Does the prognosis of cardiac arrest differ in trauma patients?

Prognosis, risk factors, and scoring model of patients resuscitated from traumatic cardiac arrest: A multicenter observational study in Japan

BACKGROUND

A subset of patients with traumatic cardiac arrest is salvageable when the reversible causes of cardiac arrest are promptly treated. However, prognosis and risk factors of survivors upon hospital admission after traumatic cardiac arrest remain unclear. We aimed to describe the outcomes, identify risk factors, and develop a simple risk-scoring model for patients resuscitated from traumatic cardiac arrest.

METHODS

This observational multicenter study analyzed data from the Japan Trauma Data Bank from January 1, 2019, to December 31, 2021. Patients who underwent cardiopulmonary resuscitation in the emergency department and survived to the day after hospital admission for traumatic cardiac arrest were included. Factors associated with survival to hospital discharge were determined using mixed-effects multivariable logistic regression analysis. A simple scoring model was developed to stratify the probability of survival to hospital discharge.

RESULTS

In total, 452 patients from 119 hospitals (median age, 64 years; 334 [74.4%] men) were included in the analysis. Of these, 130 (28.8%) survived until discharge. Penetrating injury, signs of life upon hospital arrival, and Injury Severity Score were significantly associated with survival at hospital discharge. A scoring model that assigned 1 point each for penetrating injury and signs of life upon hospital arrival effectively stratified the probability of survival to hospital discharge, with scores of 0, 1, and 2 corresponding to survival probabilities of 12.2%, 35.2%, and 83.3%, respectively.

CONCLUSION

This study described the outcomes and risk factors of patients resuscitated from traumatic cardiac arrest. Our simple scoring model effectively stratified the likelihood of survival to hospital discharge.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

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.

Association between out-of-hospital cardiac arrest and survival in paediatric traumatic population: results from the French national registry

Trauma is an important cause of paediatric out-of-hospital cardiac arrest (OHCA) with a high mortality rate. The first aim of this study was to compare the survival rate at day 30 and at hospital discharge following paediatric traumatic and medical OHCA. The second aim was to compare the rates of return of spontaneous circulation and survival rates at hospital admission (Day 0). This multicentre comparative post-hoc study was conducted between July 2011 and February 2022 based on the French National Cardiac Arrest Registry data. All patients aged <18 years with OHCA were included in the study. Patients with traumatic aetiology were matched with those with medical aetiology using propensity score matching. Endpoint was the survival rate at day 30. There were 398 traumatic and 1061 medical OHCAs. Matching yielded 227 pairs. In non-adjusted comparisons, days 0 and 30 survival rates were lower in the traumatic aetiology group than in the medical aetiology group [19.1% vs. 24.0%, odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, and 2.0% vs. 4.5%, OR 0.43, 95% CI, 0.20-0.92, respectively]. In adjusted comparisons, day 30 survival rate was lower in the traumatic aetiology group than in the medical aetiology group (2.2% vs. 6.2%, OR 0.36, 95% CI, 0.13-0.99). In this post-hoc analysis, paediatric traumatic OHCA was associated with a lower survival rate than medical cardiac arrest.

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.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

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.

Manual versus mechanical chest compression in in-hospital cardiac arrest: A retrospective cohort in emergency department patients

OBJECTIVE:

Mechanical chest compression (CC) devices are frequently used in in-hospital and out-of-hospital settings. In this study, mechanical and manual CC in in-hospital cardiac arrest was compared in terms of survival.

METHODS:

Adult patients who were admitted to the emergency department (ED) for 2 years period and had cardiac arrest in the ED were included in this retrospective, observational study. Return of spontaneous circulation (ROSC), 7-day and 30-day survival and hospital discharge data were compared between the two groups of patients who underwent manual CC and those who had mechanical CC with the Lund University Cardiac Assist System-2 device.

RESULTS:

Although the rate of ROSC in the mechanical CC group was lower than in the manual CC group, this difference was not statistically significant (41.7% vs. 50.4%; P = 0.133). The 7-day survival rate was found to be statistically significantly higher in the mechanical CC group (19.4% vs. 8.9%; P = 0.012). The 30-day survival rate was also found to be high in the mechanical CC group, but this difference was not statistically significant (10.6% vs. 7.3%; P = 0.339).

CONCLUSION:

In the light of these results, we can say that the use of piston-based mechanical CC devices in ED may be beneficial. More reliable results can be obtained with a prospective study to be performed in the ED.

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.

Establishment of a swine model of traumatic cardiac arrest induced by haemorrhage and ventricular fibrillation

OBJECTIVE

To establish and evaluate a swine model of traumatic cardiac arrest (TCA) induced by haemorrhage and ventricular fibrillation.

METHODS

Thirteen male pigs were divided into a sham group (n = 5) and TCA group (n = 8). Animals in the sham-operated group underwent intubation and monitoring but not haemorrhage and resuscitation, while animals in the TCA group underwent 40% blood volume haemorrhage over 20 min followed by 5 min of ventricular fibrillation and 5 min of cardiopulmonary resuscitation with fluid resuscitation.

RESULTS

Restoration of spontaneous circulation was achieved in seven of eight animals in the TCA group. After resuscitation, the heart rate was significantly increased while the mean arterial pressure and ejection fraction were significantly decreased in the TCA group. The TCA group had significant cardiac and neurological injuries post-resuscitation and had higher serum creatinine and blood lactic acid levels and lower PaO₂ than the sham group. Animals in the TCA group also exhibited significantly higher apoptotic indices and caspase-3 protein levels in the heart, brain and kidney than the sham group.

CONCLUSION

Animals in this swine model of TCA exhibited high rates of successful resuscitation, significant vital organ injury and prolonged survival. The model is suitable for use in further TCA research.

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.

Pre-hospital CPR and early REBOA in trauma patients - results from the ABOTrauma Registry

Background

Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR.

Methods

Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate.

Results

Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25–75). Fourteen patients (54%) had been admitted to the hospital with ongoing CPR. Nine patients (35%) died within the first 24 h, while seventeen patients (65%) survived post 24 h. The survival rate to hospital discharge was 27% (n = 7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p = 0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. The survival rate in the 16 patients responding to REBOA was 37.5% (n = 6). REBOA with a median (range) duration of 45 (8–70) minutes significantly increases blood pressure from the median (range) 56.5 (0–147) to 90 (0–200) mmHg.

Conclusions

Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.

Maternal cardiac arrest

PURPOSE OF REVIEW

The review is intended to serve as a practical clinical aid for the clinician called to maternal cardiac arrest.

RECENT FINDINGS

Anesthesia complications comprise an important cause of maternal cardiac arrest in developed countries Also predominant are hemorrhage and infections. Recent in-depth reports highlight fractionated care for pregnant women with cardiac and also probably neurological comorbidities. Pathology reports reveal a prevalence of thromboembolic phenomena that is higher than previously assumed but still rare. These are accompanied by particularly high mortality rates. The presenting rhythms of cardiac arrest which differ from most cardiac arrest populations, suggest the need for further in-depth investigation of both the causes and management of these cases. Despite these, outcomes are far better than those of most arrests. Key differences in treatment include are consideration of early airway management and possible medication complications. Pulseless electrical activity and VF should always alert to the possibility of hemorrhage. Echocardiography can diagnose thromboembolism. Also different are the need for Left uterine displacement and early delivery within after 4-5 min of initiation of resuscitation effort in cases with suspected compromise of the venous return or a poor likelihood of a good maternal outcome.

SUMMARY

Maternal cardiac arrest should be managed similarly to other adult cardiac arrests. At the same time its unique reversible causes require a different form of thought regarding diagnosis and treatment during the code.

Adrenaline and vasopressin for cardiac arrest

BACKGROUND

Adrenaline and vasopressin are widely used to treat people with cardiac arrest, but there is uncertainty about the safety, effectiveness and the optimal dose.

OBJECTIVES

To determine whether adrenaline or vasopressin, or both, administered during cardiac arrest, afford any survival benefit.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and DARE from their inception to 8 May 2018, and the International Liaison Committee on Resuscitation 2015 Advanced Life Support Consensus on Science and Treatment Recommendations. We also searched four trial registers on 5 September 2018 and checked the reference lists of the included studies and review papers to identify potential papers for review.

SELECTION CRITERIA

Any randomised controlled trial comparing: standard-dose adrenaline versus placebo; standard-dose adrenaline versus high-dose adrenaline; and adrenaline versus vasopressin, in any setting, due to any cause of cardiac arrest, in adults and children. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials for review, assessed risks of bias and extracted data, resolving disagreements through re-examination of the trial reports and by discussion. We used risk ratios (RRs) with 95% confidence intervals (CIs) to compare dichotomous outcomes for clinical events. There were no continuous outcomes reported. We examined groups of trials for heterogeneity. We report the quality of evidence for each outcome, using the GRADE approach.

MAIN RESULTS

We included 26 studies (21,704 participants).Moderate-quality evidence found that adrenaline increased survival to hospital discharge compared to placebo (RR 1.44, 95% CI 1.11 to 1.86; 2 studies, 8538 participants; an increase from 23 to 32 per 1000, 95% CI 25 to 42). We are uncertain about survival to hospital discharge for high-dose compared to standard-dose adrenaline (RR 1.10, 95% CI 0.75 to 1.62; participants = 6274; studies = 10); an increase from 33 to 36 per 1000, 95% CI 24 to 53); standard-dose adrenaline versus vasopressin (RR 1.25, 95% CI 0.84 to 1.85; 6 studies; 2511 participants; an increase from 72 to 90 per 1000, 95% CI 60 to 133); and standard-dose adrenaline versus vasopressin plus adrenaline (RR 0.76, 95% CI 0.47 to 1.22; 3 studies; 3242 participants; a possible decrease from 24 to 18 per 1000, 95% CI 11 to 29), due to very low-quality evidence.Moderate-quality evidence found that adrenaline compared with placebo increased survival to hospital admission (RR 2.51, 95% CI 1.67 to 3.76; 2 studies, 8489 participants; an increase from 83 to 209 per 1000, 95% CI 139 to 313). We are uncertain about survival to hospital admission when comparing standard-dose with high-dose adrenaline, due to very low-quality evidence. Vasopressin may improve survival to hospital admission when compared with standard-dose adrenaline (RR 1.27, 95% CI 1.04 to 1.54; 3 studies, 1953 participants; low-quality evidence; an increase from 260 to 330 per 1000, 95% CI 270 to 400), and may make little or no difference when compared to standard-dose adrenaline plus vasopressin (RR 0.95, 95% CI 0.83 to 1.08; 3 studies; 3249 participants; low-quality evidence; a decrease from 218 to 207 per 1000 (95% CI 181 to 236).There was no evidence that adrenaline (any dose) or vasopressin improved neurological outcomes.The rate of return of spontaneous circulation (ROSC) was higher for standard-dose adrenaline versus placebo (RR 2.86, 95% CI 2.21 to 3.71; participants = 8663; studies = 3); moderate-quality evidence; an increase from 115 to 329 per 1000, 95% CI 254 to 427). We are uncertain about the effect on ROSC for the comparison of standard-dose versus high-dose adrenaline and standard-does adrenaline compared to vasopressin, due to very low-quality evidence. Standard-dose adrenaline may make little or no difference to ROSC when compared to standard-dose adrenaline plus vasopressin (RR 0.97, 95% CI 0.87 to 1.08; 3 studies, 3249 participants; low-quality evidence; a possible decrease from 299 to 290 per 1000, 95% CI 260 to 323).The source of funding was not stated in 11 of the 26 studies. The study drugs were provided by the manufacturer in four of the 26 studies, but neither drug represents a profitable commercial option. The other 11 studies were funded by organisations such as research foundations and government funding bodies.

AUTHORS' CONCLUSIONS

This review provides moderate-quality evidence that standard-dose adrenaline compared to placebo improves return of spontaneous circulation, survival to hospital admission and survival to hospital discharge, but low-quality evidence that it did not affect survival with a favourable neurological outcome. Very low -quality evidence found that high-dose adrenaline compared to standard-dose adrenaline improved return of spontaneous circulation and survival to admission. Vasopressin compared to standard dose adrenaline improved survival to admission but not return of spontaneous circulation, whilst the combination of adrenaline and vasopressin compared with adrenaline alone had no effect on these outcomes. Neither standard dose adrenaline, high-dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome. Many of these studies were conducted more than 20 years ago. Treatment has changed in recent years, so the findings from older studies may not reflect current practice.

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.

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.

Risk stratification of survival in injured patients with cardiopulmonary resuscitation within the first hour of arrival to trauma centre: retrospective analysis from the national trauma data bank

BACKGROUND

The purpose of this study was to evaluate overall survival and associated survival factors for patients with trauma who had cardiopulmonary resuscitation (CPR) within 1 hour after arrival to a hospital.

METHODS

Retrospective patient data was retrieved from the 2007-2010 edition of the US National Trauma Data Bank. Inhospital survival was the primary outcome; only patients with a known outcome were included in the analysis. Summary statistics and univariate analyses were first reported. Eighty per cent of the patients were then randomly selected and used for multivariate logistic regression analysis. The identified risk factors were further assessed for discrimination and calibration with the remaining patients with trauma using area under the curve (AUC) analysis and a Hosmer-Lemeshow test.

RESULTS

From 19 310 total cases that were reviewed, only 2640 patients required CPR within 1 hour of hospital arrival and met the additional inclusion criteria. Of these patients, 2309 (87.5%) died and 331 (12.5%) survived to discharge. There were statistical differences for race (p=0.003), initial systolic BP (p<0.001), initial pulse (p<0.001), cause of injury (p<0.001), presence of head injury (p=0.02), Injury Severity Score (ISS) (p<0.001), Glasgow Coma Scale (GCS) total score (p<0.001) and GCS motor score (p<0.001); though not all were clinically significant. The multiple logistic regression model (AUC=0.72) identified lower ISS, higher GCS motor score, Caucasian race, American College of Surgeons (ACS) level 2 trauma designation and higher initial SBP as the most predictive of survival to hospital discharge.

CONCLUSION

Approximately 13% of patients who had CPR within an hour of arrival to a trauma centre survived their injury. Therefore, implementation of an aggressive first hour in-hospital resuscitation strategy may result in better survival outcomes for this patient population.

Long-term prognosis after out-of-hospital resuscitation of cardiac arrest in trauma patients: prehospital trauma-associated cardiac arrest

BACKGROUND

Although prehospital cardiac arrest (CA) remains associated with poor long-term outcome, recent studies show an improvement in the survival rate after prehospital trauma associated CA (TCA). However, data on the long-term neurological outcome of TCA, particularly from physician-staffed Emergency Medical Service (EMS), are scarce, and results reported have been inconsistent. The objective of this pilot study was to evaluate the long-term outcome of patients admitted to several trauma centres after a TCA.

METHODS

This study is a retrospective database review of all patients from a multicentre prospective registry that experienced a TCA and had undergone successful cardiopulmonary resuscitation (CPR) prior their admission at the trauma centre. The primary end point was neurological outcome at 6 months among patients who survived to hospital discharge.

RESULTS

88 victims of TCA underwent successful CPR and were admitted to the hospital, 90% of whom were victims of blunt trauma. Of these 88 patients, 10 patients (11%; CI 95% 6% to 19%) survived to discharge: on discharge, 9 patients displayed a GCS of 15 and Cerebral Performance Categories (CPC) 1-2 and one patient had a GCS 7 and CPC of 3. Hypoxia was the most frequent cause of CA among survivors. 6-month follow-up was achieved for 9 patients of the 10 surviving patients. The 9 patients with a good outcome on hospital discharge had a CPC of 1 or 2 6 months post discharge. All returned to their premorbid family and social settings.

CONCLUSIONS

Among patients admitted to hospital after successful CPR from TCA, hypoxia as the likely aetiology of arrest carried a more favourable prognosis. Most of the patients successfully resuscitated from TCA and surviving to hospital discharge had a good neurological outcome, suggesting that prehospital resuscitation may not be futile.

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.

Prehospital intravenous epinephrine may boost survival of patients with traumatic cardiac arrest: a retrospective cohort study

BACKGROUND

Prehospital resuscitation for patients with major trauma emphasizes a load-and-go principle. For traumatic cardiac arrest (TCA) patients, the administration of vasopressors remains under debate. This study evaluated the effectiveness of epinephrine in the prehospital setting for patients with TCA.

METHODS

We conducted a retrospective cohort study using a prospectively collected registry for out-of-hospital cardiac arrest in Taipei. Enrollees were ≥18 years of age with TCA. Patients with signs of obvious death like decapitation or rigor mortis were excluded. Patients were grouped according to prehospital administration, or lack thereof, of epinephrine. Outcomes were sustained (≥2 h) recovery of spontaneous circulation (ROSC) and survival to discharge. A subgroup analysis was performed by stratified total prehospital time.

RESULTS

From June 1 2010 to May 31 2013, 514 cases were enrolled. Epinephrine was administered in 43 (8.4%) cases. Among all patients, sustained ROSC and survival to discharge was 101 (19.6%) and 20 (3.9%), respectively. The epinephrine group versus the non-epinephrine group had higher sustained ROSC (41.9% vs. 17.6%, p < 0.01) and survival to discharge (14.0% vs. 3.0%, p < 0.01). The adjusted odds ratios (ORs) of epinephrine effect were 2.24 (95% confidence interval (CI) 1.05-4.81) on sustained ROSC, and 2.94 (95% CI 0.85-10.15) on survival to discharge. Subgroup analysis showed increased ORs of epinephrine effect on sustained ROSC with a longer prehospital time.

CONCLUSION

Among adult patients with TCA in an Asian metropolitan area, administration of epinephrine in the prehospital setting was associated with increased short-term survival, especially for those with a longer prehospital time.

Comparative effectiveness of inhospital trauma resuscitation at a French trauma center and matched patients treated in the United States

OBJECTIVE

The objective of this paper is to compare mortality outcomes between patients treated at a trauma center in France and matched patients in the United States.

BACKGROUND

Although trauma systems in France and the United States differ significantly in prehospital and inhospital management, previous comparisons have been challenged by the lack of comparable data.

METHODS

Coarsened exact matching identified matching patients between a single center trauma database from Lyon, France, and the National Trauma Data Bank (NTDB) of the United States. Moderate to severely injured [injury severity score (ISS) > 8] adult patients (age ≥ 16) presenting alive to level 1 trauma centers from 2002 to 2005 with blunt or penetrating injuries were included. After matching patients, multivariate regression analyses were performed to determine difference in mortality between patients in Lyon and the NTDB.

RESULTS

A total of 1043 significantly injured patients were presented to the Lyon center. Matching eligible patients with complete records were sought from 219,985 patients in the NTDB. The unadjusted odds of mortality at the Lyon center was 2.5 times higher than that of the NTDB [95% confidence interval (CI) = 2.18-2.98]. However, the Lyon center received patients with higher ISS, lower Glasgow Coma Score (GCS), and lower systolic blood pressure (SBP) (all P < 0.001). After 1:1 matching, 858 patient pairs were produced, and the odds of mortality became equivalent [odds ratio (OR) = 1.3, 95% CI = 0.91-1.73]. Similar results were found in multiple subset analyses.

CONCLUSIONS

Trauma patients admitted to a single French trauma center had an equal chance of survival compared with similarly injured patients treated at US trauma centers.

Use of automated external defibrillators in patients with traumatic out-of-hospital cardiac arrest

BACKGROUND

Because out-of-hospital cardiac arrests (OHCAs) due to a major trauma rarely present with shockable rhythms, the potential benefits of using automated external defibrillators (AEDs) at the scene of traumatic OHCAs have not been examined.

METHODS

We conducted an observational, retrospective cohort study using an Utstein-style analysis in Tainan city, Taiwan. The enrollees were adult patients with traumatic OHCAs accessed by emergency medical technicians (EMTs) from January 1, 2004 to December 31, 2010. The exposure was the use or non-use of AEDs at the scene, as determined by the clinical judgment of the EMTs. The primary outcome evaluated was a sustained (≥2h) return of spontaneous circulation (ROSC), and the secondary outcomes were prehospital ROSC, overall ROSC, survival to hospital admission, survival at one month and favorable neurologic status at one month.

RESULTS

A total of 424 patients (313 males) were enrolled, of whom 280 had AEDs applied, and 144 did not. Only 25 (5.9%) patients had received bystander cardiopulmonary resuscitation (CPR), and merely 21 (7.5%) patients in the AED group presented with shockable rhythms. Compared to the non-AED group, the primary and secondary outcomes of the AED group were not significantly different, except for a significantly lower prehospital ROSC rate (1.1% vs. 4.9%, p<0.05). Multivariate analysis showed no significant interactions between the use of AEDs and other key variables. Use of the AED was not associated with sustained ROSC (OR 1.33; 95% CI 0.75-2.38, p=0.33).

CONCLUSIONS

In a community with a low prevalence of shockable rhythms and administration of bystander CPR in patients with traumatic OHCA, we found no significant differences in the sustained ROSC between the AED and the non-AED groups. Considering scene safety and the possible interruption of CPR, we do not encourage the routine use of AEDs at the scene of traumatic OHCAs.

[The TraumaRegister DGU® as the basis of medical quality management. Ten years experience of a national trauma centre exemplified by emergency room treatment]

BACKGROUND

The trauma register of the German Society of Trauma Surgery (TraumaRegister DGU®/TR-DGU) has been proven to be a valuable tool for external assessment of quality in the treatment of patients with major trauma. This publication shows for the first time how the quality of trauma treatment in a level I trauma centre could be improved over a period of almost ten years with the help of continuous quality management, i.e. recognizing a problem, developing a solution and evaluating its effect.

MATERIALS AND METHODS

Tracer parameters and indicators of quality are presented in four periods over a total study period from 1st January 1989 to 31st March 2007. The division into four periods is due to major changes in the trauma treatment algorithms or structural changes in the trauma room. The results are displayed for all patients treated in the trauma room and for those patients with an injury severity score (ISS)≥16.

RESULTS

Over all four periods a total number of n=2,239 patients were admitted to the trauma room. Based on the results of the trauma register a number of changes were made, not only structural changes, such as the introduction of point-of-care diagnostics, initially conventional X-ray, then digital X-ray and finally multislice computed tomography (CT) scanning in the trauma room but also changes in the way personnel participating in the trauma treatment are trained. Advanced trauma life support (ATLS®) has become the standard training for doctors and prehospital trauma life support (PHTLS®) for nurses. Time efficient treatment algorithms were introduced. All measures led to changes in several parameters which are chosen as indicators for good treatment quality. It was for instance possible to reduce the average total trauma treatment time for patients with an ISS≥16 from initially 90.9±48.6 min to 37.4±18.  min in the final study period.

CONCLUSIONS

The external quality management performed by the TR-DGU has proved to be a constant source of inspiration. The effects of the changes made can be scientifically proven. It is to be discussed to what extent a sole external quality management can be useful.

The use of emergency department thoracotomy for traumatic cardiopulmonary arrest

Despite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageability in these situations remain difficult even for experienced physicians. Regardless, survival is limited after traumatic cardiopulmonary arrest. One applicable, well-described resuscitative technique is the emergency department thoracotomy-a procedure that, when applied correctly, is effective in saving small but significant numbers of critically injured patients. By understanding the indications, technical details, and predictors of survival along with the inherent risks and costs of emergency department thoracotomy, the physician is better equipped to make rapid futile versus salvageable decisions for this most severely injured subset of patients.

[S3 guideline on treatment of polytrauma/severe injuries. Trauma room care]

For the multidisciplinary treatment team, the medical care of the most severely injured patients in the trauma room means they have to convert a structured evaluation process into a target-oriented treatment process. Apart from the time factor and the detection of life-threatening injuries that are often summarised under the term"deadly six", also so-called trivial injuries should not be overlooked, because they occasionally can crucially affect the quality of life after trauma. The S3 guideline on polytrauma does not claim to be complete. Important subjects such as the medical care of children have not yet been integrated into the guideline, but it is planned to include them in the next revision.

Cardiopulmonary resuscitation traumatic cardiac arrest--there are survivors. An analysis of two national emergency registries

INTRODUCTION

Cardiac arrest following trauma occurs infrequently compared with cardiac aetiology. Within the German Resuscitation Registry a traumatic cause is documented in about 3% of cardiac arrest patients. Regarding the national Trauma Registry, only a few of these trauma patients with cardiac arrest survive. The aim of the present study was to analyze the outcome of cardiopulmonary resuscitation (CPR) after traumatic cardiac arrest by combining data from two different large national registries in Germany.

METHODS

This study includes 368 trauma patients (2.8%) out of 13,329 cardiac arrest patients registered within the Resuscitation Registry, whereby 3,673 patients with a cardiac cause and successful CPR served as a cardiac control group. We further analyzed a second group of 1,535 trauma patients with cardiac arrest and early CPR registered within the Trauma Registry, whereby a total of 25,366 trauma patients without any CPR attempts served as a trauma control group. The relative frequencies from each database were used to calculate relative percentages for patients with traumatic cardiac arrest in whom resuscitation was attempted.

RESULTS

Within the Resuscitation Registry, cardiac arrest was present in 331 patients (89.9%) when the EMS personal arrived at the scene and in 37 patients (10.1%) when cardiac arrest occurred after arrival. Spontaneous circulation could be achieved in 107 patients (29.1%). A total of 101 (27.4%) were transferred to hospital, 95 of whom (25.8%) had return of spontaneous circulation (ROSC) on admission. According to the Trauma Registry, the overall hospital mortality rate for cardiac arrest patients following trauma was 73% (n = 593 of 814). About half of the patients who were admitted alive to hospital died within 24 hours, resulting in 13% survivors within 24 hours. 7% of the patients survived until hospital discharge, and only 2% of the patients had good neurological outcome.

CONCLUSIONS

Our present study encourages CPR attempts in cardiac arrest patients following severe trauma. When a manageable number of patients is present, the decision on whether to start CPR or not should be done liberally, using comparable criteria as in patients with cardiac etiology. In this respect, trauma management programs that restrict CPR attempts should not be encouraged.

Outcomes of trauma victims with cardiac arrest who survive to intensive care unit admission

BACKGROUND

The prognosis for patients with return of spontaneous circulation after trauma-related cardiac arrest (TRCA) is unclear. Our purpose was to (1) determine outcomes for patients with TRCA resuscitated and admitted to the intensive care unit (ICU), (2) identify ICU-based predictors of in-hospital death in this population, and (3) compare outcomes of patients resuscitated from TRCA and atraumatic cardiac arrest (ATCA).

METHODS

We performed a cohort study using a registry of ICU admissions from 120 US hospitals from 2001 to 2005. Inclusion criteria were age >17 years, admission to ICU via the emergency department, and cardiopulmonary resuscitation preceding ICU arrival. The primary outcome measure was survival to hospital discharge. We compared TRCA and ATCA using binomial test and performed multivariable logistic regression to determine independent predictors of death among trauma subjects.

RESULTS

A total of 4,048 subjects were included (309 TRCA and 3,739 nonTRCA). Forty percent of trauma subjects survived. Independent predictors of death among trauma subjects included persistent postresuscitation cardiovascular failure in the ICU and presentation to a nontrauma center. Despite being younger and having fewer comorbidities, subjects with TRCA had lower survival than subjects with ATCA (40% vs. 49%, p = 0.003).

CONCLUSIONS

Despite lower survival than ATCAs, a significant percentage of TRCAs surviving to ICU admission were discharged alive. This suggests aggressive support of this population is not necessarily futile. Investigation into whether optimization of postresuscitation factors would improve outcome for these patients may be warranted.

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

INTRODUCTION

Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of adult traumatic OHCA.

METHODS

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged ≥16 years.

RESULTS

Between 2000 and 2009, EMS attended 33,178 OHCAs of which 2187 (6.6%) had a traumatic aetiology. The median age (IQR) of traumatic OHCA cases was 36 (25-55) years and 1612 were male (77.5%). Bystander CPR was performed in 201 cases (10.2%) with median (IQR) EMS response time 8 (6-11)min. The first recorded rhythm by EMS was asystole seen in 1650 (75.4%), PEA in 294 (13.4%) cases and VF in 35 cases (1.6%). Cardiac output was present in 208 (9.5%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 545 (24.9%) patients of whom 84 (15.4%) achieved ROSC and were transported, and 27 (5.1%) survived to hospital discharge; 107 were transported with CPR of whom 8 (7.4%) survived to hospital discharge. Where EMS attempted resuscitation in traumatic OHCAs, survival for VF was 11.8% (n=4), PEA 5.1% (n=10) and asystole 2.4% (n=3). In EMS witnessed traumatic OHCA, resuscitation was attempted in 175 cases (84.1%), 35 (16.8%) patients achieved sustained ROSC before transport of whom 5 (14%) survived to leave hospital and 60 (28.8%) were transported with CPR of whom 6 (10%) survived to leave hospital. Compared to OHCA cases with 'presumed cardiac' aetiology traumatic OHCAs were younger [median years (IQR): 36 (25-55) vs 74 (61-82)], had resuscitation attempted less (25% vs 48%), were less likely to have a shockable rhythm (1.6% vs 17.1%), were more likely to be witnessed (62.8% vs 38.1%) and were less likely to receive bystander CPR (10.2% vs 25.5%) (p<0.001, respectively). Multivariate logistic regression identified factors associated with EMS decision to attempt resuscitation. The odds ratio [OR (95% CI)] for 'presence of bystander CPR' was 5.94 (4.11-8.58) and for 'witnessed arrest' was 2.60 (1.86-3.63).

CONCLUSION

In this paramedic delivered EMS attempted resuscitation was not always futile in traumatic OHCA with a survival of 5.1%. The quality of survival needs further study.

Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study

AIM

To determine the characteristics of military traumatic cardiorespiratory arrest (TCRA), and to identify factors associated with successful resuscitation.

METHODS

Data was collected prospectively for adult casualties suffering TCRA presenting to a military field hospital in Helmand Province, Afghanistan between 29 November 2009 and 13 June 2010.

RESULTS

Data was available for 52 patients meeting the inclusion criteria. The mean age (range) was 25 (18-36) years. The principal mechanism of injury was improvised explosive device (IED) explosion, the lower limbs were the most common sites of injury and exsanguination was the most common cause of arrest. Fourteen (27%) patients exhibited ROSC and four (8%) survived to discharge. All survivors achieved a good neurological recovery by Glasgow Outcome Scale. Three survivors had arrested due to exsanguination and one had arrested due to pericardial tamponade. All survivors had arrested after commencing transport to hospital and the longest duration of arrest associated with survival was 24 min. All survivors demonstrated PEA rhythms on ECG during arrest. When performed, 6/24 patients had ultrasound evidence of cardiac activity during arrest; all six with cardiac activity subsequently exhibited ROSC and two survived to hospital discharge.

CONCLUSION

Overall rates of survival from military TCRA were similar to published civilian data, despite military TCRA victims presenting with high Injury Severity Scores and exsanguination due to blast and fragmentation injuries. Factors associated with successful resuscitation included arrest beginning after transport to hospital, the presence of electrical activity on ECG, and the presence of cardiac movement on ultrasound examination.

Preventing cardiac arrest during hemorrhagic shock with vasopressin

The optimal strategy of stabilizing hemodynamic function in uncontrolled traumatic hemorrhagic shock states is unclear. Although fluid replacement is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is controversial, because it may worsen bleeding. In the refractory phase of severe hemorrhagic shock, arginine vasopressin has been shown to be beneficial in selected cases due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site toward the heart and brain, and decrease in fluid-resuscitation requirements. Especially in patients with severe traumatic brain injury, rapid stabilization of cardiocirculatory function is essential to ensure adequate brain perfusion, thus, to prevent neurologic damage and to improve outcome. In addition, despite wide distribution of highly developed and professional emergency medical systems in western industrialized countries, survival chances of patients with uncontrolled traumatic hemorrhagic shock in the preclinical setting are still poor.

Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures

OBJECTIVE

The purpose of this study was to describe a blinded intra-aortic balloon occlusion (IABO) procedure in pelvic fractures (PF) for patients with critically uncontrollable hemorrhagic shock (CUHS).

METHODS

Of 2,064 patients treated for PF, 13 underwent IABO during initial resuscitation to control massive pelvic bleeding leading to CUHS. Our IABO procedure consists of internal aortic occlusion without fluoroscopy, using a latex balloon inflated in the infrarenal aorta. Retrospectively collected data included demographics, fracture classification, additional injuries, blood transfusions, surgical interventions, angiographic procedure, physiologic parameters, and survival.

RESULTS

All balloons were successfully placed, and a significant increase in systolic blood pressure (70 mm Hg, p = 0.001) was observed immediately after IABO. Twelve of 13 patients became transferrable. Angiography performed after IABO was positive for arterial injury in 92% of patients, and 9 patients benefitted from arterial embolization. Survival rate was 46% (6 of 13) and was inversely related to the length of inflation (p = 0.026) and the mean Injury Severity Score (p = 0.011).

CONCLUSION

This IABO procedure can be life saving in the management of patients with CUHS from PF, permitting transport to angiography. However, the decision for such treatment must be as quickly as possible after trauma to reduce the time of occlusion.

[Open chest cardiopulmonary resuscitation: is there an interest in France?]

OBJECTIVE

To expose and clarify indications, techniques, results, complications and cost for open chest cardiopulmonary resuscitation manoeuvres (OCCRM) in traumatic or nontraumatic cardiac arrest.

DATA SOURCES

References were obtained from Pubmed data bank using the following keywords: "emergency thoracotomy", "resuscitative thoracotomy".

STUDY SELECTION

We focused on publications in English language, from 2000 to 2007.

DATA SYNTHESIS

OCCRM are useful especially in case of traumatic cardiac arrest, penetrating trauma, but also in blunt trauma. Time between cardiac arrest and realisation of the thoracotomy seems to be the most important factor for the prognosis.

CONCLUSION

According to the French "physician in ambulance" prehospital system, OCCRM might be promising in France, because this system favours the fastness of care and therefore would minimize the time factor.