Prospective randomized trial of standard left anterolateral thoracotomy vs modified bilateral clamshell thoracotomy performed by emergency physicians in a live tissue penetrating cardiac injury model.

OBJECTIVE

Resuscitative thoracotomy (RT) is a critical, time-sensitive procedure that may be performed by emergency medicine (EM) physicians. The left anterolateral thoracotomy (LAT) is the technique traditionally used in the United States. However, its limited exposure may hinder effective intervention. The modified bilateral clamshell thoracotomy (MCT), developed by Barts Health NHS Trust clinicians at London's Air Ambulance (LAA), offers greater exposure and may be more suitable for EM physicians. This study aimed to determine the optimal RT technique for EM physicians while also assessing technical challenges, procedural concerns, and provider preferences.

METHODS

EM staff and resident physicians from a level one trauma center participated after receiving standardized training on both MCT and LAT techniques. Participants were randomized to perform each technique on live tissue swine with a novel penetrating injury model. Success was defined as heart delivery from the pericardial sac, cardiac hemorrhage control, and full thoracic aorta occlusion. The primary outcome was time to successful RT completion. Secondary outcomes included procedural success rates, adequate exposure, hemorrhage control, cross-clamping success, iatrogenic injuries, and participant feedback.

RESULTS

Ten EM physicians completed the study. There was not a significant difference in time to successful completion of the MCT and LAT techniques (585 s vs 664.9 s, hazard ratio 0.63, CI 95 % 0.27 to 1.49). Success rates were similar (80 % vs 70 %, difference - 10 %, 95 % CI -50.6 % to 30.6 %). Provider procedure preference favored the MCT over the LAT (100 % vs 0 %).

CONCLUSION

Though participants were more experienced with the LAT, the MCT performed as well and was universally preferred. The MCT may be the ideal technique for EM physicians confronting a penetrating thoracic injury with pulselessness or extremis in the absence of a surgical provider.