Factors associated with outcomes in traumatic cardiac arrest patients without prehospital return of spontaneous circulation

The role of REBOA in patients in traumatic cardiac arrest subsequent to hemorrhagic shock: a scoping review

Purpose

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a useful adjunct in treatment of patients in severe hemorrhagic shock. Hypothetically, REBOA could benefit patients in traumatic cardiac arrest (TCA) as balloon occlusion of the aorta increases afterload and may improve myocardial performance leading to return of spontaneous circulation (ROSC). This scoping review was conducted to examine the effect of REBOA on patients in TCA.

Methods

This scoping review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) Statement. PubMed, EMBASE.com and the Web of Science Core Collection were searched. Articles were included if they reported any data on patients that underwent REBOA and were in TCA. Of the included articles, data regarding SBP, ROSC and survival were extracted and summarized.

Results

Of 854 identified studies, 26 articles met criteria for inclusion. These identified a total of 785 patients in TCA that received REBOA (presumably less because of potential overlap in patients). This review shows REBOA elevates mean SBP in patients in TCA. The achievement of ROSC after REBOA deployment ranged from 18.2% to 67.7%. Survival to discharge ranged from 3.5% to 12.1%.

Conclusion

Overall, weak evidence is available on the use of REBOA in patients in TCA. This review, limited by selection bias, indicates that REBOA elevates SBP and may benefit ROSC and potentially survival to discharge in patients in TCA. Extensive further research is necessary to further clarify the role of REBOA during TCA.

A novel scoring system using easily assessible predictors of return of spontaneous circulation and mortality in traumatic out-of-hospital cardiac arrest patients: A retrospective cohort study

BACKGROUND

An accident event may necessitate triage of multiple cases of traumatic out-of-hospital cardiac arrest (TOHCA). However, factors for prioritizing treatment among multiple TOHCA patients have not been established. This study aims to use easily assessible predictors of TOHCA outcomes to develop a triage scoring system.

METHODS

Patients with TOHCA brought to our hospital by emergency medical services (EMS) were included for analysis to identify independent risk factors for poor outcomes. A scoring system was developed and validated internally and externally.

RESULTS

Of the 401 included patients, 86 (21.4%) had return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) for 30 min (81 patients, 94.2%) or 45 min (86 patients, 100%). The emergency department (ED) mortality rate was 89.3% and overall in-hospital mortality rate was 99%. Univariate and multivariate analyses identified body temperature <33 °C (OR, 4.65; 95% CI, 1.37-15.86), obvious chest injury (OR, 2.11; 95% CI, 1.03-4.34), and presumable etiology of out-of-hospital cardiac arrest (OR, 1.73; 95% CI, 1.01-2.98) as significant independent risk factors for non-ROSC. The TOHCA score, calculated as 1 point per risk factor, correlated significantly with the rate of non-ROSC and ED mortality (TOHCA score 0, 1, 2, 3: non-ROSC rate, 63.0%, 80.4%, 90.8%, 100%, respectively; ED mortality rate, 79.5%, 91.5%, 96.1%, and 100% respectively). The results of internal and external validations show a similar trend in both non-ROSC and mortality in the ED with increasing score.

CONCLUSIONS

Termination of CPR for TOHCA after 45 min is reasonable; a 30-minute resuscitation is acceptable in case of insufficient medical staff or resources. The TOHCA score may be able to be used with caution for triage.

Prehospital traumatic cardiac arrest: a systematic review and meta-analysis

BACKGROUND

Circulatory arrest after trauma is a life-threatening situation that mandates urgent action. The aims of this systematic review and meta-analysis on prehospital traumatic cardiac arrest (TCA) were to provide an updated pooled mortality rate for prehospital TCA, to investigate the impact of the time of patient inclusion and the type of prehospital trauma system on TCA mortality rates and neurological outcome, and to investigate which pre- and intra-arrest factors are prognostic for prehospital TCA mortality.

METHODS

This review was conducted in accordance with the PRISMA and CHARMS guidelines. Databases were searched for primary studies published about prehospital TCA patients (1995-2020). Studies were divided into various EMS-system categories. Data were analyzed using MedCalc, Review Manager, Microsoft Excel, and Shinyapps Meta Power Calculator software.

RESULTS

Thirty-six studies involving 51.722 patients were included. Overall mortality for TCA was 96.2% and a favorable neurological outcome was seen in 43.5% of the survivors. Mortality rates were 97.2% in studies including prehospital deaths and 92.3% in studies excluding prehospital deaths. Favorable neurological outcome rates were 35.8% in studies including prehospital deaths and 49.5% in studies excluding prehospital deaths. Mortality rates were 97.6% if no physician was available at the prehospital scene and 93.9% if a physician was available. Favorable neurological outcome rates were 57.0% if no physician was available at the prehospital scene and 38.0% if a physician was available. Only non-shockable rhythm was associated with a higher mortality (RR 1.12, p = 0.06).

CONCLUSION

Approximately 1 in 20 patients with prehospital TCA will survive; about 40% of survivors have favorable neurological outcome.

Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study

BACKGROUND AND AIMS

The prognosis of patients with cardiac arrest following trauma is poor. Our objectives were: (1) to determine outcomes of patients following in-hospital cardiac arrest posttrauma and admitted to the intensive care unit (ICU) and (2) to identify characteristics associated with in-hospital mortality.

MATERIALS AND METHODS

This was a single-center retrospective analysis of patients admitted to ICU after resuscitation following in-hospital cardiac arrest between January 2017 and July 2018. Patients with isolated head injuries and multiple cardiac arrests were excluded. Bivariate analysis was done to determine a significant association between baseline characteristics and in-hospital mortality.

RESULTS

A total of 37 patients were included. About 35.1% of trauma subjects survived hospital discharge. Bivariate analysis showed positive association between admission Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores with in-hospital mortality. Other characteristics, such as age, duration of cardiopulmonary resuscitation (CPR), and serum lactate levels on admission, were not associated with in-hospital mortality.

CONCLUSION

Despite being at lower survival following a cardiac arrest after trauma, approximately one-third of the patients survived hospital discharge. This implies that aggressive support of this population is not necessarily futile. Optimization of postresuscitation physiological factors and their impacts on outcomes for these patients need further studies.

HOW TO CITE THIS ARTICLE

Soni KD, Rai N, Aggarwal R, Trikha A. Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study. Indian J Crit Care Med 2021;25(12):1408-1412.

Dynamic changes in arterial blood gas during cardiopulmonary resuscitation in out-of-hospital cardiac arrest

We aimed to investigate the prognostic value of dynamic changes in arterial blood gas analysis (ABGA) measured after the start of cardiopulmonary resuscitation (CPR) for return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). This prospective observational study was conducted at the emergency department of a university hospital from February 2018 to February 2020. All blood samples for gas analysis were collected from a radial or femoral arterial line, which was inserted during CPR. Changes in ABGA parameters were expressed as delta (Δ), defined as the values of the second ABGA minus the values of the initial ABGA. The primary outcome was sustained ROSC. Out of the 80 patients included in the analysis, 13 achieved sustained ROSC after in-hospital resuscitation. Multivariable logistic analysis revealed that ΔpaO₂ (odds ratio [OR] = 1.023; 95% confidence interval [CI] = 1.004–1.043, p = 0.020) along with prehospital shockable rhythm (OR = 84.680; 95% CI = 2.561–2799.939, p = 0.013) and total resuscitation duration (OR = 0.881; 95% CI = 0.805–0.964, p = 0.006) were significant predictors for sustained ROSC. Our study suggests a possible association between ΔpaO₂ in ABGA during CPR and an increased rate of sustained ROSC in the late phase of OHCA.

Factors associated with survival in adult patients with traumatic arrest: a retrospective cohort study from US trauma centers

Background

Traumatic arrests increasingly affect young adults worldwide with low reported survival rates. This study examines factors associated with survival (to hospital discharge) in traumatic arrests transported to US trauma centers.

Methods

This retrospective cohort study used the US National Trauma Databank 2015 dataset and included patients who presented to trauma centers with “no signs of life”. Univariate and bivariate analyses were done. Factors associated with survival were identified using multivariate regression analyses.

Results

The study included 5980 patients with traumatic arrests. Only 664 patients (11.1%) survived to hospital discharge. Patients were predominantly in age group 16–64 (84.6%), were mostly males (77.8%) and white (55.1%). Most were admitted to Level I (55.5%) or Level II trauma centers (31.6%). Injuries were mostly blunt (56.7%) or penetrating (39.3%). The median of the injury severity score (ISS) was 19 (interquartile range [IQR]: 9–30). Factors associated with decreased survival included: Age group ≥ 65 (Ref: 16–24), male gender, self-inflicted and other or undetermined types of injuries (Ref: assault), injuries to head and neck, injuries to torso and ISS ≥ 16 (Ref: < 16) and ED thoracotomy. While factors associated with increased survival included: All injury mechanisms (with the exception of motor vehicle transportation) (Ref: firearm), injuries to extremities or spine and back and all methods of coverage (Ref: self-pay).

Conclusion

Patients with traumatic arrests have poor outcomes with only 11.1% surviving to hospital discharge. Factors associated with survival in traumatic arrests were identified. These findings are important for devising injury prevention strategies and help guide trauma management protocols to improve outcomes in traumatic arrests.

Level of evidence

Level III.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Pre-arrest and intra-arrest prognostic factors associated with survival following traumatic out-of-hospital cardiac arrest - A systematic review and meta-analysis

AIM

To summarize the prognostic associations of pre- and intra-arrest factors with return of spontaneous circulation (ROSC) and survival (in-hospital or 30 days) after traumatic out-of-hospital cardiac arrest.

METHODS

We conducted this review in accordance with the PRISMA and CHARMS guidelines. We searched Medline, Pubmed, Embase, Scopus, Web of Science and the Cochrane Database of Systematic Reviews from inception through December 1st, 2019. We included English language studies evaluating pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA. Risk of bias was assessed using the QUIPS tool. We pooled unadjusted odds ratios using random-effects models and presented adjusted odds ratios with 95% confidence intervals. We used the GRADE method to describe certainty.

RESULTS

We included 53 studies involving 37,528 patients. The most important predictors of survival were presence of cardiac motion on ultrasound (odds ratio 33.91, 1.87-613.42, low certainty) or a shockable initial cardiac rhythm (odds ratio 7.29, 5.09-10.44, moderate certainty), based on pooled unadjusted analyses. Importantly, mechanism of injury was not associated with either ROSC (odds ratio 0.97, 0.51-1.85, very low certainty) or survival (odds ratio 1.40, 0.79-2.48, very low certainty).

CONCLUSION

This review provides very low to moderate certainty evidence that pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA predict ROSC and survival. This evidence is primarily based on unadjusted data. Further well-designed studies with larger cohorts are warranted to test the adjusted prognostic ability of pre- and intra-arrest factors and guide therapeutic decision-making.