Pre-hospital resuscitative thoracotomy performed in New South Wales, Australia: a case-series

Introduction: For patients in traumatic cardiac arrest (TCA) on scene, the brevity of the window for intervention means that hospital transfer is usually futile, and so pre-hospital resuscitative thoracotomy (PHRT) may represent the best chance of survival. Methods: In this case series we describe all cases of PHRT undertaken from 1st Jan 2013 until 31st December 2024, in NSW, Australia by physician-paramedic teams. Data were abstracted by two operators, with adjudication by a third. Patients were excluded if RT was commenced in hospital. Results: A total of 35,146 missions were conducted in our service over the study period; 14,072 were pre-hospital taskings. 34 patients underwent PHRT. 31 patients (91%, 95% CI 76%–98%) were male, and 32 cases (95%, 95% CI 79%–99%) were due to penetrating trauma. Electrical cardiac activity was the commonest sign of life, occurring in 25 patients (74%, 95% CI 55%–86%). 12 patients (35%, 95% CI 20%–54%) had pericardial effusions, and in 10 (29%, 95% CI 16%–48%) this was due to a single cardiac laceration. Five patients (15%, 95% CI 6%–32%) survived for more than 24 h in hospital, and 2 (6%, 95% CI 1%–21%) were discharged neurologically intact. Despite central stab wounds, the survivors had exsanguinated from extra-thoracic trauma, with no evidence of intrathoracic injury. Conclusion: Our study demonstrates that even in low-volume settings, PHRT can achieve neurologically intact unexpected survivors.