Survival after pre-hospital emergency clamshell thoracotomy for blunt cardiac rupture

Published:September 16, 2019DOI:


      • Cardiac rupture associated with blunt trauma is usually associated with a high mortality.
      • Our patient had a traumatic cardiac arrest due to blunt trauma. Thoracotomy was performed to relieve a tamponade.
      • The evidence for indiscriminate thoracotomy for blunt traumatic cardiac arrest is poor. The addition of ultrasound can support decision making.
      • The first documented case of neurological survival post pre-hospital clamshell thoracotomy for blunt traumatic arrest.


      Blunt trauma causing cardiac rupture is usually fatal. We report a patient with blunt cardiac injury that suffered traumatic cardiac arrest in the pre-hospital phase of their care. A cardiac tamponade was confirmed with portable ultrasound in a brief return of circulation. The patient had a further cardiac arrest and subsequently underwent damage control emergency surgery via a clamshell thoracotomy at the scene. The tamponade was released and a clamp was applied to the identified left atrial appendage rupture, a return of circulation then occurred.
      He was transferred to a cardiothoracic centre where a left atrial appendage rupture was identified and closed. The patient had a complicated recovery in hospital but went on to survive neurologically intact. This is the first documented case report of a neurologically intact survivor of a pre-hospital clamshell thoracotomy for blunt trauma. Although survivors of blunt trauma who have pre-hospital thoracotomy are extremely rare it should be considered in very specific circumstances.


      To read this article in full you will need to make a payment
      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Teixera P.G.
        • Inaba K.
        • Oncel D.
        • DuBose J.
        • Chan L.
        • Rhee P.
        • et al.
        Blunt cardiac rupture: a 5-year NTDB analysis.
        J Trauma. 2009; 67: 788-791
        • Clancy K.
        • Velopulos C.
        • Bilaniuk J.W.
        • Collier B.
        • Crowley W.
        • Kurek S.
        • et al.
        Screening for blunt cardiac injury.
        J Trauma. 2012; 73: 301-306
        • Parmley F.F.
        • Manion W.C.
        • Mattingey T.W.
        Non penetrating traumatic injury of the heart.
        Circulation. 1958; 18: 371-393
        • Meera T.H.
        • Nabachandra H.
        A postmortem study of blunt cardiac injuries.
        J Indian Acad Forensic Med. 2005; 27: 82-84
        • Turk E.E.
        • Tsokos M.
        Blunt cardiac trauma caused by fatal falls from height: an autopsy-based assessment of the injury pattern.
        J Trauma. 2004; 57: 301-304
        • Ryu D.W.
        • Lee S.L.
        • Lee M.K.
        Rupture of the left atrial roof due to blunt trauma.
        Interact Cardiovasc Thorac Surg. 2013; 17: 912-913
        • Endo A.
        • Shiraishi A.
        • Otomo Y.
        • Tomita M.
        • Matsui H.
        • Murata K.
        Open-chest versus closed-chest cardiopulmonary resuscitation in blunt trauma: an analysis of a nationwide trauma registry.
        Crit Care. 2017; 21: 169-178
        • Simms E.R.
        • Flaris A.N.
        • Franchino X.
        • Thomas M.
        • Caillot J.
        • Voiglio E.
        Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study.
        World J Surg. 2013; 37: 1277-1285
        • Wise D.
        • Davies G.
        • Coats T.
        • Lockey D.
        • Hyde J.
        • Good A.
        Emergency thoracotomy: “how to do it”.
        Emerg Med J. 2005; 22: 22-24
        • Seamon M.J.
        • Haut E.R.
        • Van Arendonk K.
        • Barbosa R.
        • Chiu W.
        • Dente C.
        • 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: 159-173
        • Truhlár A.
        • Deakin C.
        • Soar J.
        • Khalifa G.
        • Alfonzo A.
        • Bierens J.
        • et al.
        European resuscitation council guidelines for 2015 section 4. Cardiac arrest in special circumstances.
        Resuscitation. 2015; : 148-201
        • Lockey D.
        • Crewdson K.
        • Davies G.
        Traumatic cardiac arrest: who are the survivors?.
        Ann Emerg Med. 2006; 48: 240-244
        • Lockey D.J.
        • Brohi K.
        Pre-hospital thoracotomy and the evolution of pre-hospital critical care for victims of trauma.
        Injury. 2017; 48: 1863-1864