Prehospital thoracotomy for traumatic cardiac arrest

William Ottestad; Per B. Bredmose; Per Olav Berve; Halvard Stave; Gunnar Farstad; Lars Wik; Mårten Sandberg

doi:10.4045/tidsskr.16.0798

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Prehospital thoracotomy for traumatic cardiac arrest

Norwegian

William Ottestad, Per B. Bredmose, Per Olav Berve, Halvard Stave, Gunnar Farstad, Lars Wik, Mårten Sandberg

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William Ottestad

William Ottestad (born 1974) Specialist in anaesthesiology and senior consultant with the Air Ambulance Department, Oslo University Hospital.

The author has completed the ICMJE form and reports no conflicts of interest.

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Per B. Bredmose

Per P. Bredmose (born 1973) Specialist in anaesthesiology and senior consultant working with prehospital medicine and transport medicine at the Air Ambulance Department, Oslo University Hospital. The author has previously worked at the Royal London Hospital’s London Air Ambulance and has experience with prehospital thoracotomy and with medical education and instruction in this procedure.

The author has completed the ICMJE form and reports no conflicts of interest.

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Per Olav Berve

Per Olav Berve (born 1976) Specialist in anaesthesiology, senior consultant at the Department of Anaesthesia, Oslo University Hospital, Ullevål, Air Ambulance Department, Oslo University Hospital, the physician ambulance 119 and PhD candidate in the Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS).

The author has completed the ICMJE form and reports no conflicts of interest.

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Halvard Stave

Halvard Stave (born 1976) Specialist in anaesthesiology and head of section in the Air Ambulance Department, Oslo University Hospital.

The author has completed the ICMJE form and reports no conflicts of interest.

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Gunnar Farstad

Gunnar Farstad (born 1967) Specialist in anaesthesiology and senior consultant in the Air Ambulance Department, Oslo University Hospital.

The author has completed the ICMJE form and reports no conflicts of interest.

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Lars Wik

Lars Wik (born 1957) Specialist in anaesthesiology, senior consultant at the Department of Anaesthesia, Oslo University Hospital, Ullevål, Air Ambulance Department, Oslo University Hospital, the physician ambulance 119 and senior researcher at the Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS).

The author has completed the ICMJE form and reports the following conflicts of interest: He is principal investigator in a cardiac arrest study sponsored by Physio-Control, and he holds patents licenced from Inven2 to Zoll Medical and Physio-Control.

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Mårten Sandberg

Mårten Sandberg (born 1960) Specialist in anaesthesiology and senior consultant at the Air Ambulance Department, Oslo University Hospital, and adjunct professor in prehospital acute medicine, University of Oslo.

The author has completed the ICMJE form and reports no conflicts of interest.

Email: marten.sandberg@gmail.com

Article

Standard cardiopulmonary resuscitation (CPR) is ineffective for treating traumatic cardiac arrest. The mortality of patients whose vital signs fail at the scene of injury and are brought to hospital with ongoing CPR is almost 100 %.

Prehospital resuscitative thoracotomy is a procedure that can improve the prognosis for patients with traumatic cardiac arrest, but the National Advisory Unit on Trauma and the Norwegian Surgical Association recently advised against introducing this procedure in Norway. However, we believe that resuscitative thoracotomy has a place in a specialist prehospital medical service, also in Norway.

Observational studies in Europe and the USA have shown that the mortality of patients who are without vital signs at the scene of injury after a penetrating thoracic trauma is almost 100 %, even if they receive targeted surgical treatment on arrival at hospital (1) – (4). Conventional cardiopulmonary resuscitation is ineffective for traumatic cardiac arrest (5, 6). Patients whose vital signs fail during transport to hospital and who are undergoing CPR on arrival at hospital therefore have a very poor prognosis, and seldom survive with their neurological function intact (7, 8). There is general consensus that resuscitative thoracotomy should not be performed on patients whose vital signs fail or are absent at the scene of injury when they subsequently arrive in hospital (1) – (3, 8) – (10).

The trauma group at Oslo University Hospital has published data on the survival after a heart penetrating injury of patients arriving at the hospital in the period 2001 – 10 (10). Mortality was 100 % for patients whose vital signs were absent at the scene of injury or failed during transportation if the transport time to the hospital exceeded 10 minutes. The authors proposed that these patients should be given no further treatment because of the hopelessness of their prognosis. This recommendation is consistent with the guidelines in the training programme Advanced Trauma Life Support (ATLS) (11).

Experience from London

The prehospital medical service in London has wanted to give this patient group a treatment option by offering prehospital resuscitative thoracotomy. The indication is penetrating injury to the thorax and/or upper abdomen with subsequent cardiac arrest (asystole, pulseless electrical activity or ventricular fibrillation), and the aim is primarily to counter a potential cardiac tamponade (12) (Box 1).

BOX 1

Procedure for prehospital thoracotomy

Here is a proposal for performing the procedure in the manner the authors regard as correct (12, 16)

A bilateral thoracotomy is performed between the 4th and 5th ribs in the mid-axillary line, and a finger is inserted in the pleural cavity. If circulation is restored at this point because of a released tension pneumothorax, the procedure is halted.
The two thoracotomies are linked up via deep cutaneous incisions. The intercostal musculature is cut on both sides from the thoracotomies towards the sternum. The lungs are kept deflated with an open endotracheal tube, and a finger is kept between scissors and lung. The sternum is cut through with scissors.
After the thoracotomies have been extended dorsally, the thorax is opened so that heart and lungs are exposed.
The pericardium is opened with a longitudinal incision in the central line to release a tamponade.
If spontaneous circulation is not restored, internal cardiac massage is started. In a situation with persistent ventricular fibrillation, the thorax is closed, and external defibrillation is performed according to standard guidelines.
The descending aorta is compressed manually. In the event of hypovolaemia and difficulty in establishing intravenous access, the heart may be filled directly.
In the event of haemorrhaging holes in the heart muscle after the restoration of spontaneous circulation, a finger can be kept in the hole. Suturing may be an option both before and after spontaneous circulation.
The four internal thoracic arteries are compressed on the way to the hospital.

The procedure is counter-indicated if circulation has stopped for more than ten minutes, or in cases of blunt trauma, and must never be performed on patients with signs of preserved circulation. In the period 1993 – 2008, 71 resuscitative thoracotomies were performed in London outside hospitals on patients with penetrating chest injuries and subsequent cardiac arrest. Thirteen patients survived to discharge from hospital (18 %), 11 of them with good neurological function (13). With support in the guidelines of the European Resuscitation Council (14) and the aforementioned data from London, we believe that this procedure should be implemented throughout or in parts of the specialist prehospital medical service in Norway. However, the National Advisory Unit on Trauma and the Norwegian Surgical Association recently issued a statement advising against the introduction of such a procedure in Norway (15).

Who should perform prehospital thoracotomy?

The Norwegian Society of Anaesthesiology has taken the initiative to draw up national guidelines for prehospital thoracotomy. In their consultative submission, the National Advisory Unit on Traumatology and the Norwegian Surgical Association maintain that the need for the procedure is too limited to justify training in and a focus on this procedure. They are concerned that the procedure might be carried out on patients who could have survived with rapid transport to hospital, and that the risk factors associated with prehospital thoracotomy are made light of.

A knife wound or other penetrating injury to the heart is rare, but in our view frequency is not an argument for failing to use a potentially life-saving procedure. In our prehospital service we are committed to providing necessary medical aid to all, irrespective of the incidence of the condition and the prognosis. In a meaningful discussion of prehospital thoracotomy, it must be assumed that experienced anaesthetists comply conscientiously with the indication for the procedure and possess the necessary expertise to determine whether the patient is without circulation. Prehospitally, we constantly having to address clinical challenges that we have been trained to deal with, while focusing simultaneously on bringing the patient as fast as possible to the correct treatment level.

The trauma surgery milieu has defined the limits for appropriate use of resuscitative thoracotomy in hospitals. This delimitation is well-founded and supported by repeated observational studies from different countries and trauma systems (1, 2, 7, 8, 13). Direct transport to hospital is only appropriate in a situation where it is believed that the procedure can be performed inside the hospital within ten minutes of circulatory arrest (4, 9, 13). The question of which specialist group performs the procedure is secondary to the time aspect. The real risk lies in transporting these patients during ongoing CPR, and then performing the procedure outside the time limit that offers a chance of survival. Patients who meet the criteria for prehospital resuscitative thoracotomy do not have any real treatment alternative.

The London Air Ambulance Service has over 20 years of experience of performing prehospital thoracotomy, and in a health service that resembles ours in many ways, anaesthetists have demonstrated that they can perform a procedure of this nature safely and effectively (13). We acknowledge that a successfully performed procedure and restored circulation still leaves a highly demanding situation with respect to haemorrhage control and further stabilisation, but this scenario is preferable to the alternative.

Training

Training must be mandatory for anaesthetists who might conceivably find themselves in a situation outside hospital where resuscitative thoracotomy is indicated. Training in resuscitative thoracotomy demands relatively limited resources, as it can be included in existing courses where medical staff practise accepted and highly important procedures associated with haemorrhage control and management of airways.

The Air Ambulance Department at Oslo University Hospital has arranged a number of these courses, and uses a specialised pig model. The learning curve is steep, and this is clearly illustrated in a recently published cadaver study, where both anaesthetists and medical students were found to be capable of performing a resuscitative thoracotomy as swiftly and surely as surgeons after a short period of training and practice on a cadaver model (17). There are of course evident weaknesses associated with such a study, but a cadaver model is relevant, and the transfer value is high as this procedure is performed exclusively on patients without circulation. Practice on dummies can also be a valuable supplement to regular practice in standard operating procedures.

What is ethically correct?

A consultative statement from the National Advisory Unit on Trauma and the Norwegian Surgical Association found prehospital thoracotomy to be ethically questionable. At the same time, it is maintained that establishing a surgical airway is a valid procedure that does not present ethical challenges. It is difficult to understand why it is ethically legitimate to make an incision on the neck of a patient with blocked airways, but unethical to make a larger incision in the patient’s thorax in the absence of circulation. Is it the size of the incision that determines whether this is ethically justifiable? The underlying question here is in our view one of aesthetics. Prehospital thoracotomy is unaesthetic, but this is unfortunately confused with the overriding ethical issues. We find it ethically challenging not to offer a treatment that may save lives in a situation where the alternative is to terminate treatment.

A place in Norway too

For the past 20 years, prehospital resuscitative thoracotomy performed on selected patients with traumatic cardiac arrest has contributed to higher survival with intact neurological function. This procedure should therefore have a place in a specialist prehospital medical service in Norway. We hope that training, practice and the development of procedures for Norwegian conditions may be strengthened through dialogue and cooperation with the trauma surgery milieu. Prehospital resuscitative thoracotomy is a procedure that can save lives in a situation where other treatments have proved futile.

Literature

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Van Waes OJ, Van Riet PA, Van Lieshout EM et al. Immediate thoracotomy for penetrating injuries: ten years' experience at a Dutch level I trauma center. Eur J Trauma Emerg Surg 2012; 38: 543 – 51. [PubMed] [CrossRef]
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Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med 2006; 48: 240 – 4. [PubMed] [CrossRef]
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Luna GK, Pavlin EG, Kirkman T et al. Hemodynamic effects of external cardiac massage in trauma shock. J Trauma 1989; 29: 1430 – 3. [PubMed] [CrossRef]
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Mattox KL, Feliciano DV. Role of external cardiac compression in truncal trauma. J Trauma 1982; 22: 934 – 6. [PubMed] [CrossRef]
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Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg 2006; 1: 4. [PubMed] [CrossRef]
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Seamon MJ, Haut ER, Van Arendonk K et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015; 79: 159 – 73. [PubMed] [CrossRef]
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Moore EE, Knudson MM, Burlew CC et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma 2011; 70: 334 – 9. [PubMed] [CrossRef]
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Kaljusto M-L, Skaga NO, Pillgram-Larsen J et al. Survival predictor for penetrating cardiac injury; a 10-year consecutive cohort from a scandinavian trauma center. Scand J Trauma Resusc Emerg Med 2015; 23: 41. [PubMed] [CrossRef]
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Ohrt-Nissen S, Colville-Ebeling B, Kandler K et al. Indication for resuscitative thoracotomy in thoracic injuries-Adherence to the ATLS guidelines. A forensic autopsy based evaluation. Injury 2016; 47: 1019 – 24. [PubMed] [CrossRef]
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Wise D, Davies G, Coats T et al. Emergency thoracotomy: “how to do it». Emerg Med J 2005; 22: 22 – 4. [PubMed] [CrossRef]
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Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results. J Trauma 2011; 70: E75 – 8. [PubMed] [CrossRef]
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Truhlář A, Deakin CD, Soar J et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95: 148 – 201. [PubMed] [CrossRef]
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Nasjonal kompetansetjeneste for traumatologi. Høringsuttalelse 28.3.2016. http://traumatologi.no/wp-content/uploads/2014/11/Prehospital-thorakotomi-høringssvar-NKT-T-og-NKF1.pdf (31.10.2016).
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Lockey DJ, Lyon RM, Davies GE. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation 2013; 84: 738 – 42. [PubMed] [CrossRef]
17.
Puchwein P, Sommerauer F, Clement HG et al. Clamshell thoracotomy and open heart massage – A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study. Injury 2015; 46: 1738 – 42. [PubMed] [CrossRef]

Comments ( 3 )

Dette kommentarfeltet modereres, men kommentarer blir ikke redaksjonelt behandlet ut over å sikre at de følger retningslinjer for vårt kommentarfelt.

13.01.2017:

Ottestad og medarbeidere foreslår, som Norsk Anestesiologisk Forening, prehospital torakotomi ved traumatisk hjertestans på gitte indikasjoner i Tidsskriftet nr. 23 (1, 2). Norsk kirurgisk forening og Nasjonal kompetansetjeneste for traumatologi har i en høringsuttalelse frarådet å innføre prosedyren i Norge(3).

Ottestad og medarbeidere viser til erfaringer fra London. Luftambulansetjenesten i London dekker mer enn to ganger Norges befolkning. Det er kort avstand til traumesentre, og et svært høyt antall stikkskader i europeisk sammenheng. Tjenesten er bemannet med en gruppe spesialtrente leger. Indikasjonene for torakotomi er mistanke om hjertetamponade, tap av livstegn < 10 minutter før aktuell prosedyre iverksettes og transporttid til sykehus > 10 minutter. Etter utført prosedyre er imidlertid transporttiden til sykehus uansett kort i sentrale London sammenlignet med de fleste steder i Norge. Prehospital nødtorakotomi krever derfor opplæring av et begrenset antall personer i samme tjeneste, og utføres anslagsvis to ganger per uke (personlig meddelelse Gareth Davies, oktober 2016). Resultatene er 13 overlevende i perioden 1993-2008(4).

I Norge skjer de fleste stikkskader mot thorax i sentrum av de største byene. Vi mener derfor at prehospital torakotomi ikke er indisert i disse tilfellene i henhold til retningslinjene fra London. De færreste skadene er enkle knivstikk mot hjertet som lar seg kontrollere med en finger. I et upublisert materiale over 12 år fra Oslo (traumeregisteret OUS, 2002-2013) var det 19 pasienter med penetrerende hjerteskade som ble fraktet til sykehus. Kun ni av disse hadde hjertetamponade som gir teoretisk mulighet for effektiv prehospital håndtering. I Norge vil det innebære færre enn én prosedyre per prehospitallege i hele hennes karriere, forutsatt at man antar at like mange stikkes i hjertet i landet for øvrig som i Oslo. Videre forutsetter det optimalt tidspunkt samt begrensede intratorakale skader som kan håndteres under gitt transportavstand til sykehus.

Ottestad og medarbeidere anfører at trening og opplæring er relativt lite ressurskrevende. Vår erfaring fra kurs (Definitive Surgical Trauma Care og krigskirurgi) og klinisk praksis er at opplæring og trening krever god kirurgisk bakgrunn, gjentatte øvinger og hyppig repetisjon for å kunne utføres på en tilfredsstillende måte. Pasientene er vårt felles ansvar, og vi må samarbeide om opplæring i nødvendige prehospitale kirurgiske prosedyrer(3). Vi må heller rette oppmerksomheten mot relevante og hyppigere forekommende prosedyrer som thoraxdren og håndtering av ytre blødninger, med percutan drenasje for hjertetamponade som mer realistisk.
Ottestad og medforfattere skriver at vi – i høringsuttalelsen fra Nasjonal kompetansetjeneste for traumatologi og Norsk kirurgisk forening – har hevdet at prehospital torakotomi er etisk tvilsomt. Det stemmer ikke. Vi mener at ressursbruken som kreves for adekvat opplæring av alle leger som jobber prehospitalt i Norge vil være så omfattende at slik bruk av begrensede helseressurser ikke er etisk forsvarlig.

Litteratur
1. Ottestad W, Bredmose PB, Berve PO et al. Prehospital torakotomi ved traumatisk hjertestans. Tidsskr Nor Legeforen 2016; 136:1964-5
2. Årsmøtesak: Kirurgiske nødprosedyrer utført av anestesileger prehospitalt. Norsk Anestesiologisk Forening. http://nafweb.no/ukategorisert/arsmotesak-kirurgiske-nodprosedyrer-utfort-av-anestesileger-prehospitalt/ (11.1.2017)
3. NKT-T og NKF. Høringsuttalelse 28.3.2016. http://traumatologi.no/wp-content/uploads/2014/11/Prehospital-thorakotomi-høringssvar-NKT-T-og-NKF1.pdf (11.1.2017)
4. Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results. J Trauma 2011; 70: E75 – 8.

24.01.2017:

Ottestad og medarbeidarar skriv i Tidsskriftet nr. 23 2016 om prehospital torakotomi ved traumatisk hjartestans (1). Leiar i Norsk kirurgisk forening, Inge Glambek, har kommentert denne artikkelen.

Det førre styret i Norsk anestesiologisk forening (NAF) ynskte å sikre eit rammeverk kring prehospitale naudprosedyrar (inkludert torakotomi ved traumatisk hjartestans), og la fram eit tilrådingsbrev for årsmøtet i NAF i oktober 2015. Etter diskusjon konkluderte årsmøtet med at saka burde utgreiast nærare. Det nye styret i NAF sende difor 31.01.16 ut eit høyringsbrev. Etter høyringsrunden (med sterkt sprikande tilrådingar) arrangerte Nasjonal kompetansetjeneste for prehospital akuttmedisin (NAKOS) eit fagmøte på Ullevål 03.11.16 med dette som tema. Der kom mange aktørar til orde, utan at ein kom fram til noka semje.
Etter dette fagmøtet fekk styret i NAF med seg NAKOS og Nasjonal kompetansetjeneste for traumatologi (NKT), og sende ein førespurnad til sekretariatet for "Bestillerforum RHF" om å få gjort ei nasjonal metodevurdering i denne saka. Slik kan vi få gjort ei fagleg vurdering også av ein «nøytral» instans.

Deler av det prehospitale miljøet er klart for å innføre prehospital torakotomi som ein prosedyre som på gjevne indikasjonar kan utførast (1), medan Norsk kirurgisk forening og Nasjonal kompetansetjeneste for traumatologi i klare ordelag har gått imot (2). Det er ikkje til å leggje skjul på at det er ulike syn også internt i NAF i denne saka, noko som kom fram både på årsmøtet og fagmøtet. Styret i NAF ynskjer difor å sjå resultatet av ei nasjonal metodevurdering før vi konkluderer.

Litteratur
1. Ottestad W, Bredmose PB, Berve PO et al. Prehospital torakotomi ved traumatisk hjertestans. Tidsskr Nor Legeforen 2016; 136:1964-5

2. Høringsuttalelse fra Norsk kirurgisk forening (NKF) og Nasjonal kompetansetjeneste for traumatologi (NKT traume) vedrørende prehospital clam-‐shell thoracotomi utført av anestesileger 28.3.2016. http://traumatologi.no/wp-content/uploads/2014/11/Prehospital-thorakotomi-høringssvar-NKT-T-og-NKF1.pdf (24.1.2017)

25.01.2017:

Kaljusto og medarbeidere ved OUS, Ullevål, publiserte nylig en studie som viste utkomme hos pasienter med penetrerende hjerteskade i perioden 2001–2010 (1). De identifiserte 60 pasienter hvorav 31 ankom Ullevål, mens 29 pasienter døde på åstedet. Det er omlag tre ganger så mange som Glambek og medforfattere legger til grunn i sin kommentar. I det publiserte arbeidet var det totalt 46 pasienter som oppfylte de anatomiske og fysiologiske kriteriene for prehospital thorakotomi. Av disse ble 29 erklært døde utenfor sykehus, mens 17 ble transportert til sykehus, hvorav åtte ikke hadde tegn til liv på skadestedet og ni fikk hjertestans under transport til sykehuset.
Når det gjelder transporttid til Ullevål så fastholder Glambek og medforfattere at de fleste stikkskader i Norge skjer i sentrum av de største byene. I den omtalte studien fra Ullevål hadde imidlertid alle pasientene en transporttid over 10 minutter med unntak av en pasient. Avhengig av hvordan pasientpopulasjonen stratifiseres så varierte median transporttid fra 21 til 30 minutter. Majoriteten av pasientene er dermed lengre enn 10 minutter fra sykehus, men de har allikevel relativt kort transporttid, og i følge Glambek og medforfattere likner dette på situasjonen i London.
Det er korrekt at Gareth Davies fra London Air Ambulance under et foredrag i oktober 2016 i Oslo fortalte at de i London nå utfører to prehospitale thorakotomier pr. uke. Dette skyldes at de har utvidet indikasjonen for prosedyren og det er derfor ikke korrekt å knytte dagens praksis til overlevelsesresultater fra 1993-2008.
Glambek og medforfattere understreker at det ikke er selve prosedyren de mener er etisk tvilsom, men ressursbruken knyttet til opplæring av anestesileger som jobber prehospitalt. Vi har beskrevet hvordan undervisning foregår i allerede etablerte kurs hvor obligatoriske og standariserte prosedyrer innøves, og at ressursbruken derfor er meget begrenset. Det er heller ikke slik at trening på thorakotomi går på bekostning av trening på mer hyppige eller relevante prosedyrer. Glambek og medforfattere hevder at prosedyren forutsetter kirurgisk bakgrunn for å kunne utføres på en tilfreds-stillende måte. Vi mener at dette er tilbakevist med den praksis som foregår i London, hvor anestesileger uten kirurgisk erfaring og med begrenset trening utfører dette raskt og sikkert i henhold til en standard operasjonsprosedyre. Hva som er kirurgisk “tilfredsstillende” utførelse må tolkes inn i en kontekst hvor pasientens alternativ er å bli erklært død på skadested.
Registerdata er en verdifull ressurs for å monitorere effekten av ulike behandlingstiltak. Når man bruker slike data for å bygge premissene i en svært viktig diskusjon rundt en potensiell behandlings-modalitet er det uheldig at man ikke definerer den aktuelle populasjonen presist. I tillegg er det bemerkelsesverdig at man unnlater å nevne publiserte data som omhandler samme populasjon og tilsvarende tidsrom. Vi er overbevist om at alle ønsker en kunnskapsbasert og akademisk tilnærming til en diskusjon omkring våre aller sykeste pasienter.

1. Kaljusto, M.-L., Skaga, N. O., Pillgram-Larsen, J. & Tønnessen, T. Survival predictor for penetrating cardiac injury; a 10-year consecutive cohort from a scandinavian trauma center. Scand J Trauma Resusc Emerg Med 23, 1–7 (2015).

This article was published more than 12 months ago and we have therefore closed it for new comments.

Published: 20 December 2016

Tidsskr Nor Legeforen 20 December 2016

doi:

10.4045/tidsskr.16.0798

Received 19 September 2016, first revision submitted 30 October 2016, accepted 14 November 2016. Editor: Ketil Slagstad

136

:

1964-5

Published: 20 December 2016

Tidsskr Nor Legeforen 2016

136

:

1964-5

doi: 10.4045/tidsskr.16.0798

Received 19 September 2016, first revision submitted 30 October 2016, accepted 14 November 2016. Editor: Ketil Slagstad

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Prehospital thoracotomy for traumatic cardiac arrest

Experience from London

Procedure for prehospital thoracotomy

Who should perform prehospital thoracotomy?

Training

What is ethically correct?

A place in Norway too

Prehospital torakotomi ved traumatisk hjertestans

Prehospital torakotomi ved traumatisk hjartestans

Prehospital thorakotomi ved traumatisk hjertetsans

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