Cardiac arrest following trauma is not a dead end.

In this issue, Lockey et al. from London’s Air Ambulance present heir concept of a common algorithm for effective management f traumatic cardiac arrest, including resuscitative thoracotomy n penetrating chest injuries.1 According to the authors, the algoithm does not necessarily distinguish between prehospital and n-hospital care. However, their approach of delivering resuscitaive thoracotomy by non-surgeons to the trauma patient in the eld with cardiac arrest, instead of scoop and run, will be perceived s provocative; emergency room thoracotomy by surgeons is well stablished but even this is controversial. Let’s face it: enormous fforts have been undertaken for decades to educate, train and erform high quality resuscitation in patients with out-of-hospital ardiac arrest even though the majority are in asystole and have ismally low survival rates. Now the London HEMS group have nitiated a new and radical approach by performing standardised esuscitative thoracotomy in the field. And they have been successul – achieving survival rates of 18% in patients with cardiac arrest ollowing penetrating chest injuries.2 Following non-traumatic cariac arrest, worldwide survival to hospital discharge is 8–11% for ll-rhythm and 21–22% for ventricular fibrillation.3 Following trauatic cardiac arrest, survival is between 0 and 17%, with much igher survival rates in penetrating injuries versus blunt trauma. ince 2005, published survival rates have improved reasons that re not clear.4,5 To this day there are only few studies analysing prehospital horacotomy. Though, a recent literature review confirmed the imited evidence resulting in five case series, four of them were rom London HEMS.6 Already 12 years ago, Coats et al. from Lonon HEMS published their first retrospective analysis and later in 011 Davies et al. reported a 15-year retrospective database review f 71 prehospital thoracotomies with 13 survivors and good neuroogical outcome in 85% of survivors.2,7 Following their established tandard operating procedure, prehospital thoracotomy was perormed in penetrating chest injury with cardiac arrest occurring ithin 10 min before team arrival at scene and at least 5 min transort time to an appropriate centre. All reported survivors suffered rom stab wounds to the chest or epigastrium with cardiac tampoade, all neurologically intact survivors developed cardiac arrest ith the HEMS team in attendance or within 3 min of their arrival; ve presented with initial asystole, six with pulseless electrical ctivity and two with unknown rhythm.2 Based on these promising ata, the authors developed a simple algorithm to guide effective anagement of traumatic cardiac arrest, including resuscitative horacotomy in penetrating chest injuries. However, some aspects of successful prehospital thoracotomy eported by the authors have to be considered as potential requireents for survival. The relatively high incidence of penetrating