumulates in the sac surrounding the heart and prevents it from pumping effectively.

The work appears in JAMA Surgery.

The research team includes researchers from London's Air Ambulance, Queen Mary University of London, Barts Health NHS Trust, London Ambulance Service NHS Trust, the University of Groningen, the University of British Columbia, Harvard Medical School, Beth Israel Deaconess Medical Center, and Nobles Hospital (Manx Care).

TCA is a critical trauma that results from a patient's inability to sustain spontaneous cardiac output due to severe injury. Immediate intervention is required to reverse potentially salvageable causes such as exsanguination (excessive blood loss) or cardiac tamponade.

RT is a drastic measure to restart a heart that involves physically opening the chest and directly manipulating the heart and vessels to restore circulation, control bleeding, and relieve pressure on the heart. Unlike open-heart surgery, it is only performed in an emergency situation, often under suboptimal conditions, with the goal of stabilizing the patient for later surgery at a trauma center.

Current prehospital trauma care strategies often prioritize rapid "scoop and run" transport over on-scene interventions, yet most patients in TCA die before reaching the hospital. Previous studies have focused on in-hospital RT, but research on its effectiveness in prehospital settings remains limited in part because such interventions are extremely rare. Unlike typical ambulance crews staffed by paramedics or EMTs, London's Air Ambulance operates with a physician–paramedic team. These physicians have surgical training and are capable of performing RT when necessary.

In the study, titled "Prehospital Resuscitative Thoracotomy for Traumatic Cardiac Arrest, " researchers conducted a retrospective cohort analysis to assess the association between prehospital RT and survival outcomes for TCA patients. Data from all prehospital RT cases managed by London's Air Ambulance from January 1999 to December 2019 were analyzed.

Among 45, 647 trauma cases attended by the emergency response team, 3, 223 involved TCA, with 601 patients undergoing RT. Most patients were young males (median age: 25 years), with 88% sustaining penetrating trauma.

Median TCA onset occurred 12 minutes after an emergency call, with 82% of cases occurring before the trauma team's arrival. The leading cause of TCA was exsanguination (69.6%), followed by cardiac tamponade (17.5%) and combined tamponade-exsanguination (12%).

RT was performed using a standardized approach, including bilateral thoracostomies, clamshell thoracotomy, pericardiotomy, and cardiac resuscitation techniques. Patients underwent targeted interventions such as hemorrhage control and blood transfusions as clinically indicated.

Among patients receiving prehospital RT, 5% survived to hospital discharge, with 76.6% of survivors exhibiting favorable neurological outcomes. TCA cause and duration significantly influenced survival. Patients experiencing TCA from cardiac tamponade had a 21% survival rate, whereas those with exsanguination had 1.9% survival, and none with combined tamponade-exsanguination survived.

No patient survived if RT was performed beyond 15 minutes after tamponade-induced TCA or 5 minutes after exsanguination-induced TCA. Witnessed arrest and pulseless electrical activity at the time of RT also correlated with higher survival rates.

Findings support RT as a viable intervention in physician-led prehospital trauma systems, particularly for cardiac tamponade cases where immediate intervention is essential. RT proved ineffective for most exsanguination cases, indicating a need for additional strategies such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and expanded prehospital blood transfusion programs.

In an invited commentary by three MDs from the Department of Surgery at the University of Pittsburgh, titled "Racing Against Time in Thoracotomy for Traumatic Cardiac Arrest, " the practical application of RT in prehospital settings is considered.

They agree that the study provides valuable data on patient selection and survival factors in prehospital thoracotomy. Yet, its applicability is limited, particularly in the United States, where prehospital physician involvement is not in place, even in the most well-resourced urban centers.

Specialized teams typically require mobilization, delaying intervention beyond the critical window for RT. The study population, consisting primarily of young males with stab wounds, further limits generalizability (to gunshot wounds).

Several trauma societies recommend RT primarily for penetrating injuries due to the high fatality rate of cardiac arrest following blunt trauma. Current guidelines stress the importance of early intervention, presence of signs of life, and an injury mechanism conducive to survival. They find the survival windows well documented by the study, yet timeframes remain short with interventions required within 10 minutes for tamponade-induced TCA and 5 minutes for exsanguination-induced TCA.

Distinguishing between tamponade and exsanguination at the scene is also difficult. Mechanism of injury, timing, cardiac rhythm, and signs of life remain the key factors guiding RT decisions. The study reaffirms that survival declines sharply between 5 and 10 minutes post-arrest, reinforcing the need to push trauma interventions closer to the point of injury.

More information: Zane B. Perkins et al, Prehospital Resuscitative Thoracotomy for Traumatic Cardiac Arrest, JAMA Surgery (2025). DOI: 10.1001/jamasurg.2024.7245 Christine M. Leeper et al, Racing Against Time in Thoracotomy for Traumatic Cardiac Arrest, JAMA Surgery (2025). DOI: 10.1001/jamasurg.2024.7231  Journal information: JAMA Surgery

Christine M. Leeper et al, Racing Against Time in Thoracotomy for Traumatic Cardiac Arrest, JAMA Surgery (2025). DOI: 10.1001/jamasurg.2024.7231

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