Skip to main content

Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients: effect size is probably higher for penetrating injury

To the Editor,

Endo et al. [1] recently reported that compared to closed-chest cardiopulmonary resuscitation (CCCPR), open-chest cardiopulmonary resuscitation (OCCPR) was associated with significantly higher survival at hospital discharge in severe trauma patients with signs of life upon emergency department arrival.

The authors should be congratulated for their very interesting study in the utmost important field of traumatic cardiac arrest. Nevertheless, we believe that some points of their study should be pointed out.

Endo et al. used a propensity score matching analysis to mimic a randomized control trial, and the readers should be aware that this methodology reduces the differences according to the type of injury. Indeed, international guidelines for cardiopulmonary resuscitation (CPR) recommend, beyond symptomatic CPR, the etiological treatment of reversible causes of cardiac arrest, which are summarized by the 4H and 4T mnemonic tool (i.e., hypovolemia, hypoxemia, hypo/hyperkalemia, hypothermia, toxic, tamponade, pneumothorax, and pulmonary/coronary thrombosis) [2, 3]. However, propensity score matching reduces the differences between blunt and penetrating injury groups, for whom cardiac arrest etiological treatment present major differences. First, penetrating injuries result in a higher cardiac arrest proportion requiring an open-chest intervention that may fully explain the relative weight of the variable, “number of trauma surgeons in a hospital,” on outcomes observed in Endo et al. study [1]. Second, blunt trauma patients generally present multiple injuries, many of which include brain trauma, which could dramatically impair prognosis whenever any injury occurs that is accessible to treatment by OCCPR. Finally, the propensity score matching does not include two major cardiac arrest outcome determinants: the no-flow and the low-flow durations [4, 5].

Beyond these considerations, we agree with Endo et al. [1], that the use of OCCPR should be considered more frequently for trauma patients presenting with cardiac arrest upon hospital arrival, especially those with penetrating injury.

Availability of data and materials

Not applicable.


  1. 1.

    Endo A, Kojima M, Hong ZJ, Otomo Y, Coimbra R. Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients with signs of life upon hospital arrival: a retrospective multicenter study. Crit Care. 2020;24(1):541.

    Article  Google Scholar 

  2. 2.

    Panchal AR, Berg KM, Hirsch KG, Kudenchuk PJ, Del Rios M, Cabanas JG, et al. 2019 American Heart Association focused update on advanced cardiovascular life support: use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2019;140(24):e881–94.

    PubMed  Google Scholar 

  3. 3.

    Perkins GD, Olasveengen TM, Maconochie I, Soar J, Wyllie J, Greif R, European Resuscitation Council, et al. update. Resuscitation. 2017;2018(123):43–50.

    Google Scholar 

  4. 4.

    Adnet F, Triba MN, Borron SW, Lapostolle F, Hubert H, Gueugniaud PY, et al. Cardiopulmonary resuscitation duration and survival in out-of-hospital cardiac arrest patients. Resuscitation. 2017;111:74–81.

    Article  Google Scholar 

  5. 5.

    Jouffroy R, Vivien B. Prognostic value of venous blood analysis at the start of CPR in non-traumatic out-of-hospital cardiac arrest: association with ROSC and the neurological outcome: do not forget the no-flow influence! Crit Care. 2020;24(1):232.

    Article  Google Scholar 

Download references





Author information




BV and RJ wrote the manuscript. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Benoît Vivien.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Jouffroy, R., Vivien, B. Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients: effect size is probably higher for penetrating injury. Crit Care 24, 655 (2020).

Download citation