Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries

Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients

INTRODUCTION

Relative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival.

METHODS

Retrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05.

RESULTS

In 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89).

CONCLUSIONS

This is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival.

Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers

BACKGROUND

Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA.

METHODS

We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process.

RESULTS

A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS.

CONCLUSION

TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.

Evidence-Based Guideline for Prehospital Airway Management

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Trauma Anesthesiology Perioperative Management Update

Anesthesia for patients with life-threatening injuries is an essential part of post-accident care. Unfortunately, there is variability in trauma anesthesia care and numerous nonstandardized methods of working with patients remain. Uncertainty exists as to when and how best to intubate trauma patients, the use of vasopressors, and the appropriate management of severe traumatic brain injury. Some physicians recommend prehospital rapid sequence intubation, whereas others use bag-mask ventilation at lower pressures with no cricoid pressure and early transport to a trauma center. Overall, the absence of uniformity in trauma anesthesia care underlines the need for continued study and dialogue to define best practices and optimize patient outcomes.

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 of prehospital traumatic cardiac arrest managed by helicopter emergency medical service personnel in Japan: a registry data analysis

BACKGROUND

Traumatic cardiac arrest (TCA) is associated with poor outcomes. Helicopter emergency medical services (HEMSs) are often used to transport critically ill patients to hospitals. However, the role of HEMS in the treatment of TCA remains unclear. Therefore, in this study, we aimed to determine the current status of patients with prehospital TCA managed by HEMS personnel in Japan and compare the outcomes of patients who experienced TCA before and after the arrival of HEMS.

METHODS

The Japanese Society for Aeromedical Services registry data of patients managed by HEMS personnel from April 2015 to March 2020 were analyzed in this retrospective cohort study. HEMS arrival and physicians' interventions at the scene were the variables of interest. The survival rate and neurological outcomes at 28 days after injury were analyzed.

RESULTS

Of the 55 299 registered patients, 722 who experienced prehospital TCA were included in the analysis. The distribution of first-witnessed TCA was as follows: pre-emergency medical service (EMS) arrival (n = 426/722, 60.3%), after EMS arrival (n = 113/722, 16.0%), and after HEMS arrival (n = 168/722, 23.8%). The 28-day survival rate was 6.2% (n = 44/706), with a cerebral performance category of 1 or 2 in 18 patients. However, patients who experienced TCA after receiving interventions provided by physicians before HEMS arrival had the worst outcomes, with only 0.6% of them surviving with favorable neurological outcomes. Multivariable analysis revealed that securing the intravenous route by the EMS team (adjusted odds ratio: 2.43, 95% confidence interval [CI]: 1.11-5.30) and tranexamic acid infusion by the HEMS team (adjusted odds ratio: 2.78, 95% CI: 1.16-6.64) may have increased the return of spontaneous circulation (ROSC) rate.

CONCLUSIONS

The results of our study were similar to those reported in previous studies with regards to the use of HEMS in Japan for transporting patients with TCA. Our findings suggest that in patients with severe trauma, cardiac arrest after initiation of HEMS, the highest level of prehospital medical intervention, may be associated with an inferior prognosis. Tracheal intubation and administration of tranexamic acid by the EMS team may increase the rate of ROSC in TCA.

Intact survival from a blunt trauma cardiac arrest using intraoperative automated CPR

Survival following a blunt traumatic cardiac arrest is rare. Current guidelines suggest that a resuscitative thoracotomy may be performed under specific circumstances. This approach is almost always futile. Technology such as reliable point of care ultrasound and automated compression devices may allow surgeons to consider a damage control laparotomy as the initial surgical approach in blunt trauma cardiac arrest when the point of care ultrasound is positive for intraabdominal injury and there is low suspicion of an unstable intrathoracic injury. Here we present what we believe to be the first reported successful resuscitation of a patient who suffered a blunt trauma cardiac arrest utilizing an automated CPR device before and during an exploratory damage control laparotomy. Despite severe trauma this patient was discharged home, neurologically intact. We believe this case may support the use of automated CPR in the setting of blunt trauma cardiac arrest in patients, assuming the patient has a negative point of care ultrasound for intrathoracic injury, a positive point of care ultrasound for intraperitoneal hemorrhage, and is receiving vigorous blood product administration.

Stay and play or load and go? The association of on-scene advanced life support interventions with return of spontaneous circulation following traumatic cardiac arrest

INTRODUCTION

Traumatic out-of-hospital cardiac arrest (tOHCA) has a mortality rate over 95%. Many current protocols dictate rapid intra-arrest transport of these patients. We hypothesized that on-scene advanced life support (ALS) would increase the odds of arriving at the emergency department with ROSC (ROSC at ED) in comparison to performance of no ALS or ALS en route.

METHODS

We utilized the 2018-2021 ESO Research Collaborative public use datasets for this study, which contain patient care records from ~2000 EMS agencies across the US. All OHCA patients with an etiology of "trauma" or "exsanguination" were screened (n=15,691). The time of advanced airway management, vascular access, and chest decompression was determined for each patient. Logistic regression modeling was used to evaluate the association of ALS intervention timing with ROSC at ED.

RESULTS

4942 patients met inclusion criteria. 14.6% of patients had ROSC at ED. In comparison to no vascular access, on-scene (aOR: 2.14 [1.31, 3.49]) but not en route vascular access was associated with increased odds of having ROSC at ED arrival. In comparison to no chest decompression, neither en route nor on-scene chest decompression were associated with ROSC at ED arrival. Similarly, in comparison to no advanced airway management, neither en route nor on-scene advanced airway management were associated with ROSC at ED arrival. The odds of ROSC at ED decreased by 3% (aOR: 0.97 [0.94, 0.99]) for every 1-minute increase in time to vascular access and decreased by 5% (aOR: 0.95 [0.94, 0.99]) for every 1-minute increase in time to epinephrine.

CONCLUSION

On-scene ALS interventions were associated with increased ROSC at ED in our study. These data suggest that initiating ALS prior to rapid transport to definitive care in the setting of tOHCA may increase the number of patients with a palpable pulse at ED arrival.

Survival following Prehospital Traumatic Cardiac Arrest Resuscitation in the Israel Defense Forces: A Retrospective Study

BACKGROUND

Prehospital traumatic cardiac arrest (TCA) is associated with a poor prognosis and requires urgent interventions to address its potentially reversible causes. Resuscitative efforts of TCA in the prehospital setting may entail significant resource allocation and impose added tolls on caregivers. The Israel Defense Forces Medical Corps (IDF-MC) instructs clinicians to perform a set protocol in the case of TCA, providing prompt oxygenation, chest decompression and volume resuscitation. This study investigates the settings, interventions, and outcomes of TCA resuscitation by IDF-MC teams over 25 years in both combat and civilian settings.

METHODS

Retrospective study of the IDF-MC Trauma Registry between 1997-2022. Search criteria were applied to identify cases where the TCA protocol was initiated. A manual review of cases matching the search criteria was performed by two curators to determine the indications, interventions, and outcomes of casualties with prehospital TCA. Patients for whom interventions were performed outside of the TCA protocol, such as with measurable vital signs, were excluded. The primary outcome was survival to hospital admission, with the secondary outcome being return of vital signs in the prehospital setting.

RESULTS

Following case review, 149 patients with prehospital TCA were included, with a median age of 21 (interquartile range 19-27). Eighty-four (56.4%) presented with TCA in military or combat settings, with gunshot wounds and blast injuries being the most common mechanisms in this group. For 56 casualties (37.8%), all components of the protocol were performed (oxygenation, chest decompression, and volume resuscitation). Five (3.4%) casualties had return of vital signs in the prehospital setting, but none survived to hospital admission.

CONCLUSION

The prognosis of prehospital TCA is poor, and efforts to address its potentially reversible causes may often be futile. These notions may be further emphasized in military settings, where resources are limited, and extensive penetrating injuries are more common.

Traumatic cardiac arrest - a nationwide Danish study

BACKGROUND

Cardiac arrest following trauma is a leading cause of death, mandating urgent treatment. This study aimed to investigate and compare the incidence, prognostic factors, and survival between patients suffering from traumatic cardiac arrest (TCA) and non-traumatic cardiac arrest (non-TCA).

METHODS

This cohort study included all patients suffering from out-of-hospital cardiac arrest in Denmark between 2016 and 2021. TCAs were identified in the prehospital medical record and linked to the out-of-hospital cardiac arrest registry. Descriptive and multivariable analyses were performed with 30-day survival as the primary outcome.

RESULTS

A total of 30,215 patients with out-of-hospital cardiac arrests were included. Among those, 984 (3.3%) were TCA. TCA patients were younger and predominantly male (77.5% vs 63.6%, p =  < 0.01) compared to non-TCA patients. Return of spontaneous circulation occurred in 27.3% of cases vs 32.3% in non-TCA patients, p < 0.01, and 30-day survival was 7.3% vs 14.2%, p < 0.01. An initial shockable rhythm was associated with increased survival (aOR = 11.45, 95% CI [6.24 - 21.24] in TCA patients. When comparing TCA with non-TCA other trauma and penetrating trauma were associated with lower survival (aOR: 0.2, 95% CI [0.02-0.54] and aOR: 0.1, 95% CI [0.03 - 0.31], respectively. Non-TCA was associated with an aOR: 3.47, 95% CI [2.53 - 4,91].

CONCLUSION

Survival from TCA is lower than in non-TCA. TCA has different predictors of outcome compared to non-TCA, illustrating the differences regarding the aetiologies of cardiac arrest. Presenting with an initial shockable cardiac rhythm might be associated with a favourable outcome in TCA.

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.

Higher Oxygenation Is Associated with Improved Survival in Severe Traumatic Brain Injury but Not Traumatic Shock

Pre-hospital resuscitation of critically injured patients traditionally includes supplemental oxygen therapy to address potential hypoxemia. The objective of this study was to explore the association between pre-hospital hypoxemia, hyperoxemia, and mortality in patients with traumatic brain injury (TBI) and traumatic shock. We hypothesized that both hypoxemia and hyperoxemia would be associated with increased mortality. We used the Resuscitation Outcomes Consortium Prospective Observational Prehospital and Hospital Registry for Trauma (ROC PROPHET) database of critically injured patients to identify a severe TBI cohort (pre-hospital Glasgow Coma Scale [GCS] 3-8) and a traumatic shock cohort (systolic blood pressure ≤90 mm Hg and pre-hospital GCS >8). Arterial blood gas (ABG) obtained within 30 min of hospital arrival was required for inclusion. Patients with hypoxemia (PaO₂ <80 mm Hg) and hyperoxemia (PaO₂ >400 mm Hg) were compared to those with normoxemia (PaO₂ 80-400 mm Hg) with regard to the primary outcome measure of in-hospital mortality in both the TBI and traumatic shock cohorts. Multiple logistic regression was used to calculate odds ratios (ORs) after adjustment for multiple covariables. In addition, regression spline curves were generated to estimate the risk of death as a continuous function of PaO₂ levels. A total of 1248 TBI patients were included, of whom 396 (32%) died before hospital discharge. Associations between hypoxemia and increased mortality (OR, 1.8; 95% confidence interval [CI], 1.2-2.8; p = 0.008) and between hyperoxemia and decreased mortality (OR, 0.6; 95% CI, 0.4-0.9; p = 0.018) were observed. A total of 582 traumatic shock patients were included, of whom 52 (9%) died before hospital discharge. No statistically significant associations were observed between in-hospital mortality and either hypoxemia (OR, 1.0; 95% CI, 0.4-2.4; p = 0.987) or hyperoxemia (OR, 1.9; 95% CI, 0.6-5.7; p = 0.269). Among patients with severe TBI but not traumatic shock, hypoxemia was associated with an increase of in-hospital mortality and hyperoxemia was associated with a decrease of in-hospital mortality.

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01039-9.

Early risk stratification for progression to death by neurological criteria following out-of-hospital cardiac arrest

BACKGROUND

Some patients resuscitated from out-of-hospital cardiac arrest (OHCA) progress to death by neurological criteria (DNC). We hypothesized that initial brain imaging, electroencephalography (EEG), and arrest characteristics predict progression to DNC.

METHODS

We identified comatose OHCA patients from January 2010 to February 2020 treated at a single quaternary care facility in Western Pennsylvania. We abstracted demographics and arrest characteristics; Pittsburgh Cardiac Arrest Category, initial motor exam and pupillary light reflex; initial brain computed tomography (CT) grey-to-white ratio (GWR), sulcal or basal cistern effacement; initial EEG background and suppression ratio. We used two modeling approaches: fast and frugal tree (FFT) analysis to create an interpretable clinical risk stratification tool and ridge regression for comparison. We used bootstrapping to randomly partition cases into 80% training and 20% test sets and evaluated test set sensitivity and specificity.

RESULTS

We included 1,569 patients, of whom 147 (9%) had diagnosed DNC. Across bootstrap samples, >99% of FFTs included three predictors: sulcal effacement, and in cases without sulcal effacement, the combination of EEG background suppression and GWR ≤ 1.23. This tree had mean sensitivity and specificity of 87% and 81%. Ridge regression with all available predictors had mean sensitivity 91 % and mean specificity 83%. Subjects falsely predicted as likely to progress to DNC generally died of rearrest or withdrawal of life sustaining therapies due to poor neurological prognosis. Two of these cases awakened from coma during the index hospitalization.

CONCLUSIONS

Sulcal effacement on presenting brain CT or EEG suppression with GWR ≤ 1.23 predict progression to DNC after OHCA.

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.

Survival Rates After Pediatric Traumatic Out-of-Hospital Cardiac Arrest Suggest an Underappreciated Therapeutic Opportunity

OBJECTIVES

Children with traumatic arrests represent almost one third of annual pediatric out-of-hospital cardiac arrests (OHCAs). However, traumatic arrests are often excluded from study populations because survival posttraumatic arrest is thought to be negligible. We hypothesized that children treated and transported by emergency medical services (EMS) personnel after traumatic OHCA would have lower survival compared with children treated after medical OHCA.

METHODS

We performed a secondary, observational study of children younger than 18 years treated and transported by 78 EMS agencies in southwestern Pennsylvania after OHCA from 2010 to 2014. Etiology was determined as trauma or medical by EMS services. We analyzed patient, cardiac arrest, and resuscitation characteristics and ascertained vital status using the National Death Index. We used multivariable logistic regression to test the association of etiology with mortality after covariate adjustment.

RESULTS

Forty eight of 209 children (23%) had traumatic OHCA. Children with trauma were older than those with medical OHCA (13.2 [3.8-15.9] vs 0.5 [0.2-2.4] years, P < 0.001). Prehospital return of spontaneous circulation frequency for trauma versus medical etiology was similar (90% vs 87%, P = 0.84). Patients with trauma had higher mortality (69% vs 45% P = 0.004).

CONCLUSIONS

More than 8 of 10 children with EMS treated and transported OHCA achieved return of spontaneous circulation. Despite lower survival rates than medical OHCA patients, almost one third of children with a traumatic etiology survived throughout the study period. Future research programs warrant inclusion of children with traumatic OHCA to improve outcomes.

Prehospital Airway Management: A Systematic Review

Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.

Prehospital care for traumatic cardiac arrest in the US: A cross-sectional analysis and call for a national guideline

AIM

We describe emergency medical services (EMS) protocols and prehospital practice patterns related to traumatic cardiac arrest (TCA) management in the U.S.

METHODS

We examined EMS management of TCA by 1) assessing variability in recommended treatments in state EMS protocols for TCA and 2) analyzing EMS care using a nationwide sample of EMS activations. We included EMS activations involving TCA in adult (≥18 years) patients where resuscitation was attempted by EMS. Descriptive statistics for recommended and actual treatments were calculated and compared between blunt and penetrating trauma using χ² and independent 2-group Mann-Whitney U tests.

RESULTS

There were 35 state EMS protocols publicly available for review, of which 16 (45.7%) had a specific TCA protocol and 17 (48.5%) had a specific termination of resuscitation protocol for TCA. Recommended treatments varied. We then analyzed 9,565 EMS activations involving TCA (79.1% blunt, 20.9% penetrating). Most activations (93%) were managed by advanced life support. Return of spontaneous circulation was achieved in 25.5% of activations, and resuscitation was terminated by EMS in 26.4% of activations. Median prehospital scene time was 16.4 minutes; scene time was shorter for penetrating mechanisms than blunt (12.0 vs 17.0 min, p < 0.001). Endotracheal intubation was performed in 32.0% of activations, vascular access obtained in 66.6%, crystalloid fluids administered in 28.8%, and adrenaline administered in 60.1%.

CONCLUSION

Actual and recommended approaches to EMS treatment of TCA vary nationally. These variations in protocols and treatments highlight the need for a standardized approach to prehospital management of TCA in the U.S.

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.

Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients

INTRODUCTION

"Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma.

METHODS

We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018.

RESULTS

Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively.

CONCLUSIONS

Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

No Resuscitative Thoracotomy? When to Stop Chest Compressions After Prehospital Traumatic Cardiac Arrest

INTRODUCTION

Although indications and outcomes for trauma patients who require resuscitative thoracotomies are well studied, little is known about how prehospital chest compressions support survival in patients who do not meet criteria for subsequent resuscitative thoracotomy.

METHODS

Data from a single institutional retrospective review of trauma patients who required prehospital chest compressions from 1/2015 to 12/2020 were collected. Patients who underwent compressions only were compared to those who underwent subsequent resuscitative thoracotomy. The primary outcome was in-hospital mortality.

RESULTS

Fifty-two patients were identified, 22 of whom underwent compressions only and 30 of whom went on to undergo thoracotomy. Patients who underwent compressions only were more likely to be female (36% vs 10%, P = .04), older (mean 46 vs 35 years, P = .04), and to experience blunt trauma (78% vs 43%, P = .01). Injury severity score was similar between the cohorts (mean 18 vs 28, P = .11). One patient in the compressions only cohort had a REBOA placed compared to two in the thoracotomy cohort (1.9% vs 3.67%, P > .99). Return of spontaneous circulation (ROSC) was achieved in 17% of the compressions only cohort compared to 45% of the thoracotomy cohort (P = .03). In-hospital mortality in the compressions only cohort was 100%, whereas in-hospital mortality in the thoracotomy cohort was 94% (P = .50), with a mean of zero survival days in both groups (P = .33).

CONCLUSION

Prehospital chest compressions without thoracotomy were uniformly fatal, even if transient ROSC was obtained. Our findings support termination of chest compressions for those trauma patients who do not meet criteria for resuscitative thoracotomy.

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.

Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest

BACKGROUND

Traumatic cardiac arrests (TCAs) are associated with high mortality and the majority of deaths occur at the prehospital scene. The aim of the present study was to assess, in a prehospital physician-led emergency medical system, the factors associated with sustained return of spontaneous circulation (ROSC) in TCA, including advanced life procedures. The secondary objectives were to assess factors associated with 30-day survival in TCA, evaluate neurological recovery in survivors, and describe the frequency of organ donation among patients experiencing a TCA.

METHODS

We conducted a retrospective study of all TCA patients included in the French nationwide cardiac arrest registry from July 2011 to November 2020. Multivariable logistic regression analysis was used to identify factors independently associated with ROSC.

RESULTS

A total of 120,045 out-of-hospital cardiac arrests were included in the registry, among which 4,922 TCA were eligible for analysis. Return of spontaneous circulation was sustained on-scene in 21.1% (n = 1,037) patients. Factors significantly associated with sustained ROSC were not-asystolic initial rhythms (pulseless electric activity (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.40-2.35; p < 0.001), shockable rhythm (OR, 1.83; 95% CI, 1.12-2.98; p = 0.016), spontaneous activity (OR, 3.66; 95% CI, 2.70-4.96; p < 0.001), and gasping at the mobile medical team (MMT) arrival (OR, 1.40; 95% CI, 1.02-1.94; p = 0.042). The MMT interventions significantly associated with ROSC were as follows: intravenous fluid resuscitation (OR, 3.19; 95% CI, 2.69-3.78; p < 0.001), packed red cells transfusion (OR, 2.54; 95% CI, 1.84-3.51; p < 0.001), and external hemorrhage control (OR, 1.74; 95% CI, 1.31-2.30; p < 0.001). Among patients who survived (n = 67), neurological outcome at Day 30 was favorable (cerebral performance categories 1-2) in 72.2% cases (n = 39/54) and 1.4% (n = 67/4,855) of deceased patients donated one or more organ.

CONCLUSION

Sustained ROSC was frequently achieved in patients not in asystole at MMT arrival, and higher ROSC rates were achieved in patients benefiting from specific advanced life support interventions. Organ donation was somewhat possible in TCA patients undergoing on-scene resuscitation.

LEVEL OF EVIDENCE

Prognostic and epidemiologic, Level III.

Incidence, characteristics and predictors of mortality following cardiac arrest in ICUs of a German university hospital: A retrospective cohort study

BACKGROUND

Cardiac arrest in intensive care is a rarely studied type of in-hospital cardiac arrest.

OBJECTIVE

This study examines the incidence, characteristics, risk factors for mortality as well as long-term prognosis following cardiac arrest in intensive care.

DESIGN

Retrospective cohort study.

SETTING

Five noncardiac surgical ICUs (41 surgical and 37 medical beds) at a German university hospital between 2016 and 2019.

PATIENTS

Adults experiencing cardiac arrest defined as the need for chest compressions and/or defibrillation occurring for the first time on the ICU.

MAIN OUTCOME MEASURES

Primary endpoint: occurrence of cardiac-arrest in the ICU. Secondary endpoints: diagnostic and therapeutic measures; risk factors and marginal probabilities of no-return of spontaneous circulation; rates of return of spontaneous circulation, hospital discharge, 1-year-survival and 1-year-neurological outcome.

RESULTS

A total of 114 cardiac arrests were observed out of 14 264 ICU admissions; incidence 0.8%; 95% confidence interval (CI) 0.7 to 1.0; 45.6% received at least one additional diagnostic test, such as blood gas analysis (36%), echocardiography (19.3%) or chest x-ray (9.9%) with a resulting change in therapy in 52%, (more frequently in those with a return of spontaneous circulation vs none, P = 0.023). Risk factors for no-return of spontaneous circulation were cardiac comorbidities (OR 5.4; 95% CI, 1.4 to 20.7) and continuous renal replacement therapy (OR 5.9; 95% CI, 1.7 to 20.8). Bicarbonate levels greater than 21 mmol l-1 were associated with a higher mortality risk in combination either with cardiac comorbidities (bicarbonate <21 mmol l-1: 13%; 21 to 26 mmol l-1: 45%; >26 mmol l-1: 42%) or with a SOFA at least 2 (bicarbonate <21 mmol l-1: 8%; 21 to 26 mmol l-1: 40%; >26 mmol l-1: 37%). In-hospital mortality was 78.1% (n=89); 1-year-survival-rate was 10.5% (95% CI, 5.5 to 17.7) and survival with a good neurological outcome was 6.1% (95% CI, 2.5 to 12.2).

CONCLUSION

Cardiac arrest in ICU is a rare complication with a high mortality and low rate of good neurological outcome. The development of a structured approach to resuscitation should include all available resources of an ICU and adequately consider the complete diagnostic and therapeutic spectra as our results indicate that these are still underused. The development of prediction models of death should take into account cardiac and hepatic comorbidities, continuous renal replacement therapy, SOFA at least 2 before cardiac arrest and bicarbonate level. Further research should concentrate on identifying early predictors and on the prevention of cardiac arrest in ICU.

Survival Trends in Adults with Out-Of-Hospital Cardiac Arrests after Traffic Collisions in Japan: A Population-Based Study

The 1-month survival rate from out-of-hospital cardiac arrest (OHCA) of cardiac origin has reportedly improved recently, at ≥5%. However, the characteristics of patients with OHCA after a traffic collision have not been adequately evaluated in Japan. We analyzed the All-Japan Utstein Registry data of 12,577 adult patients aged ≥ 20 years with OHCA due to traffic collisions who were resuscitated by emergency medical service personnel or bystanders and were then transported to medical institutions between 2013 and 2019. Multiple logistic regression analysis was used to assess factors potentially associated with the 1-month survival rate after OHCA. The 1-month survival rate was 1.4% (174/12,577). The proportion of 1-month survival of all OHCAs after a traffic collision origin did not increase significantly (from 1.6% [30/1919] in 2013 to 1.8% [25/1702] in 2019), and the adjusted odds ratio for 1-year increments was 1.04 (95% confidence interval, 0.96–1.12). In multivariate analysis, men who received ventricular fibrillation, pulseless electrical activity, intravenous fluid replacement, or early emergency medical service response and had a traffic collision during daytime had significantly favorable 1-month outcomes. In Japan, the 1-month survival after OHCA of a traffic collision origin was lower than that of a cardiac origin and remains stable.

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.

Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document

Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.

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.

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.

Epidemiology, management and survival outcomes of adult out-of-hospital traumatic cardiac arrest due to blunt, penetrating or burn injury

BACKGROUND

Survival from out-of-hospital traumatic cardiac arrest (TCA) is poor. Regional variation exists regarding epidemiology, management and outcomes. Data on prognostic factors are scant. A better understanding of injury patterns and outcome determinants is key to identifying opportunities for survival improvement.

METHODS

Included were adult (≥18 years) out-of-hospital TCA due to blunt, penetrating or burn injury, who were attended by Queensland Ambulance Service paramedics between 1 January 2007 and 31 December 2019. We compared the characteristics of patients who were pronounced dead on paramedic arrival and those receiving resuscitation from paramedics. Intra-arrest procedures were described for attempted-resuscitation patients. Survival up to 6 months postarrest was reported, and factors associated with survival were investigated.

RESULTS

3891 patients were included; 2394 (61.5%) were pronounced dead on paramedic arrival and 1497 (38.5%) received resuscitation from paramedics. Most arrests (79.8%) resulted from blunt trauma. Motor vehicle collision (42.4%) and gunshot wound (17.7%) were the most common injury mechanisms in patients pronounced dead on paramedic arrival, whereas the most prevalent mechanisms in attempted-resuscitation patients were motor vehicle (31.3%) and motorcycle (20.6%) collisions. Among attempted-resuscitation patients, rates of transport and survival to hospital handover, to hospital discharge and to 6 months were 31.9%, 15.3%, 9.8% and 9.8%, respectively. Multivariable model showed that advanced airway management (adjusted OR 1.84; 95% CI 1.06 to 3.17), intravenous access (OR 5.04; 95% CI 2.43 to 10.45) and attendance of high acuity response unit (highly trained prehospital care clinicians) (OR 2.54; 95% CI 1.25 to 5.18) were associated with improved odds of survival to hospital handover.

CONCLUSIONS

By including all paramedic-attended patients, this study provides a more complete understanding of the epidemiology of out-of-hospital TCA. Contemporary survival rates from adult out-of-hospital TCA who receive resuscitation from paramedics may be higher than historically thought. Factors identified in this study as associated with survival may be useful to guide prognostication and treatment.

Survival outcomes in emergency medical services witnessed traumatic out-of-hospital cardiac arrest after the introduction of a trauma-based resuscitation protocol

AIM

In this study, we examine the impact of a trauma-based resuscitation protocol on survival outcomes following emergency medical services (EMS) witnessed traumatic out-of-hospital cardiac arrest (OHCA).

METHODS

We included EMS-witnessed OHCAs arising from trauma and occurring between 2008 and 2019. In December 2016, a new resuscitation protocol for traumatic OHCA was introduced prioritising the treatment of potentially reversible causes before conventional cardiopulmonary resuscitation. The effect of the new protocol on survival outcomes was assessed using adjusted multivariable logistic regression models.

RESULTS

Paramedics attempted resuscitation on 490 patients, with 341 (69.6%) and 149 (30.4%) occurring during the control and intervention periods, respectively. A reduction in the proportion of cases receiving cardiopulmonary resuscitation and epinephrine administration were found in the intervention period compared to the control period, whereas trauma-based interventions increased significantly, including blood administration (pre-arrest: 17.9% vs 3.7%; intra-arrest: 24.1% vs 2.7%), splinting (pre-arrest: 38.6% vs 17.1%; intra-arrest: 20.7% vs 5.2%), and finger thoracostomy (pre-arrest: 13.1% vs 0.6%; intra-arrest: 22.8% vs 0.9%), respectively, with p-values < 0.001 for all comparisons. After adjustment, the trauma-based resuscitation protocol was not associated with an improvement in survival to hospital discharge (AOR 1.29, 95% CI: 0.51-3.23), event survival (AOR 0.72, 95% CI: 0.41-1.28) or prehospital return of spontaneous circulation (AOR 0.63, 95% CI: 0.39-1.03).

CONCLUSION

In our region, the introduction of a trauma-based resuscitation protocol led to an increase in the delivery of almost all trauma interventions; however, this did not translate into better survival outcomes following EMS-witnessed traumatic OHCA.

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of “obvious death” or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP’s decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43–3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28–7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02–0.08), age > 80 years (OR = 0.14, 95% CI: 0.09–0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06–0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP’s decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of evidence

Level III.

[Cardiac arrest under special circumstances]

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

Outcomes after Prehospital Traumatic Cardiac Arrest in the Netherlands: a Retrospective Cohort Study

BACKGROUND

Traumatic cardiac arrest (TCA) is a severe and life-threatening situation that mandates urgent action. Outcomes after on-scene treatment of TCA in the Netherlands are currently unknown. The aim of the current study was to investigate the rate of survival to discharge in patients who suffered from traumatic cardiac arrest and who were subsequently treated on-scene by the Dutch Helicopter Emergency Medical Services (HEMS).

METHODS

A retrospective cohort study was performed including patients ≥ 18 years with TCA for which the Dutch HEMS were dispatched between January 1^st 2014 and December 31^st 2018. Patients with TCA after hanging, submersion, conflagration or electrocution were excluded. The primary outcome measure was survival to discharge after prehospital TCA. Secondary outcome measures were return of spontaneous circulation (ROSC) on-scene and neurological status at hospital discharge.

RESULTS

Nine-hundred-fifteen patients with confirmed TCA were included. ROSC was achieved on-scene in 261 patients (28.5%). Thirty-six (3.9%) patients survived to hospital discharge of which 17 (47.2%) had a good neurological outcome. Age < 70 years (0.7% vs. 5.2%; p=0.041) and a shockable rhythm on first ECG (OR 0.65 95%CI 0.02-0.28; p<0.001) were associated with increased odds of survival.

CONCLUSION

Neurologic intact survival is possible after prehospital traumatic cardiac arrest. Younger patients and patients with a shockable ECG rhythm have higher survival rates after TCA.

LEVEL OF EVIDENCE

prognostic study, level III.

Factors affecting outcomes in patients with cardiac arrest who receive target temperature management: The multi-center TIMECARD registry

BACKGROUND

Target temperature management (TTM) is a recommended therapy for patients after cardiac arrest (PCA). The TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry was established for PCA who receive TTM therapy in Taiwan. We aim to determine the variables that may affect neurologic outcomes in PCA who undergo TTM.

METHODS

We retrieved demographic variables, resuscitation variables, and cerebral performance category (CPC) scale score at hospital discharge from the TIMECARD registry. The primary outcome was a favorable neurologic outcome, defined as a CPC scale of 1 or 2 at discharge. A total of 540 PCA treated between January 2014 and September 2019 were identified from the registry. Univariate and multivariate analyses were performed to identify significant variables.

RESULTS

The mortality rate was 58.1% (314/540). Favorable neurologic outcomes were noted in 117 patients (21.7%). The factors significantly influencing the neurologic outcome (p < 0.05) were the presence of an initial shockable rhythm or pulseless electric activity, a witnessed cardiac-arrest event, bystander cardiopulmonary resuscitation, a smaller total dose of epinephrine, the diastolic blood pressure value at return of spontaneous circulation, a pre-arrest CPC score of 1, coronary angiography, new-onset seizure, and new-onset serious infection. Older patients and those with premorbid diabetes mellitus, chronic kidney disease, malignancy, obstructive lung disease, or cerebrovascular accident were more likely to have an unfavorable neurologic outcome.

CONCLUSIONS

In the TIMECARD registry, some PCA baseline characteristics, cardiac arrest events, cardiopulmonary resuscitation characteristics, and post-arrest management characteristics were significantly associated with neurologic outcomes.

Depiction of Resuscitation on Medical Dramas: Proposed Effect on Patient Expectations

The public has unrealistic views regarding the success of cardiopulmonary resuscitation, and one potential source of misinformation is medical dramas. Prior research has shown that depictions of resuscitation on television are skewed towards younger patients with acute injuries, while most cardiac arrests occur in older patients as a result of medical comorbidities. Additionally, the success rate of televised resuscitations on older shows has vastly exceeded good outcomes in the real world. We sought to understand resuscitation outcomes on current medical dramas and to review the literature for evidence that media affects patient decision-making. We reviewed medical dramas to evaluate the demographics of cardiac arrest victims and the success rate of resuscitations and compared the results to outcomes for real-world patients. Medical dramas continue to focus on trauma as the main cause of cardiac arrest and portray favorable outcomes more frequently than should be expected. Patients who believe the overly optimistic prognoses portrayed on television may be more likely to desire aggressive medical care in the face of serious illness. Healthcare workers should anticipate the need to counter misinformation when discussing patient goals of care and end-of-life planning.

Advanced Life Support vs. Basic Life Support for Patients With Trauma in Prehospital Settings: A Systematic Review and Meta-Analysis

Background: Advanced Life Support (ALS) is regarded to be associated with improved survival in pre-hospital trauma care when compared to Basic Life Support (BLS) irrespective of lack of evidence. The aim of this study is to ascertain ALS improves survival for trauma in prehospital settings when compared to BLS.

Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for published controlled trials (CTs), and observational studies that were published until Aug 2017. The population of interest were adults (>18 years old) trauma patients who were transported by ground transportation and required resuscitation in prehospital settings. We compared outcomes between the ALS and BLS groups. The primary outcome was in-hospital mortality and secondary outcomes were neurological outcome and time spent on scene.

Results: We identified 2,502 studies from various databases and 10 studies were included in the analysis (two CTs, and eight observational studies). The outcomes were not statistically significant between the ALS and BLS groups (pooled OR 1.14; 95% CI 0.95 to 1.36 for mortality, pooled OR 1.12; 95% CI 0.88 to 1.42 for good neurological outcomes, pooled mean difference −0.96; 95% CI−6.64 to 4.72 for on-scene time) in CTs. In observational studies, ALS prolonged on-scene time and increased mortality (pooled OR 1.56; 95% CI: 1.31 to 1.86 for mortality, and pooled mean difference, 1.26; 95% CI: 0.07 to 2.45 for on-scene time).

Conclusions: In prehospital settings, the present study showed no advantages of ALS on the outcomes in patients with trauma compared to BLS.

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

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

Survival Following Lay Resuscitation

BACKGROUND

Resuscitation by laypersons is important in bridging the time between the occurrence of an out-of-hospital cardiac arrest (OHCA) and the arrival of emergency rescue service personnel. Depending on the reason for the cardiac arrest, however, the effectiveness of chest compressions is uncertain. The aim of this study was to explore the impact of lay resuscitation on survival following OHCA of different causes.

METHODS

The data set for analysis comprised all cases of cardiac arrest before the arrival of emergency rescue service personnel that were fully documented in the German Resuscitation Registry in the period 2007-2019. The following endpoints related to resuscitation by bystanders were evaluated-separately for each cause-descriptively and by means of multivariate logistic regression analysis: return of spontaneous circulation (ROSC), 30 days' survival/discharged alive from the hospital, and good neurological function at discharge.

RESULTS

Altogether, 40 604 cases of cardiac arrest were included. Resuscitation by laypersons was carried out in 35.1% of these cases. The rate of ROSC was statistically significantly higher after lay resuscitation for OHCA caused by cardiac events, drowning, intoxication, or central nervous system disorders (overall 48.1% versus 41.0%). For all causes-with the exception of trauma/bleeding to death and sepsis- the endpoint 30 days' survival/discharged alive was better with lay resuscitation (overall 17.0% versus 9.5%). In multivariate regression analysis, lay resuscitation was associated with improvement of the endpoint 30 days' survival/discharged alive only for OHCA caused by cardiac events (odds ratio [OR] 1.16) or intoxication (OR 1.81). For all other causes-except hypoxia-lay resuscitation tended to yield better results. Neurological function at discharge was also significantly better (overall 11.5% versus 6.1%) after lay resuscitation for OHCA of all causes except trauma/ bleeding to death, hypoxia, and sepsis.

CONCLUSION

Resuscitation by laypersons is associated with an improved result regarding the endpoint 30 days' survival/discharged alive in cases of OHCA caused by cardiac events and intoxication. These two groups account for 81% of the resuscitation patients in the study. Because there was also a tendency towards higher survival rates following OHCA of other causes (except hypoxia), laypersons should continue to be encouraged to attempt resuscitation in all cases of OHCA, whatever the cause.

The Safety and Utility of Ground Transport of Traumatic Cardiopulmonary Arrest Patients by Helicopter Emergency Medical Services Crews

OBJECTIVE

Patients suffering from traumatic cardiopulmonary arrest (TCPA) typically demonstrate dismal survival rates. Some helicopter emergency medical services (HEMS) systems transport TCPA patients via ground with a referring agency when cardiopulmonary pulmonary resuscitation is in progress. With expanding research on the inherent risk of ground emergency medical services (GEMS) transport with the use of lights and sirens to both crew and the general public, the benefits may not outweigh the risks of transporting these patients by GEMS. The aim of this study was to determine the number of TCPA patients transported by GEMS with HEMS crews on board who survived to hospital discharge.

METHODS

A retrospective chart review was performed of approximately 10 years of data from a regional Midwest HEMS service. Survival to hospital discharge was the primary outcome.

RESULTS

Flight crews transported 54 patients via ambulance with GEMS crews; 31 patients met all inclusion and exclusion criteria. Of the 31 patients transported, 0 survived to hospital discharge.

CONCLUSION

Based on our 0% survival rate and the inherent risk of injury and death to emergency medical services crews and the general public, the risk of transporting adult TCPA patients by GEMS using lights and sirens outweighs the benefit.

Impact of a trauma-focused resuscitation protocol on survival outcomes after traumatic out-of-hospital cardiac arrest: An interrupted time series analysis

AIM

In this study, we examine the impact of a trauma-focused resuscitation protocol on survival outcomes following adult traumatic out-of-hospital cardiac arrest (OHCA).

METHODS

We included adult traumatic OHCA patients aged >16 years occurring between 2008 and 2019. In December 2016, a new resuscitation protocol for traumatic OHCA was introduced prioritising the treatment of potentially reversible causes before conventional cardiopulmonary resuscitation (CPR). The effect of the new protocol on survival outcomes was assessed using adjusted interrupted time series regression.

RESULTS

Over the study period, paramedics attempted resuscitation on 996 patients out of 3,958 attended cases. Of the treated cases, 672 (67.5%) and 324 (32.5%) occurred during pre-intervention and intervention periods, respectively. The frequency of almost all trauma interventions was significantly higher in the intervention period, including external haemorrhage control (15.7% vs 7.6; p-value <0.001), blood administration (3.8% vs 0.2%; p-value <0.001), and needle thoracostomy (75.9% vs 42.0%; p-value <0.001). There was also a significant reduction in the median time from initial patient contact to the delivery of needle thoracostomy (4.4 min vs 8.7 min; p-value <0.001) and splinting (8.7 min vs 17.5 min; p-value = 0.009). After adjustment, the trauma-focused resuscitation protocol was not associated with a change in the level of survival to hospital discharge (adjusted odds ratio [AOR] 0.98; 95% confidence interval [CI]: 0.11-8.59), event survival (AOR 0.82; 95% CI: 0.33-2.03), or prehospital return of spontaneous circulation (AOR 1.30; 95% CI: 0.61-2.76).

CONCLUSION

Despite an increase in trauma-based interventions and a reduction in the time to their administration, our study did not find a survival benefit from a trauma-focused resuscitation protocol over initial conventional CPR. However, survival was low with both approaches.

Cardiac arrest after severe traumatic brain injury can be survivable with good outcomes

Background

Resuscitation for traumatic cardiac arrest (TCA) in patients with severe traumatic brain injury (sTBI) has historically been considered futile. There is little information on the characteristics and outcomes of these patients to guide intervention and prognosis. The purpose of the current study is to report the clinical characteristics, survival, and long-term neurological outcomes in patients who experienced TCA after sTBI and analyze the factors contributing to survival.

Methods

A retrospective review identified 42 patients with TCA from a total of 402 patients with sTBI (Glasgow Coma Scale (GCS) score ≤8) who were admitted to Stony Brook University Hospital, a level I trauma center, from January 2011 to December 2018. Patient demographics, clinical characteristics, survival, and neurological functioning during hospitalization and at follow-up visits were collected.

Results

Of the 42 patients, the average age was 45 years and 21.4% were female. Eight patients survived the injury (19.0%) to discharge and seven survived with good neurological function. Admission GCS score and bilateral pupil reactivity were found to be significant indicators of survival. The mean GCS score was 5.3 in survivors and 3.2 in non-survivors (p=0.020). Age, Injury Severity Score, or cardiac rhythm was not associated with survival. Frequent neuroimaging findings included subarachnoid hemorrhage, subdural hematoma, and diffuse axonal injury.

Discussion

TCA after sTBI is survivable and seven out of eight patients in our study recovered with good neurological function. GCS score and pupil reactivity are the best indicators of survival. Our results suggest that due to the possibility of recovery, resuscitation and neurosurgical care should not be withheld from this patient population.

Level of evidence

Level IV, therapeutic/care management.

Impact of temporal changes in the epidemiology and management of traumatic out-of-hospital cardiac arrest on survival outcomes

AIM

We aimed to investigate the impact of temporal changes in the epidemiology and management of traumatic out-of-hospital cardiac arrest (OHCA) on emergency medical service (EMS) attempted resuscitations and survival outcomes.

METHODS

A retrospective observational study of traumatic OHCA cases involving patients aged > 16 years in Victoria, Australia, who arrested between 2001 and 2018. Unadjusted and adjusted logistic regression was performed to assess trends in survival outcomes over the study period.

RESULTS

Between 2001 and 2018, the EMS attended 5,631 cases of traumatic OHCA, of which 1,237 cases (22.0%) received an attempted resuscitation. EMS response times increased significantly over time (from 7.0 min in 2001-03 to 9.8 min in 2016-18; p trend < 0.001) as did rates of bystander cardiopulmonary resuscitation (CPR) (from 37.8% to 63.6%; p trend < 0.001). Helicopter EMS attendance on scene increased from 7.1% to 12.4% (p trend = 0.01), and transports of patients with return of spontaneous circulation (ROSC) to designated major trauma centres also increased from 36.6% to 82.4% (p trend < 0.001). The frequency of EMS trauma-specific interventions increased over the study period, including needle thoracostomy from 7.7% to 61.6% (p trend < 0.001). Although the risk-adjusted odds of ROSC (OR 1.06, 95% CI: 1.03-1.10) and event survival (OR 1.05, 95% CI: 1.01-1.09) increased year-on-year, there were no temporal changes in survival to hospital discharge.

CONCLUSION

Despite higher rates of bystander CPR and EMS trauma interventions, rates of survival following traumatic OHCA did not change over time in our region. More studies are needed to investigate the optimal EMS interventions for improved survival in traumatic OHCA.

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.