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

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.

Epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: a post hoc analysis of prospective observational study

Background

The beneficial effect of epinephrine during resuscitation from out-of-hospital cardiac arrest (OHCA) has been inconclusive, and potential harm has been suggested, particularly in trauma victims. Although no significant improvement in neurological outcomes has been found among resuscitated patients using epinephrine, including trauma patients, the use of epinephrine is recommended in the Advanced Trauma Life Support protocol. Given that the use of vasopressors was reported to be associated with increased mortality in patients with massive bleeding, the undesirable effects of epinephrine during the resuscitation of traumatic OHCA should be elucidated. We hypothesised that resuscitation with epinephrine would increase mortality in patients with OHCA following trauma.

Methods

This study is a post-hoc analysis of a prospective, multicentre, observational study on patients with OHCA between January 2012 and March 2013. We included adult patients with traumatic OHCA who were aged ≥15 years and excluded those with missing survival data. Patient data were divided into epinephrine or no-epinephrine groups based on the use of epinephrine during resuscitation at the hospital. Propensity scores were developed to estimate the probability of being assigned to the epinephrine group using multivariate logistic regression analyses adjusted for known survival predictors. The primary outcome was survival 7 days after injury, which was compared among the two groups after propensity score matching.

Results

Of the 1125 adults with traumatic OHCA during the study period, 1030 patients were included in this study. Among them, 822 (79.8%) were resuscitated using epinephrine, and 1.1% (9/822) in the epinephrine group and 5.3% (11/208) in the no-epinephrine group survived 7 days after injury. The use of epinephrine was significantly associated with decreased 7-day survival (odds ratio = 0.20; 95% CI = 0.08–0.48; P < 0.01), and this result was confirmed by propensity score-matching analysis, in which 178 matched pairs were examined (adjusted odds ratio = 0.11; 95% CI = 0.01–0.85; P = 0.02).

Conclusions

The relationship between the use of epinephrine during resuscitation and decreased 7-day survival was found in patients with OHCA following trauma, and the propensity score-matched analyses validated the results. Resuscitation without epinephrine in traumatic OHCA should be further studied in a randomised controlled trial.

Incidence, Characteristics, and Survival Trend of Cardiopulmonary Resuscitation Following In-hospital Compared to Out-of-hospital Cardiac Arrest in Northern Jordan

BACKGROUND

Cardiac arrest remains a leading cause of mortality worldwide. Early cardiopulmonary resuscitation (CPR) is the cornerstone intervention to optimize the survival rates.

OBJECTIVES

The main aim of this study was to determine and compare the incidence, characteristics, risk factors, and outcomes of CPR in a referral university hospital following in-hospital cardiac arrests (IHCAs) and out-of-hospital cardiac arrest (OHCA) in Northern Jordan.

PATIENTS AND METHODS

Retrospective observational study of adults referred to King Abdulla University Hospital who received CPR between January 2014 and January 2015. Data were obtained from the medical recorded of included patients. The primary outcome was survival to hospital discharge. Chi-square and logistic regression analyses were performed to identify risk factors associated with survival to discharge.

RESULTS

A total of 79 OHCA and 257 IHCA were included in the study. The overall survival rate for OHCA was 2.97%. The survival rate increased to 4.3% if CPR performed before arriving the hospital. Only 22% of the OHCA cases had CPR performed mainly due to lack of knowledge and skills of bystanders. The survival rate for IHCA was 14.88%. In this study, patient survival was not associated with age, smoking habit, diabetes mellitus, cancer status, hypertension, or heart failure.

CONCLUSION

This is the first study to describe the incidence and outcome of adult IHCA and OHCA in Jordan. The findings will serve as a benchmark to evaluate future impact of changes in service delivery, organization, and treatment for OHCA and IHCA. Furthermore, findings will urge the regulatory bodies to establish well-structured Emergency Medical Service system. Educational programs at the national level to improve public awareness of CPR intervention are crucial to improve survival rates.

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.

Prognostic factors for death and survival with or without complications in cardiac arrest patients receiving CPR within 24 hours of anesthesia for emergency surgery

Purpose

To determine prognostic factors for death and survival with or without complications in cardiac arrest patients who received cardiopulmonary resuscitation (CPR) within 24 hours of receiving anesthesia for emergency surgery.

Patients and methods

A retrospective cohort study approved by the Maharaj Nakorn Chiang Mai University Hospital Ethical Committee. Data used were taken from records of 751 cardiac arrest patients who received their first CPR within 24 hours of anesthesia for emergency surgery between January 1, 2003 and October 31, 2011. The reviewed data included patient characteristics, surgical procedures, American Society of Anesthesiologist (ASA) physical status classification, anesthesia information, the timing of cardiac arrest, CPR details, and outcomes at 24 hours after CPR. Univariate and polytomous logistic regression analyses were used to determine prognostic factors associated with the outcome variable. P-values of less than 0.05 were considered statistically significant.

Results

The outcomes at 24 hours were death (638/751, 85.0%), survival with complications (73/751, 9.7%), and survival without complications (40/751, 5.3%). The prognostic factors associated with death were: age between 13–34 years (OR =3.08, 95% CI =1.03–9.19); ASA physical status three and higher (OR =6.60, 95% CI =2.17–20.13); precardiopulmonary comorbidity (OR =3.28, 95% CI =1.09–9.90); the condition of patients who were on mechanical ventilation prior to receiving anesthesia (OR =4.11, 95% CI =1.17–14.38); surgery in the upper abdominal site (OR =14.64, 95% CI =2.83–75.82); shock prior to cardiac arrest (OR =6.24, 95% CI =2.53–15.36); nonshockable electrocardiography (EKG) rhythm (OR =5.67, 95% CI =1.93–16.62); cardiac arrest occurring in postoperative period (OR =7.35, 95% CI =2.89–18.74); and duration of CPR more than 30 minutes (OR =4.32, 95% CI =1.39–13.45). The prognostic factors associated with survival with complications were being greater than or equal to 65 years of age (OR =4.30, 95% CI =1.13–16.42), upper abdominal site of surgery (OR =10.86, 95% CI =1.99–59.13), shock prior to cardiac arrest (OR =3.62, 95% CI =1.30–10.12), arrhythmia prior to cardiac arrest (OR =4.61, 95% CI =1.01–21.13), and cardiac arrest occurring in the postoperative period (OR =3.63, 95% CI =1.31–10.02).

Conclusion

The mortality and morbidity in patients who received anesthesia for emergency surgery within 24 hours of their first CPR were high, and were associated with identifiable patient comorbidity, age, shock, anatomic site of operation, the timing of cardiac arrest, EKG rhythm, and the duration of CPR. EKG monitoring helps to identify cardiac arrest quickly and diagnose the EKG rhythm as a shockable or nonshockable rhythm, with CPR being performed as per the American Heart Association (AHA) CPR Guidelines 2010. The use of the fast track system in combination with an interdisciplinary team for surgery, CPR, and postoperative care helps to rescue patients in a short time.

Factors influencing outcomes after cardiopulmonary resuscitation in emergency department

BACKGROUND

The outcome of cardiopulmonary resuscitation (CPR) may depend on a variety of factors related to patient status or resuscitation management. To evaluate the factors influencing the outcome of CPR after cardiac arrest (CA) will be conducive to improve the effectiveness of resuscitation. Therefore, a study was designed to assess these factors in the emergency department (ED) of a city hospital.

METHODS

A CPR registry conforming to the Utstein-style template was conducted in the ED of the First Affiliated Hospital of Wenzhou Medical College from January 2005 to December 2011. The outcomes of CPR were compared in various factors groups. The primary outcomes were rated to return of spontaneous circulation (ROSC), 24-hour survival, survival to discharge and discharge with favorable neurological outcomes. Univariate analysis and multivariable logistic regression analysis were performed to evaluate factors associated with survival.

RESULTS

A total of 725 patients were analyzed in the study. Of these patients, 187 (25.8%) had ROSC, 100 (13.8%) survived for 24 hours, 48 (6.6%) survived to discharge, and 23 (3.2%) survived to discharge with favorable neurologic outcomes. A logistic regression analysis demonstrated that the independent predictors of ROSC included traumatic etiology, first monitored rhythms, CPR duration, and total adrenaline dose. The independent predictors of 24-hour survival included traumatic etiology, cardiac etiology, first monitored rhythm and CPR duration. Previous status, cardiac etiology, first monitored rhythms and CPR duration were included in independent predictors of survival to discharge and neurologically favorable survival to discharge.

CONCLUSIONS

Shockable rhythms, CPR duration ≤15 minutes and total adrenaline dose ≤5 mg were favorable predictors of ROSC, whereas traumatic etiology was unfavorable. Cardiac etiology, shockable rhythms and CPR duration ≤15 minutes were favorable predictors of 24-hour survival, whereas traumatic etiology was unfavorable. Cardiac etiology, shockable rhythms, CPR duration ≤15 minutes were favorable predictors of survival to discharge and neurologically favorable survival to discharge, but previous terminal illness or multiple organ failure (MOF) was unfavorable.

The initial success rate of cardiopulmonary resuscitation and its associated factors in patients with cardiac arrest within 24 hours after anesthesia for an emergency surgery

PURPOSE

To determine the initial success rate and its associated factors on cardiopulmonary resuscitation (CPR) in patients with cardiac arrest within 24 hours after receiving anesthesia for an emergency surgery.

PATIENTS AND METHODS

After the hospital ethical committee gave approval for this study, the anesthesia providers recorded all relevant data regarding CPR in patients with cardiac arrest within 24 hours after anesthesia for emergency surgery at Maharaj Nakorn Chiang Mai Hospital, a university hospital in Northern Thailand. Only data from the cardiac arrest patients who received the first CPR attempt were included in the analysis. The end point of the initial success of CPR was return of spontaneous circulation (ROSC). Factors related to ROSC were determined by univariate analyses and multiple logistic regression analysis. The odds ratios (OR) and 95% confidence intervals (CI) were used to calculate the strength of the factors associated with the ROSC.

RESULTS

Of the 96 cardiac arrest patients, 44 patients (45.8%) achieved ROSC. Factors associated with ROSC were electrocardiogram monitoring for detected cardiac arrest (OR =4.03; 95% CI =1.16-14.01; P=0.029), non-shock patients before arrest (OR =8.54; 95% CI =2.13-34.32; P=0.003), timing to response of activated CPR team within 1 minute (OR =9.37; 95% CI =2.55-34.39; P<0.001), having trained CPR teams (OR =8.76; 95% CI =2.50-30.72; P<0.001), and administration of more than one dose of epinephrine (OR =5.62; 95% CI =1.32-23.88; P<0.019).

CONCLUSION

Patients undergoing anesthesia for an emergency surgery are at risk for perioperative cardiac arrest with high mortality which requires immediate CPR. Our results have confirmed that early detection of cardiac arrest by vigilant electrocardiogram monitoring and prompt management with a qualified team are important factors in improving the success of CPR. Emergency surgical patients at risk for cardiac arrest should be promptly managed, with facilities available not only during the operation but also during the pre- to postoperative period.

Intraoperative cardiac arrest and mortality in trauma patients. A 14-yr survey from a Brazilian tertiary teaching hospital

BACKGROUND

Little information on the factors influencing intraoperative cardiac arrest and its outcomes in trauma patients is available. This survey evaluated the associated factors and outcomes of intraoperative cardiac arrest in trauma patients in a Brazilian teaching hospital between 1996 and 2009.

METHODS

Cardiac arrest during anesthesia in trauma patients was identified from an anesthesia database. The data collected included patient demographics, ASA physical status classification, anesthesia provider information, type of surgery, surgical areas and outcome. All intraoperative cardiac arrests and deaths in trauma patients were reviewed and grouped by associated factors and also analyzed as totally anesthesia-related, partially anesthesia-related, totally surgery-related or totally trauma patient condition-related.

FINDINGS

Fifty-one cardiac arrests and 42 deaths occurred during anesthesia in trauma patients. They were associated with male patients (P<0.001) and young adults (18-35 years) (P=0.04) with ASA physical status IV or V (P<0.001) undergoing gastroenterological or multiclinical surgeries (P<0.001). Motor vehicle crashes and violence were the main causes of trauma (P<0.001). Uncontrolled hemorrhage or head injury were the most significant associated factors of intraoperative cardiac arrest and mortality (P<0.001). All cardiac arrests and deaths reported were totally related to trauma patient condition.

CONCLUSIONS

Intraoperative cardiac arrest and mortality incidence was highest in male trauma patients at a younger age with poor clinical condition, mainly related to uncontrolled hemorrhage and head injury, resulted from motor vehicle accidents and violence.

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.