Traumatic out-of-hospital cardiac arrests in Melbourne, Australia

Influence of pulseless electrical activity and asystole on the prognosis of patients with traumatic cardiac arrest: A retrospective cohort study

BACKGROUND

Traumatic cardiac arrest (TCA) is associated with poor prognosis. Recent advancements in resuscitation techniques have improved outcomes; however, the prognostic value of the initial cardiac rhythm in TCA remains unclear. Pulseless electrical activity (PEA) is often a sign of life, leading to ongoing resuscitation efforts; however, its effect on survival remains controversial. This study aimed to clarify the prognostic impact of PEA and asystole in patients with TCA to inform decision-making.

METHODS

This retrospective cohort study was conducted in a tertiary trauma center in Tainan, Taiwan, between 2016 and 2022 and enrolled patients with TCA transported by emergency medical services. Exclusion criteria included patients aged < 18 years with prehospital return of spontaneous circulation (ROSC) or specific trauma etiologies. Only non-shockable rhythms (PEA and asystole) were analyzed. Data on patient characteristics, trauma mechanisms, and resuscitation interventions were collected from electronic medical records. The primary outcome was ROSC at any time after reaching hospital, with secondary outcomes including sustained ROSC (ROSC for over 20 min), survival to admission, survival to discharge, and the cerebral performance category scale. Statistical analyzes were performed using the chi-square test and multivariate logistic regression. Statistical significance was defined as p < 0.05.

RESULTS

Of the 2,029 out-of-hospital cardiac arrest cases, 182 were TCA, and 46 were excluded based on various criteria. The final analysis included 136 patients divided into the PEA (n = 78, 57 %) and asystole (n = 58, 43 %) groups. No significant differences were observed in patient demographics, clinical characteristics, or resuscitative interventions between the groups. The PEA group had a significantly higher rate of ROSC (49 % vs. 26 %, p = 0.007), although survival to discharge remained low. Multivariable analysis revealed that PEA was the only factor significantly associated with ROSC (odds ratio: 2.87, p = 0.007).

CONCLUSION

In patients with TCA presenting with non-shockable rhythms, PEA was significantly associated with achieving ROSC, but not sustained ROSC or survival to admission. As a subset of patients in the PEA group survived until discharge, the existing guidelines for termination of resuscitation in TCA cases may require further evaluation.

Prehospital Management of Adults With Traumatic Out-of-Hospital Circulatory Arrest-A Joint Position Statement

The National Association of Emergency Medical Services Physicians (NAEMSP), American College of Surgeons Committee on Trauma (ACS-COT), and American College of Emergency Physicians (ACEP) believe that evidence-based, pragmatic, and collaborative protocols addressing the care of patients with traumatic out-of-hospital circulatory arrest (TOHCA) are needed to optimize patient outcomes and clinician safety. When the etiology of arrest is unclear, particularly without clear signs of life-threatening trauma, standard basic and advanced cardiac life support (BCLS/ACLS) treatments for medical cardiac arrest are appropriate. Traumatic circulatory arrest may result from massive hemorrhage, airway obstruction, obstructive shock, respiratory disturbances, cardiogenic causes, or massive head trauma. While resuscitation and/or transport is appropriate for some populations, it is appropriate to withhold or discontinue resuscitation attempts for TOHCA patients for whom these efforts are nonbeneficial. This position statement and resource document were written as an update to the 2013 joint position statements. NAEMSP, ACEP, and ACS-COT recommend.

Adherence to prehospital thoracostomy practice guidelines for traumatic cardiac arrest: A retrospective study

Objectives

The management of traumatic cardiac arrest (TCA) focuses on the immediate treatment of reversible causes, including bilateral thoracostomy. In our prehospital emergency service, bilateral thoracostomy has been recommended since 2012 for the management of TCA. We sought to analyse the prehospital management and clinical course of patients with TCA, focusing on changes over time in the use of thoracostomy.

Methods

In this single-centre retrospective observational study, we included patients with TCA managed by physicians of the prehospital service of Lausanne University Hospital from 2012 to 2024. The primary outcome was the annual rate of bilateral thoracostomy. Secondary outcomes included the rate of additional on-site measures, such as pelvic binder placement and airway management, and follow-up at 48 h.

Results

Among 3206 cardiac arrests during the study period, 473 (15%) were TCAs. Among the 247 patients with resuscitation attempts, thoracostomy was judged as indicated in 223 (90%) and performed in 148 (66%). Twenty-seven (18%) patients who had a thoracostomy were alive on arrival at hospital, with 9 (6.1%) still alive at 48 h. The mean annual proportion of patients in whom a thoracostomy was performed was 68% (range 0-100%) and increased significantly over the years (p < 0.001).

Conclusions

The annual rate of thoracostomy in TCA patients increased significantly in the period 2012 to 2024. Larger studies are required to determine the impact of thoracostomy on survival.

Bystander cardiopulmonary resuscitation and outcomes of mass cardiac arrests caused by a crowd crush

INTRODUCTION

A crowd crush can lead to respiratory arrest and result in multiple mass cardiac arrests (MCAs), which are often classified as Black Tag in disaster triage. Recently, many laypersons have been commonly trained in compression-only cardiopulmonary resuscitation (CPR) without ventilation support in various communities. This study aims to describe the characteristics of bystander CPR administered and the outcomes of MCAs during the Itaewon crowd crush incident.

METHODS

An observational study was conducted on the CPR characteristics of MCAs during the Halloween Festival in 2022, utilizing two databases: (1) MCAs registered in the Korea Out-of-Hospital Cardiac Arrest Registry (KOHCAR) and (2) MCAs uploaded on social media platforms (Instagram and YouTube), identified through relevant keyword searches. Video clips with a minimum streaming time of 10 s and a clear view of bystander CPR were analyzed. General demographic findings were analyzed using the KOHCAR, while the type of bystander CPR (compression-only CPR with or without rescue breathing) was compared using the social media data.

RESULTS

Of the 218 patients attended by EMS, 119 MCAs were registered in KOHCAR. The mean age of the victims was 24.5 years, with 10 (8.4%) being non-Korean. The median ambulance response time was 59 min. Among the victims, 22 (18.5%) received CPR (19 bybystanders, 2 by first responders, and 1 by a disaster medical assistant team), followed by EMS resuscitation, while 7 (5.9%) received CPR first by the EMS team. The remaining 90 victims (75.6%) were pronounced deceased by EMS providers. Three victims (2.5%) achieved return of spontaneous circulation (ROSC) in the field, and one (0.8%) survived to hospital discharge. From the social media database, 26 video clips containing CPR were identified (14 from 251 clips on Instagram and 12 from 187 on YouTube), excluding duplicates and non-CPR cases. In the 26 video clips containing CPR, a total of 228 bystander CPR cases were identified in the video clips. Of these, 217 (95.2%) involved compression-only CPR, while 11 cases (4.8%) included CPR with rescue breathing.

CONCLUSION

Most MCAs were pronounced deceased, likely due to their classification as Black Tag or delayed response times. Only a small percentage (4.8%) of bystander CPR cases included rescue breathing. An optimized resuscitation protocol for MCAs in crowd crush scenarios should be developed.

Development of a prediction model for emergency medical service witnessed traumatic out-of-hospital cardiac arrest: A multicenter cohort study

BACKGROUND/PURPOSE

To develop a prediction model for emergency medical technicians (EMTs) to identify trauma patients at high risk of deterioration to emergency medical service (EMS)-witnessed traumatic cardiac arrest (TCA) on the scene or en route.

METHODS

We developed a prediction model using the classical cross-validation method from the Pan-Asia Trauma Outcomes Study (PATOS) database from 1 January 2015 to 31 December 2020. Eligible patients aged ≥18 years were transported to the hospital by the EMS. The primary outcome (EMS-witnessed TCA) was defined based on changes in vital signs measured on the scene or en route. We included variables that were immediately measurable as potential predictors when EMTs arrived. An integer point value system was built using multivariable logistic regression. The area under the receiver operating characteristic (AUROC) curve and Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration in the derivation and validation cohorts.

RESULTS

In total, 74,844 patients were eligible for database review. The model comprised five prehospital predictors: age <40 years, systolic blood pressure <100 mmHg, respiration rate >20/minute, pulse oximetry <94%, and levels of consciousness to pain or unresponsiveness. The AUROC in the derivation and validation cohorts was 0.767 and 0.782, respectively. The HL test revealed good calibration of the model (p = 0.906).

CONCLUSION

We established a prediction model using variables from the PATOS database and measured them immediately after EMS personnel arrived to predict EMS-witnessed TCA. The model allows prehospital medical personnel to focus on high-risk patients and promptly administer optimal treatment.

A Contemporary Study of Pre-hospital Traumatic Cardiac Arrest: Distinguishing Exsanguination From Non-exsanguination Arrest With a Review of Current Literature

Background Traumatic cardiac arrest (TCA) remains a challenging problem in terms of diagnosis and management. This is due to difficulty distinguishing the TCA cause and therefore understanding the pathophysiology. The goal of this study was to analyze a contemporary series of TCA patients and classify the causes of TCA into exsanguination (EX) arrest and non-exsanguination (non-EX) arrest. Methods This was a retrospective review of patients suffering TCA during 2019 at a level I trauma center. We excluded patients whose arrests were from medical causes such as ventricular fibrillation, ventricular tachycardia, pulmonary embolus, etc., hanging, drowning, thermal injury, outside transfer, and pediatric patients (age <13 as this is our institutional definition for pediatric trauma patients). We reviewed pre-hospital run-sheets, hospital charts including autopsy findings, and classified patients into EX and non-EX TCA. We defined a witnessed arrest (WA) using the traditional outside hospital cardiac (non-trauma) arrest definition. Outcomes included the incidence of EX arrest, survival to discharge, and hospital costs. Descriptive statistics were used. Significance was set at p < 0.05. Results After exclusion, 54 patients suffered TCA with a mean age of 45.9 (±19.8) years. Eighty-three percent of patients were male. The average cost per TCA was ~$16,000. Of the 54 TCAs, 26 (48%) were WA, with one (1.85%) survivor (no non-WA TCA patients survived). Twenty-two (41%) patients died from EX-arrest; 59% penetrating vs. 28% blunt (p = 0.03). The one EX-arrest survivor was a 19-year-old gunshot wound to the leg whose arrest was witnessed, with a short downtime, and the cause of arrest (bleeding leg wound) was quickly reversible. Conclusion We classified 41% of TCAs to have died from EX-arrest with only a 1.85% survival rate. This study calls for a TCA pre-hospital registry with accurate and consistent data definitions and collection. The registry should capture the cause of arrest for future research, management decision-making, and prognostication.

Outcomes in traumatic cardiac arrest patients who underwent advanced life support

OBJECTIVE

Survival following a traumatic cardiac arrest (TCA) remains poor despite research focused on specific management and guideline adaptation. Previous research has identified factors including age, arresting rhythm, injury severity and distance from hospital to be associated with prehospital TCA outcomes. The present study aimed to review the local incidence of TCA to inform local practice within a mature trauma system.

METHODS

A retrospective trauma database review from 2008 to 2021 was conducted at the Royal Brisbane and Women's Hospital. Patients were categorised by prehospital and in-hospital arrest, prehospital return of spontaneous circulation (ROSC), and year in relation to TCA management protocol changes. Descriptive comparative analysis was performed with the primary outcome of interest being survival to hospital discharge.

RESULTS

Survival to hospital discharge was similar in patients in whom TCA occurred in the prehospital environment and hospital (24 vs 29%). Mechanism of injury, response to intervention and location of cardiac arrest were important outcome associations. Patients with a positive focused assessment with sonography in trauma scan were less likely to achieve ROSC but more likely to survive to discharge. The frequency of prehospital interventions remained similar after the guideline changes; with more patients arriving to the hospital with improved haemodynamic parameters and increased survival.

CONCLUSIONS

These results support the identification and immediate management of TCA. No patients survived if they did not achieve ROSC by hospital arrival, questioning the role for aggressive management beyond the ED in this cohort. Future research will focus on the identification of patients with potentially positive survival outcomes and further define futile intervention factors.

Impact of the 2015 European guidelines for resuscitation on traumatic cardiac arrest outcomes and prehospital management: A French nationwide interrupted time-series analysis

AIM

To evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on patient outcomes following traumatic cardiac arrest (TCA) and on advanced life support interventions carried out by physician-staffed ambulances.

METHODS

Data of TCA patients aged ≥18 years were extracted from the French nationwide cardiac arrest registry. A pre- (2011-2015) and a post-publication period (2016-2020) were defined. In the guidelines, a specific TCA management algorithm was introduced to prioritise the treatment of reversible causes. Its impact was evaluated using adjusted interrupted time series analysis.

RESULTS

4,980 patients were treated (2,145 during the pre-publication period and 2,739 during the post-publication period). There was no significant change in the rates of prehospital ROSC (22.4% vs. 20.2%, p = 0.07 in the pre- and post- intervention respectively), survival (1.4% vs. 1.4%, p = 0.87) or good neurological outcome (71.4% vs. 66.7%, p = 0.93) or in the incidence of organ donation (1.6% vs. 1.3%, p = 0.50). There were nonsignificant changes in the adjusted temporal trend for ROSC (aOR 0.88; 95% CI [0.77; 1.00]), survival (aOR 1.34; 95% CI [0.83;2.17]), good neurological outcome (aOR 1.57; 95% CI [0.82;3.05]), and organ donation (aOR 1.06; 95% CI [0.71;1.60]). The use of intraosseous catheters (13.0% vs. 19.2%, p < 0.001), external haemorrhage control measures (23.9% vs. 64.8%, p < 0.001), bilateral chest decompression (13.7% vs. 16.5%, p = 0.009), and packed red cell transfusion (2.7% vs. 6.5%, p < 0.001) increased in the post-publication period.

CONCLUSIONS

Despite the increased frequency of trauma rescue interventions performed by on-scene physicians, no change in patient-centred outcomes was associated with the publication of the 2015 ERC guidelines in France.

Comparison of in-hospital and out-of-hospital cardiac arrest of trauma patients in Qatar

Background

Cardiac arrests in admitted hospital patients with trauma have not been described in the literature. We defined “in-hospital cardiac arrest of a trauma” (IHCAT) patient as “cessation of circulatory activity in a trauma patient confirmed by the absence of signs of circulation or abnormal cardiac arrest rhythm inside a hospital setting, which was not cardiac re-arrest.” This study aimed to compare epidemiology, clinical presentation, and outcomes between in- and out-of-hospital arrest resuscitations in trauma patients in Qatar. It was conducted as a retrospective cohort study including IHCAT and out-of-hospital trauma cardiac arrest (OHTCA) patients from January 2010 to December 2015 utilizing data from the national trauma registry, the out-of-hospital cardiac arrest registry, and the national ambulance service database.

Results

There were 716 traumatic cardiac arrest patients in Qatar from 2010 to 2015. A total of 410 OHTCA and 199 IHCAT patients were included for analysis. The mean annual crude incidence of IHCAT was 2.0 per 100,000 population compared to 4.0 per 100,000 population for OHTCA. The univariate comparative analysis between IHCAT and OHTCA patients showed a significant difference between ethnicities (p=0.04). With the exception of head injury, IHCAT had a significantly higher proportion of localization of injuries to anatomical regions compared to OHTCA; spinal injury (OR 3.5, 95% CI 1.5–8.3, p<0.004); chest injury (OR 2.62, 95% CI 1.62–4.19, p<0.00), and abdominal injury (OR 2.0, 95% CI 1.0–3.8, p<0.037). IHCAT patients had significantly higher hypovolemia (OR 1.66, 95% CI 1.18–2.35, p=0.004), higher mean Glasgow Coma Scale (GCS) score (OR 1.4, 95% CI 1.3–1.6, p<0.00), and a greater proportion of initial shockable rhythm (OR 3.51, 95% CI 1.6–7.7, p=0.002) and cardiac re-arrest (OR 6.0, 95% CI 3.3–10.8, p=<0.00) compared to OHTCA patients. Survival to hospital discharge was greater for IHCAT patients compared to OHTCA patients (OR 6.3, 95% CI 1.3–31.2, p=0.005).

Multivariable analysis for comparison after adjustment for age and gender showed that IHCAT was associated with higher odds of spinal injury, abdominal injury, higher pre-hospital GCS, higher occurrence of cardiac re-arrest, and better survival than for OHTCA patients.

IHCAT patients had a greater proportion of anatomically localized injuries indicating solitary injuries compared to greater polytrauma in OHTCA. In contrast, OHTCA patients had a higher proportion of diffuse blunt non-localizable polytrauma injuries that were severe enough to cause immediate or earlier onset of cardiac arrest.

Conclusion

In traumatic cardiac arrest patients, IHCAT was less common than OHTCA and might be related to a greater proportion of solitary localized anatomical blunt injuries (head/abdomen/chest/spine). In contrast, OHTCA patients were associated with diffuse blunt non-localizable polytrauma injuries with increased severity leading to immediate cardiac arrest. IHCAT was associated with a higher mean GCS score and a higher rate of initial shockable rhythm and cardiac re-arrest, and improved survival rates.

Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden

BACKGROUND

Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy.

METHODS

Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors.

RESULTS

Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min.

CONCLUSION

Survival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines.

Characteristics and Outcomes of Traumatic Cardiac Arrests in the Pan-Asian Resuscitation Outcomes Study

OBJECTIVE

Little is known about survival outcomes after traumatic cardiac arrest in Asia, or the association of Utstein factors with survival after traumatic cardiac arrests. This study aimed to describe the epidemiology and outcomes of traumatic cardiac arrests in Asia, and analyze Utstein factors associated with survival.

METHODS

Traumatic cardiac arrest patients from 13 countries in the Pan-Asian Resuscitation Outcomes Study registry from 2009 to 2018 were analyzed. Multilevel logistic regression was performed to identify factors associated with the primary outcomes of survival to hospital discharge and favorable neurological outcome (Cerebral Performance Category (CPC) 1-2), and the secondary outcome of return of spontaneous circulation (ROSC).

RESULTS

There were 207,455 out-of-hospital cardiac arrest cases, of which 13,631 (6.6%) were trauma patients aged 18 years and above with resuscitation attempted and who had survival outcomes reported. The median age was 57 years (interquartile range 39-73), 23.0% received bystander cardiopulmonary resuscitation (CPR), 1750 (12.8%) had ROSC, 461 (3.4%) survived to discharge, and 131 (1.0%) had CPC 1-2. Factors associated with higher rates of survival to discharge and favorable neurological outcome were arrests witnessed by emergency medical services or private ambulances (survival to discharge adjusted odds ratio (aOR) = 2.95, 95% confidence interval (CI) = 1.99-4.38; CPC 1-2 aOR = 2.57, 95% CI = 1.25-5.27), bystander CPR (survival to discharge aOR = 2.16; 95% CI 1.71-2.72; CPC 1-2 aOR = 4.98, 95% CI = 3.27-7.57), and initial shockable rhythm (survival to discharge aOR = 12.00; 95% CI = 6.80-21.17; CPC 1-2 aOR = 33.28, 95% CI = 11.39-97.23) or initial pulseless electrical activity (survival to discharge aOR = 3.98; 95% CI = 2.99-5.30; CPC 1-2 aOR = 5.67, 95% CI = 3.05-10.53) relative to asystole.

CONCLUSIONS

In traumatic cardiac arrest, early aggressive resuscitation may not be futile and bystander CPR may improve outcomes.

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.

Algorithm to Improve Resuscitation Outcomes in Patients With Traumatic Out-of-Hospital Cardiac Arrest

Background: This study proposed an algorithm to improve resuscitation outcomes in the emergency department (ED) for patients with traumatic out-of-hospital cardiac arrest (TOHCA). We also performed a retrospective chart review of patient outcomes before and after implementing the algorithm and sought to define factors that might influence patient outcomes.

Methods: In September 2018, we implemented an algorithm for patients with TOHCA. This algorithm rapidly identifies possible causes of TOHCA and recommends appropriate interventions. We retrospectively reviewed the outcomes of all patients with TOHCA during a five-year period (comprising periods before and after the algorithm) and compared the results before and after the implementation of the algorithm.

Results: After this algorithm was implemented, the use of the ED interventions of blood transfusion, placement of a large-bore central venous catheter, and thoracostomy increased significantly. The rate of return of spontaneous circulation (ROSC) also increased (before vs. after: ROSC: 23.6% vs. 41.5%, P = 0.035). Regarding hospital admission and survival to hospital discharge, we observed the trend of increment (hospital admission: 18.2% vs. 24.6%, P = 0.394; survival to hospital discharge: 0.0% vs. 4.6%, P = 0.107). Admitted patients exhibited a higher end-tidal CO₂ level during resuscitation than nonadmitted patients [admitted vs. nonadmitted: 41.5 (33.3-52.0) vs. 12.0 (7.5-18.8), P = 0.001].

Conclusion: Our algorithm prioritizes the three major treatable causes of TOHCA: impedance of venous return, hypovolemia, and hypoxia. We found that rate of ROSC increased with the increasing implementation of the ED interventions recommended by the algorithm.

Out-of-hospital cardiac arrests and bystander response by socioeconomic disadvantage in communities of New South Wales, Australia

Background & aim

Bystander response to out-of-hospital cardiac arrest (OHCA) may relate to area-level factors, including socioeconomic status (SES). We aimed to examine whether OHCA among individuals in more disadvantaged areas are less likely to receive bystander cardiopulmonary resuscitation (CPR) compared to those in more advantaged areas.

Methods

We analysed data on OHCAs in New South Wales, Australia collected prospectively through a statewide, population-based register. We excluded non-medical arrests; arrests witnessed by a paramedic; occurring in a medical centre, nursing home, police station; or airport, and among individuals with a Do-Not-Resuscitate order. Area-level SES for each arrest was defined using the Australian Bureau of Statistics’ Index of Relative Socioeconomic Disadvantage and its relationship to likelihood of receiving bystander CPR was examined using hierarchical logistic regression models.

Results

Overall, 39% (6622/16,914) of arrests received bystander CPR (71% of bystander-witnessed). The OHCA burden in disadvantaged areas was higher (age-standardised incidence 76–87/100,000/year in more disadvantaged quintiles 1–4 versus 52 per 100,000/year in most advantaged quintile 5). Bystander CPR rates were lower (38%) in the most disadvantaged quintile and highest (42%) in the most advantaged SES quintile. In adjusted models, younger age, being bystander-witnessed, arresting in a public location, and urban location were all associated with greater likelihood of receiving bystander CPR; however, the association between area-level SES and bystander CPR rate was not significant.

Conclusions

There are lower rates of bystander CPR in less advantaged areas, however after accounting for patient and location characteristics, area-level SES was not associated with bystander CPR. Concerted efforts to engage with communities to improve bystander CPR in novel ways could improve OHCA outcomes.

Evaluation of outcomes after EMS-witnessed traumatic out-of-hospital cardiac arrest caused by traffic collisions

AIM

The survival rate of patients with traumatic cardiac arrest is 3 % or lower. Cardiac arrest witnessed by emergency medical services (EMS) accounts for approximately 16% of prehospital traumatic cardiac arrests, but the prognosis is unknown. We aimed to compare the 1-month survival rate of cardiac arrest witnessed by EMS with that of cardiac arrest witnessed by bystanders and unwitnessed cardiac arrest in traffic trauma victims; further, the time from injury to cardiac arrest was assessed.

METHODS

This analysis used the Utstein Registry in Japan and included data of 3883 patients with traumatic cardiac arrest caused by traffic collisions registered between 2014 and 2019 in Japan.

RESULTS

The 1-month survival rate was 10.9 % in the EMS-witnessed cardiac arrest group; this was significantly higher than that in the bystander-witnessed (7.2 %) and unwitnessed (5.6 %) cardiac arrest groups (P<0.01). The median time from injury to cardiac arrest was 18 min (25% quartile: 12, 75% quartile: 26).

CONCLUSION

The 1-month survival rate was significantly higher in the EMS-witnessed cardiac arrest group than in the bystander-witnessed and unwitnessed cardiac arrest groups. It is important to prevent progression to cardiac arrest in trauma patients with intact respiratory function and pulse rate at the time of contact with EMS. A system for early recognition of severe trauma is needed, and a doctor's car or helicopter can be requested as needed. We believe that early recognition and prompt intervention will improve the prognosis of prehospital traumatic cardiac arrest.

Survival after traumatic out-of-hospital cardiac arrest in Vietnam: a multicenter prospective cohort study

BACKGROUND

Pre-hospital services are not well developed in Vietnam, especially the lack of a trauma system of care. Thus, the prognosis of traumatic out-of-hospital cardiac arrest (OHCA) might differ from that of other countries. Although the outcome in cardiac arrest following trauma is dismal, pre-hospital resuscitation efforts are not futile and seem worthwhile. Understanding the country-specific causes, risk, and prognosis of traumatic OHCA is important to reduce mortality in Vietnam. Therefore, this study aimed to investigate the survival rate from traumatic OHCA and to measure the critical components of the chain of survival following a traumatic OHCA in the country.

METHODS

We performed a multicenter prospective observational study of patients (> 16 years) presenting with traumatic OHCA to three central hospitals throughout Vietnam from February 2014 to December 2018. We collected data on characteristics, management, and outcomes of patients, and compared these data between patients who died before hospital discharge and patients who survived to discharge from the hospital.

RESULTS

Of 111 eligible patients with traumatic OHCA, 92 (82.9%) were male and the mean age was 39.27 years (standard deviation: 16.38). Only 5.4% (6/111) survived to discharge from the hospital. Most cardiac arrests (62.2%; 69/111) occurred on the street or highway, 31.2% (29/93) were witnessed by bystanders, and 33.7% (32/95) were given cardiopulmonary resuscitation (CPR) by a bystander. Only 29 of 111 patients (26.1%) were taken by the emergency medical services (EMS), 27 of 30 patients (90%) received pre-hospital advanced airway management, and 29 of 53 patients (54.7%) were given resuscitation attempts by EMS or private ambulance. No significant difference between patients who died before hospital discharge and patients who survived to discharge from the hospital was found for bystander CPR (33.7%, 30/89 and 33.3%, 2/6, P > 0.999; respectively) and resuscitation attempts (56.3%, 27/48, and 40.0%, 2/5, P = 0.649; respectively).

CONCLUSION

In this study, patients with traumatic OHCA presented to the ED with a low rate of EMS utilization and low survival rates. The poor outcomes emphasize the need for increasing bystander first-aid, developing an organized trauma system of care, and developing a standard emergency first-aid program for both healthcare personnel and the community.

Neurological outcomes after traumatic cardiopulmonary arrest: a systematic review

Background

Despite appropriate care, most patients do not survive traumatic cardiac arrest, and many survivors suffer from permanent neurological disability. The prevalence of non-dismal neurological outcomes remains unclear.

Objectives

The aim of the current review is to summarize and assess the quality of reporting of the neurological outcomes in traumatic cardiac arrest survivors.

Data sources

A systematic review of Embase, Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ProQuest databases was performed from inception of the database to July 2020.

Study eligibility criteria

Observational cohort studies that reported neurological outcomes of patients surviving traumatic cardiac arrest were included.

Participants and interventions

Patients who were resuscitated following traumatic cardiac arrest.

Study appraisal and synthesis methods

The quality of the included studies was assessed using ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) for observational studies.

Results

From 4295 retrieved studies, 40 were included (n=23 644 patients). The survival rate was 9.2% (n=2168 patients). Neurological status was primarily assessed at discharge. Overall, 45.8% of the survivors had good or moderate neurological recovery, 29.0% had severe neurological disability or suffered a vegetative state, and 25.2% had missing neurological outcomes. Seventeen studies qualitatively described neurological outcomes based on patient disposition and 23 studies used standardized outcome scales. 28 studies had a serious risk of bias and 12 had moderate risk of bias.

Limitations

The existing literature is characterized by inadequate outcome reporting and a high risk of bias, which limit our ability to prognosticate in this patient population.

Conclusions or implications of key findings

Good and moderate neurological recoveries are frequently reported in patients who survive traumatic cardiac arrest. Prospective studies focused on quality of survivorship in traumatic arrest are urgently needed.

Level of evidence

Systematic review, level IV.

PROSPERO registration number

CRD42020198482.

Finding the elusive trauma denominator: Feasibility of combining data sets to quantify the true burden of firearm trauma

BACKGROUND

Evidence guiding firearm injury prevention is limited by current data collection infrastructure. Trauma registries (TR) omit prehospital deaths and underestimate the burden of injury. In contrast, the National Violent Death Reporting System (NVDRS) tracks all firearm deaths including prehospital fatalities, excluding survivors. This is a feasibility study to link these data sets through collaboration with our state public health department, aiming to better estimate the burden of firearm injury and assess comparability of data.

METHODS

We reviewed all firearm injuries in our Level I TR from 2011 to 2017. We provided the public health department with in-hospital deaths, which they linked to NVDRS using patient identifiers and time of injury/death. The NVDRS collates information about circumstances, incident type, and wounding patterns from multiple sources including death certificates, autopsy records, and legal proceedings. We considered only subjects with injury location in a single urban county to best estimate in-hospital and prehospital mortality.

RESULTS

Of 168 TR deaths, 166 (99%) matched to NVDRS records. Based on data linkages, we estimate 320 prehospital deaths, 184 in-hospital deaths, and 453 survivors for a total of 957 firearm injuries. For the matched patients, there was near-complete agreement regarding simple demographic variables (e.g., age and sex) and good concordance between incident types (suicide, homicide, etc.). However, agreement in wounding patterns between NVDRS and TR varied.

CONCLUSION

We demonstrate the feasibility of linking TR and NVDRS data with good concordance for many variables, allowing for good estimation of the trauma denominator. Standardized data collection methods in one data set could improve methods used by the other, for example, training NVDRS abstractors to utilize Abbreviated Injury Scale designations for injury patterns. Such data integration holds immediate promise for guiding prevention strategies.

LEVEL OF EVIDENCE

Epidemiological study, level IV.

Outcome analysis of traumatic out-of-hospital cardiac arrest patients according to the mechanism of injury: A nationwide observation study

The variation in the outcome of traumatic out-of-hospital cardiac arrest (TOHCA) patients according to the mechanism of injury has been relatively unexplored. Therefore, this study aimed to determine whether the mechanism of injury is associated with survival to hospital discharge and good neurological outcome at hospital discharge in TOHCA.The study population comprised cases of TOHCA drawn from the national Out-of-hospital cardiac arrest registry (2012-2016). Traumatic causes were categorized into 6 groups: traffic accident, fall, collision, stab injury, and gunshot injury. Data were retrospectively extracted from emergency medical service and Korean Centers for Disease Control and Prevention records. Multivariate logistic regression analysis was used to identify factors associated with survival to discharge and good neurological outcome.The final analysis included a total of 8546 eligible TOHCA patients (traffic accident 5300, fall 2419, collision 572, stab injury 247, and gunshot injury 8). The overall survival rate was 18.4% (traffic accident 18.0%, fall 16.4%, collision 32.0%, stab injury 14.2%, and gunshot injury 12.5%). Good neurological outcome was achieved in 0.8% of all patients (traffic accident 0.8%, fall 0.8%, collision 1.2%, stab injury 0.8%, and gunshot injury 0.0%). In the multivariate analysis, injury mechanisms showed no significant difference in neurological outcomes, and only collision had a significant odds ratio for survival to discharge (odds ratio: 2.440; 95% confidence interval: 1.795-3.317) compared to the traffic accident group.In this study, the mechanism of injury was not associated with neurological outcome in TOHCA patients. Collision might be the only mechanism of injury to result in better survival to discharge than traffic accident.

First experience with the abdominal aortic and junctional tourniquet in prehospital traumatic cardiac arrest

INTRODUCTION

The Abdominal Aortic and Junctional Tourniquet (AAJT) increased systemic vascular resistance, mean arterial pressure, carotid blood flow and rate of return of spontaneous circulation (ROSC) in animals with hypovolaemic traumatic cardiac arrest (TCA). The objective of this study was to report the first experience of the use of the AAJT as part of a pre-hospital TCA algorithm.

METHODS

This is a descriptive case series of the use of the AAJT in patients with TCA in a civilian physician-led pre-hospital trauma service in Sydney, Australia between June 2015 to August 2019. Cases were identified and data sourced from routinely collected data sets within the retrieval service.

RESULTS

During the study, 44 TCAs were attended, 22 with AAJT application. Mean time (standard deviation) to AAJT application since last signs of life was 16 (9) min. Eighteen (16 males, 2 females) patients, with median age (interquartile range) of 40 (25-58) years, were included for analysis. Seventeen patients (94%) had blunt trauma. Sixteen patients (89%) were in TCA at the time of service contact, 11 (61%) had a change in electrical activity, 4 (22%) had ROSC, and of the 6 with documented end-tidal carbon dioxide, the mean rise was 24.0 mmHg (95% CI 12.6-35.4) (P = 0.003). Three patients (17%) had sustained ROSC on arrival to the Emergency Department. No patients survived to hospital discharge.

CONCLUSION

Physiological changes were demonstrated but there were no survivors. Further research focusing on faster application times may be associated with improved outcomes.

Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®

PURPOSE

The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients.

METHODS

In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room.

RESULTS

We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention.

CONCLUSION

Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.

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.

Should we resuscitate elderly patients with blunt traumatic cardiac arrest? Analysis of National Trauma Registry Data in Japan

OBJECTIVES

Recent studies suggest that survival after traumatic cardiac arrest (TCA) has been improving. Many elderly adults enjoy active lifestyles, which occasionally result in TCA. The epidemiology and efficacy of resuscitative procedures on blunt TCA in elderly patients are largely unknown. Our primary aim was to compare the survival to discharge following blunt TCA between non-elderly adult (ages 18-59 years) and elderly patients (age ≥60 years).

METHODS

We analysed 2004-2015 observational cohort data from a nationwide trauma registry in Japan. We included all adult patients (18 years and older) who experienced blunt TCA. We excluded patients missing data for age, survival, mechanism of injury or initial vital signs. Resuscitative procedures included thoracotomy and resuscitative endovascular balloon occlusion of the aorta. We compared survival for elderly patients (age ≥60 years old) to younger adults.

RESULTS

Of 8347 patients with blunt TCA, 3547 (42.5%) were elderly. Survival differed significantly by age: 164/4800 (3.4%) of younger adults survived whereas 188/3547 (5.3%) of elderly patients survived (p<0.001). Survival increased but Injury Severity Scores (ISSs) declined with increasing patient age. The efficacy of resuscitative procedures did not vary by age. In logistic regression models, increasing age was independently associated with better survival.

CONCLUSION

In a cohort of patients with blunt TCA, survival increased with increasing patient age. A number of patients with low ISS in the elderly group raises the possibility that this improved survival is due to preceding or concomitant medical cardiac arrest in the older cohort. Clinicians should be cautious about applying TCA algorithms to elderly patients and should not be discouraged from resuscitating TCA because of patient age.

Dispatcher-assisted cardiopulmonary resuscitation for traumatic patients with out-of-hospital cardiac arrest

Background

Resuscitation efforts for traumatic patients with out-of-hospital cardiac arrest (OHCA) are not always futile. Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) during emergency calls could increase the rate of bystander cardiopulmonary resuscitation (CPR) and thus may enhance survival and neurologic outcomes of non-traumatic OHCA. This study aimed to examine the effectiveness of DA-CPR for traumatic OHCA.

Methods

A retrospective cohort study was conducted using an Utstein-style population database with data from January 1, 2014, to December 31, 2016, in Tainan City, Taiwan. Voice recordings of emergency calls were retrospectively retrieved and reviewed. The primary outcome was an achievement of sustained (≥2 h) return of spontaneous circulation (ROSC); the secondary outcomes were prehospital ROSC, ever ROSC, survival at discharge and favourable neurologic status at discharge. Statistical significance was set at a p-value of less than 0.05.

Results

A total of 4526 OHCA cases were enrolled. Traumatic OHCA cases (n = 560, 12.4%), compared to medical OHCA cases (n = 3966, 87.6%), were less likely to have bystander CPR (10.7% vs. 31.7%, p < 0.001) and initially shockable rhythms (7.1% vs. 12.5%, p < 0.001). Regarding DA-CPR performance, traumatic OHCA cases were less likely to have dispatcher recognition of cardiac arrest (6.3% vs. 42.0%, p < 0.001), dispatcher initiation of bystander CPR (5.4% vs. 37.6%, p < 0.001), or any dispatcher delivery of CPR instructions (2.7% vs. 20.3%, p < 0.001). Stepwise logistic regression analysis showed that witnessed cardiac arrests (aOR 1.70, 95% CI 1.10–2.62; p = 0.017) and transportation to level 1 centers (aOR 1.99, 95% CI 1.27–3.13; p = 0.003) were significantly associated with achievement of sustained ROSC in traumatic OHCA cases, while DA-CPR-related variables were not (All p > 0.05).

Conclusions

DA-CPR was not associated with better outcomes for traumatic OHCA in achieving a sustained ROSC. The DA-CPR program for traumatic OHCAs needs further studies to validate its effectiveness and practicability, especially in the communities where rules for the termination of resuscitation in prehospital settings do not exist.

Association of Prehospital Epinephrine Administration With Survival Among Patients With Traumatic Cardiac Arrest Caused By Traffic Collisions

For traumatic cardiac arrest (TCA), the effect of prehospital epinephrine administration was unclear. The aim of this study was to evaluate the relationship between prehospital epinephrine administration and survival in patients with TCA caused by traffic collisions. We conducted a nationwide, prospective, population-based observational study involving patients who experienced out-of-hospital cardiac arrest (OHCA) by using the All-Japan Utstein Registry. Blunt trauma patients with TCA who received prehospital epinephrine were compared with those who did not receive prehospital epinephrine. The primary outcome was 1-month survival of patients. The secondary outcome was prehospital return of spontaneous circulation (ROSC). A total of 5,204 patients with TCA were analyzed. Of those, 758 patients (14.6%) received prehospital epinephrine (Epinephrine group), whereas the remaining 4,446 patients (85.4%) did not receive prehospital epinephrine (No epinephrine group). Eleven (1.5%) and 41 (0.9%) patients in the Epinephrine and No epinephrine groups, respectively, survived for 1 month. In addition, 74 (9.8%) and 40 (0.9%) patients achieved prehospital ROSC in the Epinephrine and No epinephrine groups, respectively. In multivariable logistic regression models, prehospital epinephrine administration was not associated with 1-month survival (odds ratio [OR] 1.495, 95% confidence interval [CI] 0.758 to 2.946) and was associated with prehospital ROSC (OR 3.784, 95% CI 2.102 to 6.812). A propensity score-matched analysis showed similar results for 1-month survival (OR 2.363, 95% CI 0.606 to 9,223) and prehospital ROSC (OR 6.870, 95% CI 3.326 to 14.192). Prehospital epinephrine administration in patients with TCA was not associated with 1-month survival, but was beneficial in regard to prehospital ROSC.

Response time in the emergency services. Systematic review

The growth of the urban population raises concern about municipal public managers in the sense of providing emergency medical services (EMS) that are aligned with the needs of prehospital emergency medical care demanded by the population. The literature review aims at presenting the response time of emergency medical services in several parts of the world and discussing some factors that interfere in the result of this indicator such as GDP (Gross Domestic Product) percentage spent on health and life expectancy of countries. The study will also show that in some of the consulted articles, authors suggest to EMS recommendations for decreasing the response time using simulations, heuristics and metaheuristics. Response time is a basic indicator of emergency medical services, in such a way that researchers use the descriptive statistics to evaluate this parameter. Europe and the USA outstand in the publication of studies that present this information. Some articles use stochastic and mathematical methods to suggest models that simulate scenarios of response time reduction and suggest such proposals to the local EMS. Countries in which the response time was identified have a high index of human development and life expectancy between 74.7 and 83.7 years.

Characteristics of traumatic out-of-hospital cardiac arrest patients presenting to major centers in Karachi, Pakistan-a longitudinal cohort study

BACKGROUND

Trauma is the leading cause of death for adults under 44 years of age. Survival after traumatic out-of-hospital cardiac arrest (OHCA) has been reported to be poor, and its epidemiology is not well defined. A few studies have reported better survival in response to pre-hospital life-saving interventions. Currently, no published data on traumatic cardiac arrests in the field exist from low- and lower middle-income countries. We aimed to explore the epidemiology and outcomes of traumatic OHCA patients from Karachi, Pakistan. We conducted a longitudinal cohort study at emergency departments (ED) of five major public and private hospitals of the city from January to April 2013. Data was collected on all adult patients (age 18 years or more) presenting to the hospitals directly from field with cardiac arrest and history of trauma using a structured questionnaire. Patients with do-not-resuscitate status and those referred from other hospitals were excluded.

RESULTS

During 3 months, a total of 187 patients were enrolled with mean age of 35.1 years. About 95% were men, and 68.4% had a penetrating injury. Even though half of the patients had a witnessed arrest, none received a bystander cardiopulmonary resuscitation (CPR). 83.4% were brought to the hospital in an ambulance, with median response and scene times of 3 and 2 min respectively; however, only 3 received any pre-hospital life-support interventions. One hundred eighty-one patients (96.7%) were pronounced dead on arrival to the ED, and of the remaining 6 patients, 4 received CPR in the EDs. Overall survival at the end of ED stay was 0%. Patients who received life-support interventions survived for longer time, though not clinically significant, as compared to those who did not (45 min vs. 35 min, p = 0.02).

CONCLUSION

There was no survival after a traumatic OHCA in Karachi, Pakistan. Even though ambulances reached the scene in a very short time, pre-hospital interventions were largely absent. There is a strong need to strengthen our pre-hospital care system but most importantly train the general public to deal with emergencies and be able to provide timely bystander CPR.

Endotracheal Intubation for Traumatic Cardiac Arrest by an Australian Air Medical Service

OBJECTIVE

Traumatic cardiac arrest (TCA) has been associated with poor outcome, but there are survivors with good neurological outcome. Treatment of hypoxia plays a key part in resuscitation algorithms, but little evidence exists on the ideal method of airway management in TCA.

METHODS

LifeFlight Retrieval Medicine is an aeromedical retrieval service based in Queensland, Australia. Data regarding all intubations performed over a 28-month period were accessed from an electronic airway registry.

RESULTS

13/22 TCA patients were male, age range 2-81 years. 7/22 (31.8%) survived to hospital admission. During the same period 271 patients were intubated due to trauma, but were not in cardiac arrest (N-TCA). There was no difference in the likelihood of difficult laryngoscopy in the TCA group (16/22 (72.7%) compared to N-TCA (215/271 (79.3%); p = 0.46). The first attempt success rate was similar in TCA group (19/22 (86.4%)) and N-TCA (241/271 (88.9%) p = 0.71.). TCA patients were more likely to be intubated while lying on the ground than the N-TCA group (11/22 (50%) versus 17/271 (6.3%) p = <0.001).

CONCLUSION

Resuscitation for predominantly blunt TCA is not futile. The endotracheal intubation first attempt success rate for TCA is comparable to that of N-TCA trauma patients.

Improved survival of hospitalized patients with cardiac arrest due to coronary heart disease after implementation of post-cardiac arrest care: A population-based study

Post-cardiac arrest care was implemented in 2010 and has been shown to improve the survival of patients with coronary heart disease (CHD). However, the findings varied for different survival conditions.We conducted a retrospective longitudinal study of records from 2007 to 2013 in the National Health Insurance Research Database. We evaluated the differences in short-term (2-day and 7-day) and long-term (30-day and survival to discharge) survival after the implementation of post-cardiac arrest care and among age subgroups. We reviewed inpatient datasets in accordance with the International Classification of Disease Clinical Modification, 9th revision codes (ICD-9-CM). Eligible participants were identified as those with simultaneous diagnoses of cardiac arrest (ICD-9-CM codes: 427.41 or 427.5) and CHD (ICD-9-CM codes: 410-414). Multiple logistic regression was applied to establish the relationship between calendar year and survival outcomes.The odds of 2-day survival from 2011 to 2013 were higher than those from 2007 to 2010 (adjusted odds ratio [aOR]: 1.15; 95% confidence interval [CI]: 1.03-1.29). Similarly, the odds of 7-day survival from 2011 to 2013 were higher than those from 2007 to 2010 (aOR: 1.11; 95% CI: 1.01-1.22). Improvements in the odds of 2-day and 7-day survival were discovered only in patients <65 years old. Our data reinforce that short-term survival improved after implementation of post-cardiac arrest care. However, older age seemed to nullify the influence of post-cardiac arrest care on survival.

Traumatic cardiac arrest is associated with lower survival rate vs. medical cardiac arrest - Results from the French national registry

INTRODUCTION

The survival from traumatic vs. medical out-of-hospital cardiac arrest (OHCA) are not yet well described. The objective of this study was to compare survival to hospital discharge and 30-day survival of non-matched and matched traumatic and medical OHCA cohorts.

MATERIAL & METHODS

National case-control, multicentre study based on the French national cardiac arrest registry. Following descriptive analysis, we compared survival rates of traumatic and medical cardiac arrest patients after propensity score matching.

RESULTS

Compared with medical OHCA (n = 40,878) trauma victims (n = 3209) were younger, more likely to be male and away from home at the time and less likely to be resuscitated. At hospital admission and at 30 days their survival odds were lower (OR: respectively 0.456 [0.353;0.558] and 0.240 [0.186;0.329]). After adjustment the survival odds for traumatic OHCA were 2.4 times lower at admission (OR: 0.416 [0.359;0.482]) and 6 times lower at day 30 (OR: 0.168 [0.117;0.241]).

CONCLUSIONS

The survival rates for traumatic OHCA were lower than for medical OHCA, with wider difference in matched vs. non-matched cohorts. Although the probability of survival is lower for trauma victims, the efforts are not futile and pre-hospital resuscitation efforts seem worthwhile.

European cardiovascular nurses’ and allied professionals’ knowledge and practical skills regarding cardiopulmonary resuscitation

Purpose:

Cardiopulmonary resuscitation (CPR) remains a cornerstone in the treatment of cardiac arrest, and is directly linked to survival rates. Nurses are often first responders and need to be skilled in the performance of cardiopulmonary resuscitation. As cardiopulmonary resuscitation skills deteriorate rapidly, the purpose of this study was to investigate whether there was an association between participants’ cardiopulmonary resuscitation training and their practical cardiopulmonary resuscitation test results.

Methods:

This comparative study was conducted at the 2014 EuroHeartCare meeting in Stavanger ( n=133) and the 2008 Spring Meeting on Cardiovascular Nursing in Malmö ( n=85). Participants performed cardiopulmonary resuscitation for three consecutive minutes CPR training manikins from Laerdal Medical®. Data were collected with a questionnaire on demographics and participants’ level of cardiopulmonary resuscitation training.

Results:

Most participants were female (78%) nurses (91%) from Nordic countries (77%), whose main role was in nursing practice (63%), and 71% had more than 11 years’ experience ( n=218). Participants who conducted cardiopulmonary resuscitation training once a year or more ( n=154) performed better regarding ventilation volume than those who trained less (859 ml vs. 1111 ml, p=0.002). Those who had cardiopulmonary resuscitation training offered at their workplace ( n=161) also performed better regarding ventilation volume (889 ml vs. 1081 ml, p=0.003) and compression rate per minute (100 vs. 91, p=0.04) than those who had not.

Conclusion:

Our study indicates a positive association between participants’ performance on the practical cardiopulmonary resuscitation test and the frequency of cardiopulmonary resuscitation training and whether cardiopulmonary resuscitation training was offered in the workplace. Large ventilation volumes were the most common error at both measuring points.

Predicting outcomes in traumatic out-of-hospital cardiac arrest: the relevance of Utstein factors

BACKGROUND

Given low survival rates in cases of traumatic out-of-hospital cardiac arrest (OHCA), there is a need to identify factors associated with outcomes. We aimed to investigate Utstein factors associated with achieving return of spontaneous circulation (ROSC) and survival to hospital in traumatic OHCA.

METHODS

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify cases of traumatic OHCA that received attempted resuscitation and occurred between July 2008 and June 2014. We excluded cases aged <16 years or with a mechanism of hanging or drowning.

RESULTS

Of the 660 traumatic OHCA patients who received attempted resuscitation, ROSC was achieved in 159 patients (24%) and 95 patients (14%) survived to hospital (ROSC on hospital handover). Factors that were positively associated with achieving ROSC in multivariable logistic regression models were age ≥65 years (adjusted OR (AOR)=1.56, 95% CI: 1.01 to 2.43) and arresting rhythm (shockable (AOR=3.65, 95% CI: 1.64 to 8.11) and pulseless electrical activity (AOR=2.15, 95% CI: 1.36 to 3.39) relative to asystole). Similarly, factors positively associated with survival to hospital were arresting rhythm (shockable (AOR=3.92, 95% CI: 1.64 to 9.41) relative to asystole), and the mechanism of injury (falls (AOR=2.16, 95% CI: 1.03 to 4.54) relative to motor vehicle collisions), while trauma type (penetrating (AOR=0.27, 95% CI: 0.08 to 0.91) relative to blunt trauma) and event region (rural (AOR=0.39, 95% CI: 0.19 to 0.80) relative to urban) were negatively associated with survival to hospital.

CONCLUSIONS

Few patient and arrest characteristics were associated with outcomes in traumatic OHCA. These findings suggest there is a need to incorporate additional information into cardiac arrest registries to assist prognostication and the development of novel interventions in these trauma patients.

Cardiopulmonary resuscitation of out-of-hospital traumatic cardiac arrest in Qatar: A nationwide population-based study

BACKGROUND

Traumatic cardiac arrest studies have reported improved survival rates recently, ranging from 1.7-7.5%. This population-based nationwide study aims to describe the epidemiology, interventions and outcomes, and determine predictors of survival from out-of-hospital traumatic cardiac arrest (OHTCA) in Qatar.

METHODS

An observational retrospective population-based study was conducted on OHTCA patients in Qatar, from January 2010 to December 2015. Traumatic cardiac arrest was redefined to include out-of-hospital traumatic cardiac arrest (OHTCA) and in-hospital traumatic cardiac arrest (IHTCA).

RESULTS

A total of 410 OHTCA patients were included in the 6-year study period. The mean annual crude incidence rate of OHTCA was 4.0 per 100,000 population, in Qatar. OHTCA mostly occurred in males with a median age of 33. There was a preponderance of blunt injuries (94.3%) and head injuries (66.3%). Overall, the survival rate was 2.4%. Shockable rhythm, prehospital external hemorrhage control, in-hospital blood transfusion, and surgery were associated with higher odds of survival. Adrenaline (Epinephrine) lowered the odds of survival.

CONCLUSION

The incidence of OHTCA was less than expected, with a low rate of survival. Thoracotomy was not associated with improved survival while Adrenaline administration lowered survival in OHTCA patients with majority blunt injuries. Interventions to enable early prehospital control of hemorrhage, blood transfusion, thoracostomy and surgery improved survival.

Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest

BACKGROUND

This study aimed to understand factors associated with paramedics' decision to attempt resuscitation in traumatic out-of-hospital cardiac arrest (OHCA) and to characterise resuscitation attempts ≤10min in patients who die at the scene.

METHODS

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all cases of traumatic OHCA between July 2008 and June 2014. We excluded cases <16 years of age or with a mechanism of hanging or drowning.

RESULTS

Of the 2334 cases of traumatic OHCA, resuscitation was attempted in 28% of cases and this rate remained steady over time (p=0.10). Multivariable logistic regression revealed that the arresting rhythm [shockable (adjusted odds ratio (AOR)=18.52, 95% confidence interval (CI):6.68-51.36) or pulseless electrical activity (AOR=12.58, 95%CI:9.06-17.45) relative to asystole] and mechanism of injury [motorcycle collision (AOR=2.49, 95%CI:1.60-3.86), fall (AOR=1.91, 95%CI:1.17-3.11) and shooting/stabbing (AOR=2.25, 95%CI:1.17-4.31) relative to a motor vehicle collision] were positively associated with attempted resuscitation. Arrests occurring in rural regions had a significantly lower odds of attempted resuscitation relative to those in urban regions (AOR=0.64, 95%CI:0.46-0.90). Resuscitation attempts ≤10min represented 34% of cases in which resuscitation was attempted but the patient died at the scene. When these resuscitation attempts were selectively excluded from the overall EMS treated population, survival to hospital discharge non-significantly increased from 3.8% to 5.0% (p=0.314).

CONCLUSION

Survival in our study was consistent with existing literature, however the large proportion of cases with resuscitation attempts ≤10min may under-represent survival in those patients that receive full resuscitation attempts.

Is 15 minutes an appropriate resuscitation duration before termination of a traumatic cardiac arrest? A case-control study

BACKGROUND

Previous guidelines suggest up to 15 minutes of cardiopulmonary resuscitation (CPR) accompanied by other resuscitative interventions before terminating resuscitation of a traumatic cardiac arrest. The current study evaluated the duration of CPR according to outcome using the model of a county-based emergency medical services (EMS) system in Taiwan.

METHODS

This study was performed as a prospectively defined retrospective review from EMS records and cardiac arrest registration between June 2011 and November 2012 in Taoyuan, Taiwan.

RESULTS

A total of 396 patients were enrolled. Among the blunt injuries, most incidents were traffic accidents (66.5%) followed by falls (31.5%). Bystander CPR was performed in 34 patients (8.6%). Of the patients, 18.4% were sent to intermediate to advanced level traumatic care hospitals. Although 4.8% of patients survived for 24 hours, only 2.3% survived to discharge, and 0.8% achieved cerebral performance category 1 or 2. Among all patients who developed return of spontaneous circulation (ROSC), 14.3% of ROSC was achieved within 15 minutes since CPR. Except for 1, most patients who developed ROSC over 24 hours but did not survive to discharge received CPR more than 15 minutes. Four of 6 patients who survived to discharge achieved ROSC after CPR for more than 15 minutes (16, 18, 22, and 24 minutes). Three patients discharged with cerebral performance category 1 or 2 received CPR for 6, 16, and 18 minutes, respectively.

CONCLUSIONS

Fifteen minutes of CPR before terminating resuscitation is inappropriate for patients undergoing traumatic cardiac arrsests, as longer duration resuscitation increases ROSC and survival.

Trends in traumatic out-of-hospital cardiac arrest in Perth, Western Australia from 1997 to 2014

AIM

This study aims to describe and compare traumatic and medical out-of-hospital cardiac arrest (OHCA) occurring in Perth, Western Australia, between 1997 and 2014.

METHODS

The St John Ambulance Western Australia (SJA-WA) OHCA Database was used to identify all adult (≥ 16 years) cases. We calculated annual crude and age-sex standardised incidence rates (ASIRs) for traumatic and medical OHCA and investigated trends over time.

RESULTS

Over the study period, SJA-WA attended 1,354 traumatic OHCA and 16,076 medical OHCA cases. The mean annual crude incidence rate of traumatic OHCA in adults attended by SJA-WA was 6.0 per 100,000 (73.9 per 100,000 for medical cases), with the majority resulting from motor vehicle collisions (56.7%). We noted no change to either incidence or mechanism of injury over the study period (p>0.05). Compared to medical OHCA, traumatic OHCA cases were less likely to receive bystander cardiopulmonary resuscitation (CPR) (20.4% vs. 24.5%, p=0.001) or have resuscitation commenced by paramedics (38.9% vs. 44.8%, p<0.001). However, rates of bystander CPR and resuscitation commenced by paramedics increased significantly over time in traumatic OHCA (p<0.001). In cases where resuscitation was commenced by paramedics there was no difference in the proportion who died at the scene (37.2% traumatic vs. 34.3% medical, p=0.17), however, fewer traumatic OHCAs survived to hospital discharge (1.7% vs. 8.7%, p<0.001).

CONCLUSIONS

Despite temporal increases in rates of bystander CPR and paramedic resuscitation, traumatic OHCA survival remains poor with only nine patients surviving from traumatic OHCA over the 18-year period.

"After-hours" staffing of trauma centres and outcomes among patients presenting with acute traumatic coagulopathy

OBJECTIVE

To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC).

DESIGN, PARTICIPANTS AND SETTING

Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011.

MAIN OUTCOME MEASURE

Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality.

RESULTS

There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1%; P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77; 95% CI, 1.10-2.87).

CONCLUSION

The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.

Epidemiology and outcome of adult out-of-hospital cardiac arrest of non-cardiac origin in Osaka: a population-based study

OBJECTIVES

To evaluate epidemiological characteristics of out-of-hospital cardiac arrests (OHCAs) by detailed non-cardiac cause and factors associated with the outcomes after OHCAs of non-cardiac origin.

DESIGN

A prospective, population-based observational study.

SETTING

The Utstein Osaka Project.

PARTICIPANTS

14,164 adult patients aged ≥20 years old with OHCAs due to non-cardiac origin who were resuscitated by emergency-medical-service personnel or bystanders, and then were transported to medical institutions from January 2005 to December 2011.

PRIMARY OUTCOME MEASURES

One-month survival after OHCA. Multiple logistic regression analysis was used to assess factors that were potentially associated with the outcome.

RESULTS

During the study period, the 1-month survival rate was 5.3% (755/14,164). The proportion of 1-month survival was 6.2% (510/8239) in external causes, 6.5% (94/1148) in respiratory diseases, 0.8% (11/1309) in malignant tumours, 4.9% (55/1114) in strokes and 4.1% (85/2054) in others. As for external causes, the proportion of 1-month survival was 14.3% (382/2670) in asphyxia, 4.2% (84/1999) in hanging, 0.7% (9/1300) in fall, 1.1% (12/1062) in drowning, 1.6% (12/765) in traffic injury, 3.7% (7/187) in drug overuse and 1.6% (4/256) in unclassified external causes. In a multivariate analysis, adults aged <65 years old with arrests witnessed by bystanders, with normal activities of daily living before the arrests, having ventricular fibrillation arrests, having arrests in public places, intravenous fluid levels and early Emergency Medical Service response time were significant predictors for 1-month outcome after OHCAs of non-cardiac origin. The proportion of 1-month survival of all OHCAs of non-cardiac origin did not significantly increase (from 4.3% (86/2023) in 2005 to 4.9% (105/2126) in 2011) and the adjusted OR for one-increment of year was 1.01 (95% CI 0.97 to 1.06).

CONCLUSIONS

From a large OHCA registry in Osaka, we demonstrated that 1-month survival after OHCAs of non-cardiac origin was poor and stable.

Salvage techniques in traumatic cardiac arrest: thoracotomy, extracorporeal life support, and therapeutic hypothermia

PURPOSE OF REVIEW

Survival from traumatic cardiac arrest is associated with a very high mortality despite aggressive resuscitation including an Emergency Department thoracotomy (EDT). Novel salvage techniques are needed to improve these outcomes.

RECENT FINDINGS

More aggressive out-of-hospital interventions, such as chest decompression or thoracotomy by emergency physicians or anesthesiologists, seem feasible and show some promise for improving outcomes. For trauma patients who suffer severe respiratory failure or refractory cardiac arrest, there seems to be an increasing role for the use of extracorporeal life support (ECLS), utilizing heparin-bonded systems to avoid systemic anticoagulation. The development of exposure hypothermia is associated with poor outcomes in trauma patients, but preclinical studies have consistently demonstrated that mild, therapeutic hypothermia (34 °C) improves survival from severe hemorrhagic shock. Sufficient data exist to justify a clinical trial. For patients who suffer a cardiac arrest refractory to EDT, induction of emergency preservation and resuscitation by rapid cooling to a tympanic membrane temperature of 10 °C may preserve vital organs long enough to allow surgical hemostasis, followed by resuscitation with cardiopulmonary bypass.

SUMMARY

Salvage techniques, such as earlier thoracotomy, ECLS, and hypothermia, may allow survival from otherwise lethal injuries.

Triaging the right patient to the right place in the shortest time

Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.

Requirement for a structured algorithm in cardiac arrest following major trauma: epidemiology, management errors, and preventability of traumatic deaths in Berlin

BACKGROUND

Despite continuous innovation in trauma care, fatal trauma remains a significant medical and socioeconomic problem. Traumatic cardiac arrest (tCA) is still considered a hopeless situation, whereas management errors and preventability of death are neglected. We analyzed clinical and autopsy data from tCA patients in an emergency-physician-based rescue system in order to reveal epidemiologic data and current problems in the successful treatment of tCA.

MATERIAL AND METHODS

Epidemiological and autopsy data of all unsuccessful tCPR cases in a one-year-period in Berlin, Germany (n=101, Group I) and clinical data of all cases of tCPR in a level 1 trauma centre in an 6-year period (n=52, Group II) were evaluated. Preventability of traumatic deaths in autopsy cases (n=22) and trauma-management failures were prospectively assessed.

RESULTS

In 2010, 23% of all traumatic deaths in Berlin received tCPR. Death after tCPR occurred predominantly prehospital (PH;74%) and only 26% of these patients were hospitalized. Of 52 patients (Group II), 46% required tCPR already PH and 81% in the emergency department (ED). In 79% ROSC was established PH and 53% in the ED. The survival rate after tCPR was 29% with 27% good neurological outcome. Management errors occurred in 73% PH; 4 cases were judged as potentially or definitive preventable death.

CONCLUSION

Trauma CPR is beyond routine with the need for a tCPR-algorithm, including chest/pericardial decompression, external pelvic stabilization and external bleeding control. The prehospital trauma management has the highest potential to improve tCPR and survival. Therefore, we suggested a pilot prehospital tCPR-algorithm.