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Obara T, Yumoto T, Bunya N, Nojima T, Hiraoka T, Hongo T, Kosaki Y, Tsukahara K, Uehara T, Nakao A, Naito H. Association between signs of life and survival in traumatic cardiac arrest patients: A nationwide, retrospective cohort study. Resusc Plus 2024; 19:100701. [PMID: 39040823 PMCID: PMC11260566 DOI: 10.1016/j.resplu.2024.100701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/08/2024] [Accepted: 06/14/2024] [Indexed: 07/24/2024] Open
Abstract
Background The clinical impact of signs of life (SOLs) in traumatic cardiac arrest (TCA) remains to be elucidated. The aim of this study was to examine the association between SOLs and survival/neurological outcomes in TCA patients. Methods Retrospective data from the Japan Trauma Data Bank (2019-2021) was reviewed. TCA patients were assigned to one of two study groups based on the presence or absence of SOLs and compared. SOLs were defined as having at least one of following criteria: pulseless electrical activity >40 beats per minute, gasping, positive light reflex, or extremity/eye movement at hospital arrival. The primary outcome was survival at hospital discharge. The secondary outcome was favorable neurological status (Glasgow Outcome Scale score of 4 or 5) at hospital discharge. Results A total of 1,981 patients (114 with SOLs and 1,867 without SOLs) were included. Characteristics of patients were as follows: age (median age 60.0 years old [interquartile range: 41-80] years vs. 55.4 [38-75] years), gender (male: 76/114 (66.7%) vs. 1,207/1,867 (65.0%), blunt trauma (90/111 [81.1%] vs. 1,559/1,844 [84.5%]), Injury Severity Score (29.2 [22-41] vs. 27.9 [20-34]). Patients with SOLs showed higher survival (10/114 (8.8%) vs. 25/1,867 (1.3%), OR 1.96 [CI 1.20-2.72]) and higher favorable neurological outcomes (4/110 (3.5%) vs. 6/1,865 (0.3%), OR 2.42 [CI 1.14-3.70]) compared with patients without SOLs. Conclusions TCA patients with SOLs at hospital arrival showed higher survival and favorable neurological outcomes at hospital discharge compared with TCA patients without SOLs.
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Affiliation(s)
- Takafumi Obara
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Naofumi Bunya
- Department of Emergency Medicine, Sapporo Medical University, Minami 1 Jo-nishi 17 chuo-ku, Sapporo 060-8556, Japan
| | - Tsuyoshi Nojima
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Tomohiro Hiraoka
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Yoshinori Kosaki
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Kohei Tsukahara
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Takenori Uehara
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
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2
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Al-Fadhl MD, Karam MN, Chen J, Zackariya SK, Lain MC, Bales JR, Higgins AB, Laing JT, Wang HS, Andrews MG, Thomas AV, Smith L, Fox MD, Zackariya SK, Thomas SJ, Tincher AM, Al-Fadhl HD, Weston M, Marsh PL, Khan HA, Thomas EJ, Miller JB, Bailey JA, Koenig JJ, Waxman DA, Srikureja D, Fulkerson DH, Fox S, Bingaman G, Zimmer DF, Thompson MA, Bunch CM, Walsh MM. Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock. J Clin Med 2024; 13:3915. [PMID: 38999481 PMCID: PMC11242176 DOI: 10.3390/jcm13133915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/08/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.
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Affiliation(s)
- Mahmoud D Al-Fadhl
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Marie Nour Karam
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Jenny Chen
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Sufyan K Zackariya
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Morgan C Lain
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - John R Bales
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Alexis B Higgins
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Jordan T Laing
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Hannah S Wang
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Madeline G Andrews
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Anthony V Thomas
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Leah Smith
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Mark D Fox
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Saniya K Zackariya
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Samuel J Thomas
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Anna M Tincher
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Hamid D Al-Fadhl
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - May Weston
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Phillip L Marsh
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Hassaan A Khan
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Emmanuel J Thomas
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Jason A Bailey
- Department of Emergency Medicine, Elkhart General Hospital, Elkhart, IN 46515, USA
| | - Justin J Koenig
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Dan A Waxman
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46601, USA
- Versiti Blood Center of Indiana, Indianapolis, IN 46208, USA
| | - Daniel Srikureja
- Department of Surgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Daniel H Fulkerson
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Sarah Fox
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Greg Bingaman
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Donald F Zimmer
- Department of Emergency Medicine, Memorial Hospital, South Bend, IN 46601, USA
| | - Mark A Thompson
- Department of Surgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Mark M Walsh
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
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Sumer RW, Woods WA. Cardiac Arrest in Special Populations. Cardiol Clin 2024; 42:289-306. [PMID: 38631796 DOI: 10.1016/j.ccl.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Best practices in cardiac arrest depend on continuous high-quality chest compressions, appropriate ventilatory management, early defibrillation of shockable rhythms, and identification and treatment of reversible causes. Although most patients can be treated according to highly vetted treatment guidelines, some special situations in cardiac arrest arise where additional skills and preparation can improve outcomes. Situations covered in this section involve cardiac arrest in context of electrical injuries, asthma, allergic reactions, pregnancy, trauma, electrolyte imbalances, toxic exposures, hypothermia, drowning, pulmonary embolism, and left ventricular assist devices.
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Affiliation(s)
- Ravi W Sumer
- Department of Emergency Medicine, 4601 Dale Road, Modesto, CA 95356-8713, USA.
| | - William A Woods
- Department of Emergency Medicine, University of Virginia Health System, PO Box 800699, Charlottesville, VA 22908-0699, USA
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Choi Y, Park JH, Ro YS, Jeong J, Kim YJ, Song KJ, Shin SD. Seat belt use and cardiac arrest immediately after motor vehicle collision: Nationwide observational study. Heliyon 2024; 10:e25336. [PMID: 38356526 PMCID: PMC10864909 DOI: 10.1016/j.heliyon.2024.e25336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 12/25/2023] [Accepted: 01/24/2024] [Indexed: 02/16/2024] Open
Abstract
Objective Motor vehicle collisions (MVCs) are known to cause traumatic cardiac arrest; it is unclear whether seat belts prevent this. This study aimed to evaluate the association between seat belt use and immediate cardiac arrest in cases of MVCs. Method This cross-sectional observational study used data from a nationwide EMS-based severe trauma registry in South Korea. The sample comprised adult patients with EMS-assessed severe trauma due to MVCs between 2018 and 2019. The primary, secondary, and tertiary outcomes were immediate cardiac arrest, in-hospital mortality, and death or severe disability, respectively. We calculated the adjusted odds ratios (AORs) of immediate cardiac arrest with seat belt use after adjusting for potential confounders. Results Among the 8178 eligible patients, 6314 (77.2 %) and 1864 (29.5 %) were wearing and not wearing seat belts, respectively. Immediate cardiac arrest, mortality, and death/severe disability rates were higher in the "no seat belt use" group than in the "seat belt use" group (9.4 % vs. 4.0 %, 12.4 % vs. 6.2 %, 17.7 % vs. 9.9 %, respectively; p < 0.001). The former group was more likely to experience immediate cardiac arrest (AOR [95 %CI]: 3.29 [2.65-4.08]), in-hospital mortality (AOR [95 %CI]: 2.72 [2.26-3.27]), and death or severe disability (AOR [95 %CI]: 2.40 [2.05-2.80]). Conclusion There was an association between wearing seat belts during MVCs and a reduced risk of immediate cardiac arrest.
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Affiliation(s)
- Yeongho Choi
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
| | - Jeong Ho Park
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Joo Jeong
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
| | - Yu Jin Kim
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Sang Do Shin
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
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5
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Schober P, Giannakopoulos GF, Bulte CSE, Schwarte LA. Traumatic Cardiac Arrest-A Narrative Review. J Clin Med 2024; 13:302. [PMID: 38256436 PMCID: PMC10816125 DOI: 10.3390/jcm13020302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
A paradigm shift in traumatic cardiac arrest (TCA) perception switched the traditional belief of futility of TCA resuscitation to a more optimistic perspective, at least in selected cases. The goal of TCA resuscitation is to rapidly and aggressively treat the common potentially reversible causes of TCA. Advances in diagnostics and therapy in TCA are ongoing; however, they are not always translating into improved outcomes. Further research is needed to improve outcome in this often young and previously healthy patient population.
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Affiliation(s)
- Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Center, 1081 HV Amsterdam, The Netherlands; (P.S.)
- Helicopter Emergency Medical Service‚ Lifeliner 1, 1044 AN Amsterdam, The Netherlands
| | - Georgios F. Giannakopoulos
- Helicopter Emergency Medical Service‚ Lifeliner 1, 1044 AN Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Carolien S. E. Bulte
- Department of Anesthesiology, Amsterdam University Medical Center, 1081 HV Amsterdam, The Netherlands; (P.S.)
- Helicopter Emergency Medical Service‚ Lifeliner 1, 1044 AN Amsterdam, The Netherlands
| | - Lothar A. Schwarte
- Department of Anesthesiology, Amsterdam University Medical Center, 1081 HV Amsterdam, The Netherlands; (P.S.)
- Helicopter Emergency Medical Service‚ Lifeliner 1, 1044 AN Amsterdam, The Netherlands
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6
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Chang YR, Kuo LW, Hsu TA, Tee YS, Fu CY, Bajani F, Mis J, Poulakidas S, Bokhari F. The Role of Open Cardiopulmonary Resuscitation in Chest Trauma Patients with No Sign of Life: A National Trauma Data Bank Study. World J Surg 2023; 47:3107-3113. [PMID: 37740005 DOI: 10.1007/s00268-023-07180-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 09/24/2023]
Abstract
PURPOSE The effectiveness of open cardiopulmonary resuscitation (OCPR) remains controversial for trauma patients. In this current study, the role of OCPR in managing chest trauma patients is evaluated using nationwide real-world data. METHODS From 2014 to 2015, the National Trauma Data Bank was retrospectively queried for chest trauma patients with out-of-hospital cardiac arrest status. The emergency department (ED) and overall survival of patients without signs of life were analyzed. Multivariate logistic regression (MLR) analysis was performed to evaluate independent factors of mortality for the target group. Furthermore, a subset group of patients who survived after the ED were studied, focusing on the duration of survival after leaving the ED. RESULTS A total of 911 patients were enrolled in this study (OCPR vs. non-OCPR: 161 patients vs. 750 patients). The average overall mortality rate was 98.6% (N = 898). Among penetrating chest trauma patients, non-survivors in the ED had significantly higher proportions of gunshot injuries (83.9% vs. 69.7%, p = 0.001) and lower proportions of OCPR (20.7% vs. 44.4%, p < 0.001). MLR analysis showed that gunshot injuries and non-OCPR were significantly related to ED mortality in penetrating trauma patients without signs of life (odds ratio = 2.039, p = 0.006 and odds ratio = 2.900, p < 0.001, respectively). However, the overall survival rate of patients after ED survival (n = 99) was 9.9%, and only 21.2% (n = 21) of them survived more than 1 day after leaving the ED. CONCLUSION OCPR could be considered in situations where appropriate indications exist. The survival benefit was observed in critically ill patients with penetrating chest trauma who show no signs of life. By enhancing ED survival, OCPR may also contribute to overall survival improvement.
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Affiliation(s)
- Yau-Ren Chang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
| | - Yu-San Tee
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan.
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA.
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Justin Mis
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
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Kuo YC, Chien CY, Li PH, Hsu TA, Fu CY, Bajani F, Mis J, Poulakidas S, Bokhari F. Validation of the Twenty-Four-Hour Threshold for Bladder Repair: Impact on Infection Rates Using the National Trauma Data Bank. World J Surg 2023; 47:3116-3123. [PMID: 37851065 DOI: 10.1007/s00268-023-07224-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE This study aimed to validate the previously reported association between delayed bladder repair and increased infection rates using the National Trauma Data Bank (NTDB). METHODS Bladder injury patients with bladder repair in the NTDB from 2013 to 2015 were included. Propensity score matching (PSM) was used to compare mortality, infection rates, and hospital length of stay (LOS) between patients who underwent bladder repair within 24 h and those who underwent repair after 24 h. Linear regression and multivariate logistic regression analyses were also performed. RESULTS A total of 1658 patients were included in the study. Patients who underwent bladder repair after 24 h had significantly higher infection rates (5.4% vs. 1.2%, p = 0.032) and longer hospital LOS (17.1 vs. 14.0 days, p = 0.032) compared to those who underwent repair within 24 h after a well-balanced 1:1 PSM (N = 166). Linear regression analysis showed a positive correlation between time to bladder repair and hospital LOS for patients who underwent repair after 24 h (B-value = 0.093, p = 0.034). Multivariate logistic regression analysis indicated that bladder repair after 24 h increased the risk of infection (odds = 3.162, p = 0.018). Subset analyses were performed on patients who underwent bladder repairs within 24 h and were used as a control group. These analyses showed that the time to bladder repair did not significantly worsen outcomes. CONCLUSIONS Delayed bladder repair beyond 24 h increases the risk of infection and prolongs hospital stays. Timely diagnosis and surgical intervention remain crucial for minimizing complications in bladder injury patients.
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Affiliation(s)
- Yu-Chi Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Branch, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Ying Chien
- Department of General Surgery, Chang Gung Memorial Hospital, Keelung Branch, Chang Gung University, Keelung, Taiwan
| | - Pei-Hua Li
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Branch, Chang Gung University, Taoyuan, Taiwan
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Branch, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Branch, Chang Gung University, Taoyuan, Taiwan.
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Justin Mis
- Department of Trauma and Burn Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Faran Bokhari
- Emergency Surgical Services, St. Francis Hospital, OSF Healthcare System, Peoria, IL, USA
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Perlman R, Tsai K, Lo J. Trauma Anesthesiology Perioperative Management Update. Adv Anesth 2023; 41:143-162. [PMID: 38251615 DOI: 10.1016/j.aan.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
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.
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Affiliation(s)
- Ryan Perlman
- Trauma Anesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA.
| | - Kevin Tsai
- Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
| | - Jessie Lo
- Trauma Education Program, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
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9
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Lugnet V, McDonough M, Gordon L, Galindez M, Mena Reyes N, Sheets A, Zafren K, Paal P. Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations. High Alt Med Biol 2023; 24:274-286. [PMID: 37733297 DOI: 10.1089/ham.2023.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
Lugnet, Viktor, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, and Peter Paal. Termination of cardiopulmonary resuscitation in mountain rescue: a scoping review and ICAR MedCom 2023 recommendations. High Alt Med Biol. 24:274-286, 2023. Background: In 2012, the International Commission for Mountain Emergency Medicine (ICAR MedCom) published recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue. New developments have necessitated an update. This is the 2023 update for termination of CPR in mountain rescue. Methods: For this scoping review, we searched the PubMed and Cochrane libraries, updated the recommendations, and obtained consensus approval within the writing group and the ICAR MedCom. Results: We screened a total of 9,102 articles, of which 120 articles met the inclusion criteria. We developed 17 recommendations graded according to the strength of recommendation and level of evidence. Conclusions: Most of the recommendations from 2012 are still valid. We made minor changes regarding the safety of rescuers and responses to primary or traumatic cardiac arrest. The criteria for termination of CPR remain unchanged. The principal changes include updated recommendations for mechanical chest compression, point of care ultrasound (POCUS), extracorporeal life support (ECLS) for hypothermia, the effects of water temperature in drowning, and the use of burial times in avalanche rescue.
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Affiliation(s)
- Viktor Lugnet
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Anesthesiology and Intensive Care, Östersund Hospital, Östersund, Sweden
- Swedish Mountain Guides Association (SBO), Gällivare, Sweden
| | - Miles McDonough
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Emergency Medicine, UCSF Fresno, Fresno, California, USA
| | - Les Gordon
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Langdale Ambleside Mountain Rescue Team, Ambleside, United Kingdom
- Department of Anaesthesia, University Hospitals of Morecambe Bay Trust, Lancaster, United Kingdom
| | - Mercedes Galindez
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Internal Medicine, Hospital Zonal Ramón Carrillo, San Carlos de Bariloche, Argentina
- Comisión de Auxilio Club Andino Bariloche, San Carlos de Bariloche, Argentina
| | - Nicolas Mena Reyes
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Emergency Medicine, Sótero del Río Hospital, Santiago de Chile, Chile
- Grupo de Rescate Médico en Montaña (GREMM), Santiago, Chile
- Emegency Medicine Section, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alison Sheets
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Emergency Medicine, Boulder Community Health, Boulder, Colorado, USA
- Wilderness Medicine Section, University of Colorado Health Sciences Center, Aurora, Colorado, USA
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Himalayan Rescue Association, Kathmandu, Nepal
- Department of Emergency Medicine, Stanford University Medical Center, Stanford, California, USA
- Alaska Native Medical Center, Anchorage, Alaska, USA
| | - Peter Paal
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
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10
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Serpa E, Zimmerman SO, Bauman ZM, Kulvatunyou N. A Contemporary Study of Pre-hospital Traumatic Cardiac Arrest: Distinguishing Exsanguination From Non-exsanguination Arrest With a Review of Current Literature. Cureus 2023; 15:e48181. [PMID: 38046709 PMCID: PMC10693434 DOI: 10.7759/cureus.48181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
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.
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Affiliation(s)
- Eduardo Serpa
- Surgery, Central Michigan University College of Medicine, Saginaw, USA
| | - Steve O Zimmerman
- Acute Care Surgery, University of Arizona College of Medicine-Tucson, Tucson, USA
| | | | - Narong Kulvatunyou
- Acute Care Surgery, University of Arizona College of Medicine-Tucson, Tucson, USA
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11
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Talmy T, Greenstein I, Gendler S, Chayen D, Radomislensky I, Ahimor A, Koler T, Glassberg E, Almog O. Survival following Prehospital Traumatic Cardiac Arrest Resuscitation in the Israel Defense Forces: A Retrospective Study. PREHOSP EMERG CARE 2023; 28:438-447. [PMID: 37578901 DOI: 10.1080/10903127.2023.2241542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/12/2023] [Accepted: 07/20/2023] [Indexed: 08/16/2023]
Abstract
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.
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Affiliation(s)
- Tomer Talmy
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University, Jerusalem, Israel
| | - Ithamar Greenstein
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - David Chayen
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University, Jerusalem, Israel
| | - Irina Radomislensky
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Alon Ahimor
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Tomer Koler
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Elon Glassberg
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Ofer Almog
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University, Jerusalem, Israel
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12
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Sumer RW, Woods WA. Cardiac Arrest in Special Populations. Emerg Med Clin North Am 2023; 41:485-508. [PMID: 37391246 DOI: 10.1016/j.emc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Best practices in cardiac arrest depend on continuous high-quality chest compressions, appropriate ventilatory management, early defibrillation of shockable rhythms, and identification and treatment of reversible causes. Although most patients can be treated according to highly vetted treatment guidelines, some special situations in cardiac arrest arise where additional skills and preparation can improve outcomes. Situations covered in this section involve cardiac arrest in context of electrical injuries, asthma, allergic reactions, pregnancy, trauma, electrolyte imbalances, toxic exposures, hypothermia, drowning, pulmonary embolism, and left ventricular assist devices.
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Affiliation(s)
- Ravi W Sumer
- Department of Emergency Medicine, 4601 Dale Road, Modesto, CA 95356-8713, USA.
| | - William A Woods
- Department of Emergency Medicine, University of Virginia Health System, PO Box 800699, Charlottesville, VA 22908-0699, USA
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13
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Stewart S, Briggs KB, Fraser JA, Svetanoff WJ, Waddell V, Oyetunji TA. Pre-hospital CPR after traumatic arrest: Outcomes at a level 1 pediatric trauma center. Injury 2023; 54:15-18. [PMID: 36229246 DOI: 10.1016/j.injury.2022.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 09/21/2022] [Accepted: 09/28/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The survival of traumatic cardiopulmonary arrest (TCA) requiring pre-hospital cardiopulmonary resuscitation (P-CPR) is abysmal across age groups. We aim to describe the mechanisms of injury and outcomes of children suffering from TCA leading to P-CPR at our institution. METHODS A retrospective review was conducted to identify children ages 0-17 years who suffered TCA leading to P-CPR at our institution between 5/2009 and 3/2020. For analysis, patients were stratified into those still undergoing CPR at arrival and those who attained pre-hospital return of spontaneous circulation (ROSC). Primary outcome was discharge alive from the hospital. RESULTS P-CPR was initiated for 48 patients who had TCA; 23 had pre-hospital ROSC. Of the 25 children undergoing CPR at presentation, none survived to discharge. The median duration of CPR, from initiation to time of death declaration was 34 min [29,50]. Seventeen patients died after resuscitation attempts in the ED, while 8 died after admission to the PICU. Of the 23 patients who attained pre-hospital ROSC, 6 survived to discharge. All survivors required intensive rehabilitation services at discharge and at most recent follow-up, 5 had residual deficits requiring medical attention. CONCLUSION There are poor outcomes in children with pre-hospital traumatic cardiopulmonary arrest, particularly in those without pre-hospital ROSC. These data further support the need for standardized guidelines for resuscitation in children with traumatic cardiopulmonary arrest.
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Affiliation(s)
- Shai Stewart
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States.
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States
| | - James A Fraser
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States
| | - Valerie Waddell
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Hospital, United States; Quality Improvement and Surgical Equity Research (QISER) Center, United States; School of Medicine, Kansas City University, United States
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14
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Seewald S, Wnent J, Gräsner JT, Tjelmeland I, Fischer M, Bohn A, Bouillon B, Maurer H, Lefering R. Survival after traumatic cardiac arrest is possible—a comparison of German patient-registries. BMC Emerg Med 2022; 22:158. [PMID: 36085024 PMCID: PMC9463728 DOI: 10.1186/s12873-022-00714-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/31/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Out-of-hospital cardiac arrest (OHCA) due to trauma is rare, and survival in this group is infrequent. Over the last decades, several new procedures have been implemented to increase survival, and a “Special circumstances chapter” was included in the European Resuscitation Council (ERC) guidelines in 2015. This article analysed outcomes after traumatic cardiac arrest in Germany using data from the German Resuscitation Registry (GRR) and the TraumaRegister DGU® (TR-DGU) of the German Trauma Society.
Methods
In this study, data from patients with OHCA between 01.01.2014 and 31.12.2019 secondary to major trauma and where cardiopulmonary resuscitation (CPR) was started were eligible for inclusion. Endpoints were return of spontaneous circulation (ROSC), hospital admission with ROSC and survival to hospital discharge.
Results
1.049 patients were eligible for inclusion. ROSC was achieved in 28.7% of the patients, 240 patients (22.9%) were admitted to hospital with ROSC and 147 (14.0%) with ongoing CPR. 643 (67.8%) patients were declared dead on scene. Of all patients resuscitated after traumatic OHCA, 27.3% (259) died in hospital. The overall mortality was 95.0% and 5.0% survived to hospital discharge (47). In a multivariate logistic regression analysis; age, sex, injury severity score (ISS), head injury, found in cardiac arrest, shock on admission, blood transfusion, CPR in emergency room (ER), emergency surgery and initial electrocardiogram (ECG), were independent predictors of mortality.
Conclusion
Traumatic cardiac arrest was an infrequent event with low overall survival. The mortality has remained unchanged over the last decades in Germany. Additional efforts are necessary to identify reversible cardiac arrest causes and provide targeted trauma resuscitation on scene.
Trial registration
DRKS, DRKS-ID DRKS00027944. Retrospectively registered 03/02/2022.
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15
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Lee MHM, Chia MYC, Fook-Chong S, Shahidah N, Tagami T, Ryu HH, Lin CH, Karim SA, Jirapong S, Rao HVR, Cai W, Velasco BP, Khan NU, Son DN, Naroo GY, El Sayed M, Ong MEH. Characteristics and Outcomes of Traumatic Cardiac Arrests in the Pan-Asian Resuscitation Outcomes Study. PREHOSP EMERG CARE 2022; 27:978-986. [PMID: 35994382 DOI: 10.1080/10903127.2022.2113941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
| | | | - Stephanie Fook-Chong
- Prehospital Emergency & Research Centre, Duke-NUS Medical School, Singapore, Singapore
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Hyun Ho Ryu
- Department of Emergency Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Sarah Abdul Karim
- Department of Emergency Medicine, Hospital Sungai Buloh, Selangor, Malaysia
| | | | - H V Rajanarsing Rao
- Emergency Medicine Learning Centre, GVK Emergency Management and Research Institute, Secunderabad, Telangana, India
| | - Wenwei Cai
- Department of Emergency Medicine, Zhejiang Provincial People's Hospital, Zhejiang, China
| | | | - Nadeem Ullah Khan
- Department of Emergency Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Do Ngoc Son
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - G Y Naroo
- ED-Trauma Centre, Rashid Hospital, Dubai, United Arab Emirates
| | - Mazen El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Health Services and Systems Research, Singapore, Singapore
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16
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Prehospital care for traumatic cardiac arrest in the US: A cross-sectional analysis and call for a national guideline. Resuscitation 2022; 179:97-104. [PMID: 35970396 DOI: 10.1016/j.resuscitation.2022.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/01/2022] [Accepted: 08/07/2022] [Indexed: 11/21/2022]
Abstract
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.
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17
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Madurska MJ, Abdou H, Elansary NN, Edwards J, Patel N, Stonko DP, Richmond MJ, Scalea TM, Rasmussen TE, Morrison JJ. Whole Blood Selective Aortic Arch Perfusion for Exsanguination Cardiac Arrest: Assessing Myocardial Tolerance to the Duration of Cardiac Arrest. Shock 2022; 57:243-250. [PMID: 35759304 DOI: 10.1097/shk.0000000000001946] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Selective aortic arch perfusion (SAAP) is an endovascular technique that consists of aortic occlusion with perfusion of the coronary and cerebral circulation. It been shown to facilitate return of spontaneous circulation (ROSC) after exanguination cardiac arrest (ECA), but it is not known how long arrest may last before the myocardium can no longer be durably recovered. The aim of this study is to assess the myocardial tolerance to exsanguination cardiac arrest before successful ROSC with SAAP. METHODS Male adult swine (n = 24) were anesthetized, instrumented, and hemorrhaged to arrest. Animals were randomized into three groups: 5, 10, and 15 min of cardiac arrest before resuscitation with SAAP. Following ROSC, animals were observed for 60 min in a critical care environment. Primary outcomes were ROSC, and survival at 1-h post-ROSC. RESULTS Shorter cardiac arrest time was associated with higher ROSC rate and better 1-h survival. ROSC was obtained for 100% (8/8) of the 5-min ECA group, 75% (6/8) of the 10-min group, 43% (3/7) of the 15-min group (P = 0.04). One-hour post-ROSC survival was 75%, 50%, and 14% in 5-, 10-, and 15-min groups, respectively (P = 0.02). One-hour survivors in the 5-min group required less norepinephrine (1.31 mg ± 0.83 mg) compared with 10-SAAP (0.76 mg ± 0.24 mg), P = 0.008. CONCLUSION Whole blood SAAP can accomplish ROSC at high rates even after 10 min of unsupported cardiac arrest secondary to hemorrhage, with some viability beyond to 15 min. This is promising as a tool for ECA, but requires additional optimization and clinical trials.Animal Use Protocol, IACUC: 0919015.
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Affiliation(s)
- Marta J Madurska
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Noha N Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Neerav Patel
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - David P Stonko
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael J Richmond
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
| | - Thomas M Scalea
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jonathan J Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
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18
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Fierro NM, Dhillon NK, Yong FA, Muniz T, Siletz AE, Barmparas G, Ley EJ. No Resuscitative Thoracotomy? When to Stop Chest Compressions After Prehospital Traumatic Cardiac Arrest. Am Surg 2022; 88:2464-2469. [PMID: 35549924 DOI: 10.1177/00031348221101500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Nicole M Fierro
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Felix A Yong
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tobias Muniz
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anaar E Siletz
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Crabb DB, Elmelige YO, Gibson ZC, Ralston DC, Harrell C, Cohen SA, Fitzpatrick DE, Becker TK. Unrecognized cardiac arrests: A one-year review of audio from emergency medical dispatch calls. Am J Emerg Med 2022; 54:127-130. [DOI: 10.1016/j.ajem.2022.01.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 01/23/2022] [Accepted: 01/30/2022] [Indexed: 01/14/2023] Open
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20
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Prehospital Factors Associated with Refractory Traumatic Arrest. Emerg Med Int 2021; 2021:4624746. [PMID: 34966563 PMCID: PMC8712169 DOI: 10.1155/2021/4624746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/07/2021] [Indexed: 12/02/2022] Open
Abstract
Objective Identification of the prehospital factors associated with a poor prognosis of immediate traumatic arrest should help reduce unwarranted treatment. We aim to reveal the clinical factors related to death after traumatic arrest on the scene. Methods We performed a multicenter (4 tertiary hospitals in urban areas of South Korea) retrospective study on consecutive adult patients with trauma arrest on scene who were transferred by fire ambulance from January 2016 to December 2018. Patients with death on arrival in the emergency room (ER) were excluded. Prehospital data were collected from first aid records, and information on each patient's survival outcome in the ER was collected from an electronic database. Patients were divided into ER death and ER survival groups, and variables associated with prehospital trauma were compared. Results A total of 145 (84.3%) and 27 (15.7%) patients were enrolled in the ER death and survival groups, respectively. Logistic regression analysis revealed that asystole (OR 4.033, 95% CI 1.342–12.115, p = 0.013) was related to ER death and that ROSC in the prehospital phase (OR 0.100, 95% CI 0.012–0.839, p = 0.034) was inversely related to ER death. In subgroup analysis of those who suffered fall injuries, greater height of fall was associated with ER death (15.0 (5.5–25.0) vs. 4.0 (2.0–7.5) meters, p = 0.001); the optimal height cutoff for prediction of ER death was 10 meters, with 66.1% sensitivity and 100% specificity. Conclusions In cases of traumatic arrest, asystole, no prehospital ROSC, and falls from a greater height were associated with trauma death in the ER. Termination of resuscitation in traumatic arrest cases should be done on the basis of comprehensive clinical factors.
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21
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Tisherman SA. Emergency preservation and resuscitation for cardiac arrest from trauma. Ann N Y Acad Sci 2021; 1509:5-11. [PMID: 34859446 DOI: 10.1111/nyas.14725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/19/2021] [Accepted: 10/22/2021] [Indexed: 01/01/2023]
Abstract
Patients who suffer a cardiac arrest from trauma rarely survive. Surgical control of hemorrhage cannot be obtained in time to prevent irreversible organ damage. Emergency preservation and resuscitation (EPR) was developed to utilize hypothermia to buy time to achieve hemostasis and allow delayed resuscitation. Large animal studies have demonstrated that cooling to tympanic membrane temperature 10 °C during exsanguination cardiac arrest can allow up to 2 h of circulatory arrest and repair of simulated injuries with normal neurologic recovery. The Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma (EPR-CAT) trial is testing the feasibility and safety of initiating EPR. Study subjects include patients with penetrating trauma who lose a pulse within 5 minutes of hospital arrival and remain pulseless despite standard care. EPR is initiated via an intra-aortic flush of ice-cold saline solution. Following hemostasis, delayed resuscitation and rewarming are accomplished with cardiopulmonary bypass. The primary outcome is survival to hospital discharge without significant neurologic deficits. If trained team members are available, subjects can undergo EPR. If not, subjects can be enrolled as concurrent controls. Ten EPR and 10 control subjects will be enrolled. If successful, EPR could save the lives of trauma patients who are currently dying from exsanguinating hemorrhage.
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Affiliation(s)
- Samuel A Tisherman
- Department of Surgery and the Program in Trauma, University of Maryland School of Medicine, RA Cowley Shock Trauma Center, Baltimore, Maryland
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22
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Do SN, Luong CQ, Pham DT, Nguyen MH, Ton TT, Hoang QTA, Nguyen DT, Pham TTN, Hoang HT, Khuong DQ, Nguyen QH, Nguyen TA, Tran TT, Vu LD, Van Nguyen C, McNally BF, Ong MEH, Nguyen AD. Survival after traumatic out-of-hospital cardiac arrest in Vietnam: a multicenter prospective cohort study. BMC Emerg Med 2021; 21:148. [PMID: 34814830 PMCID: PMC8609736 DOI: 10.1186/s12873-021-00542-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 11/12/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Pre-hospital services are not well developed in Vietnam, especially the lack of a trauma system of care. Thus, the prognosis of traumatic out-of-hospital cardiac arrest (OHCA) might differ from that of other countries. Although the outcome in cardiac arrest following trauma is dismal, pre-hospital resuscitation efforts are not futile and seem worthwhile. Understanding the country-specific causes, risk, and prognosis of traumatic OHCA is important to reduce mortality in Vietnam. Therefore, this study aimed to investigate the survival rate from traumatic OHCA and to measure the critical components of the chain of survival following a traumatic OHCA in the country. METHODS We performed a multicenter prospective observational study of patients (> 16 years) presenting with traumatic OHCA to three central hospitals throughout Vietnam from February 2014 to December 2018. We collected data on characteristics, management, and outcomes of patients, and compared these data between patients who died before hospital discharge and patients who survived to discharge from the hospital. RESULTS Of 111 eligible patients with traumatic OHCA, 92 (82.9%) were male and the mean age was 39.27 years (standard deviation: 16.38). Only 5.4% (6/111) survived to discharge from the hospital. Most cardiac arrests (62.2%; 69/111) occurred on the street or highway, 31.2% (29/93) were witnessed by bystanders, and 33.7% (32/95) were given cardiopulmonary resuscitation (CPR) by a bystander. Only 29 of 111 patients (26.1%) were taken by the emergency medical services (EMS), 27 of 30 patients (90%) received pre-hospital advanced airway management, and 29 of 53 patients (54.7%) were given resuscitation attempts by EMS or private ambulance. No significant difference between patients who died before hospital discharge and patients who survived to discharge from the hospital was found for bystander CPR (33.7%, 30/89 and 33.3%, 2/6, P > 0.999; respectively) and resuscitation attempts (56.3%, 27/48, and 40.0%, 2/5, P = 0.649; respectively). CONCLUSION In this study, patients with traumatic OHCA presented to the ED with a low rate of EMS utilization and low survival rates. The poor outcomes emphasize the need for increasing bystander first-aid, developing an organized trauma system of care, and developing a standard emergency first-aid program for both healthcare personnel and the community.
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Affiliation(s)
- Son Ngoc Do
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam.,Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Chinh Quoc Luong
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam. .,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam. .,Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.
| | - Dung Thi Pham
- Department of Nutrition and Food Safety, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - My Ha Nguyen
- Department of Health Organization and Management, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Tra Thanh Ton
- Emergency Department, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Quoc Trong Ai Hoang
- Emergency Department, Hue Central General Hospital, Hue City, Thua Thien Hue, Vietnam
| | - Dat Tuan Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Thao Thi Ngoc Pham
- Intensive Care Department, Cho Ray Hospital, Ho Chi Minh City, Vietnam.,Department of Critical Care, Emergency Medicine and Clinical Toxicology, Faculty of Medicine, Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Hanh Trong Hoang
- Intensive Care Department, Hue Central General Hospital, Hue City, Thua Thien Hue, Vietnam.,Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Medicine and Pharmacy, Hue City, Thua Thien Hue, Vietnam
| | - Dai Quoc Khuong
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam
| | - Quan Huu Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Tuan Anh Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Tung Thanh Tran
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam
| | - Long Duc Vu
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam
| | - Chi Van Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Bryan Francis McNally
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Anh Dat Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, 100000, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
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23
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Shi D, McLaren C, Evans C. Neurological outcomes after traumatic cardiopulmonary arrest: a systematic review. Trauma Surg Acute Care Open 2021; 6:e000817. [PMID: 34796272 PMCID: PMC8573669 DOI: 10.1136/tsaco-2021-000817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/10/2021] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel Shi
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Christie McLaren
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Chris Evans
- Emergency Medicine, Queen's University, Kingston, Ontario, Canada
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24
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Mladinov D, Frank SM. Massive transfusion and severe blood shortages: establishing and implementing predictors of futility. Br J Anaesth 2021; 128:e71-e74. [PMID: 34794769 DOI: 10.1016/j.bja.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/16/2021] [Accepted: 10/03/2021] [Indexed: 11/02/2022] Open
Abstract
Massive transfusion protocols were developed to deliver blood for life-threatening haemorrhage; however, there are no guidelines to advise when massive transfusion protocols may be considered futile. Early recognition of clinical futility remains a challenge as studies have not identified variables that can accurately determine early mortality. As blood is a scarce resource, efforts to distribute it equitably to all patients who would benefit are of paramount importance. In this editorial we discuss recent data and various aspects important in developing and implementing tools that assist with determining futility in massive transfusion.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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25
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A point of entry into paediatric termination of resuscitation research. Resuscitation 2021; 169:182-184. [PMID: 34718081 DOI: 10.1016/j.resuscitation.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/22/2022]
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26
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Survival outcomes in emergency medical services witnessed traumatic out-of-hospital cardiac arrest after the introduction of a trauma-based resuscitation protocol. Resuscitation 2021; 168:65-74. [PMID: 34555487 DOI: 10.1016/j.resuscitation.2021.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 01/25/2023]
Abstract
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.
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27
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Harris MI, Crowe RP, Anders J, D'Acunto S, Adelgais KM, Fishe J. Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest. Resuscitation 2021; 169:175-181. [PMID: 34555488 DOI: 10.1016/j.resuscitation.2021.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/08/2021] [Accepted: 09/13/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Prehospital Termination of Resuscitation (TOR) protocols for adults can reduce the number of futile transports of patients in cardiac arrest, yet similar protocols are not widely available for paediatric out-of-hospital cardiac arrest (POHCA). The objective of this study was to apply a set of criteria for paediatric TOR (pTOR) from the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to a large national cohort and determine its association with return of spontaneous circulation (ROSC) after POHCA. METHODS We identified patients ages 0-17 treated by Emergency Medical Services (EMS) with cardiac arrest in 2019 from the ESO dataset and and applied the applicable pTOR certeria for medical or traumatic arrests. We calculated predictive test characteristics for the outcome of prehospital ROSC, stratified by medical and traumatic cause of arrest. RESULTS We analyzed records for 1595 POHCA patients. Eighty-eight percent (n = 1395) were classified as medical. ROSC rates were 23% among medical POHCA and 27% among traumatic POHCA. The medical criteria correctly classified >99% (322/323) of patients who achieved ROSC as ineligible for TOR. The trauma criteria correctly classified 93% (50/54) of patients with ROSC as ineligible for TOR. Of the five misclassified patients, three were involved in drowning incidents. CONCLUSIONS The Maryland pTOR criteria identified eligible patients who did not achieve prehospital ROSC, while reliably excluding those who did achieve prehospital ROSC. As most misclassified patients were victims of drowning, we recommend considering the exclusion of drowning patients from future pTOR guidelines. Further studies are needed to evaluate the long-term survival and neurologic outcome of patients misclassified by pTOR criteria.
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Affiliation(s)
- Matthew I Harris
- Northwell Hofstra School of Medicine, Departments of Paediatrics and Emergency, Medicine, New Hyde Park, NY, United States.
| | | | - Jennifer Anders
- Johns Hopkins School of Medicine, Department of Paediatrics, Baltimore, MD, United States
| | - Salvatore D'Acunto
- University of Florida College of Medicine - Jacksonville, Center for Data Solutions, Jacksonville, FL United States
| | - Kathleen M Adelgais
- University of Colorado School of Medicine, Department of Paediatrics, Section of Paediatric Emergency Medicine, Aurora, CO, United States
| | - Jennifer Fishe
- University of Florida College of Medicine - Jacksonville, Center for Data Solutions, Jacksonville, FL United States; University of Florida College of Medicine - Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States
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28
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Naito H, Yumoto T, Yorifuji T, Nojima T, Yamamoto H, Yamada T, Tsukahara K, Inaba M, Nishimura T, Uehara T, Nakao A. Association between emergency medical service transport time and survival in patients with traumatic cardiac arrest: a Nationwide retrospective observational study. BMC Emerg Med 2021; 21:104. [PMID: 34530735 PMCID: PMC8447624 DOI: 10.1186/s12873-021-00499-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 08/28/2021] [Indexed: 12/05/2022] Open
Abstract
Background Patients with traumatic cardiac arrest (TCA) are known to have poor prognoses. In 2003, the joint committee of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma proposed stopping unsuccessful cardiopulmonary resuscitation (CPR) sustained for > 15 min after TCA. However, in 2013, a specific time-limit for terminating resuscitation was dropped, due to the lack of conclusive studies or data. We aimed to define the association between emergency medical services transport time and survival to demonstrate the survival curve of TCA. Methods A retrospective review of the Japan Trauma Data Bank. Inclusion criteria were age ≥ 16, at least one trauma with Abbreviated Injury Scale score (AIS) ≥ 3, and CPR performed in a prehospital setting. Exclusion criteria were burn injury, AIS score of 6 in any region, and missing data. Estimated survival rate and risk ratio for survival were analyzed according to transport time for all patients. Analysis was also performed separately on patients with sustained TCA at arrival. Results Of 292,027 patients in the database, 5336 were included in the study with 4141 sustained TCA. Their median age was 53 years (interquartile range (IQR) 36–70), and 67.2% were male. Their median Injury Severity Score was 29 (IQR 22–41), and median transport time was 11 min (IQR 6–17). Overall survival after TCA was 4.5%; however, survival of patients with sustained TCA at arrival was only 1.2%. The estimated survival rate and risk ratio for sustained TCA rapidly decreased after 15 min of transport time, with estimated survival falling below 1%. Conclusion The chances of survival for sustained TCA declined rapidly while the patient is transported with CPR support. Time should be one reasonable factor for considering termination of resuscitation in patients with sustained TCA, although clinical signs of life, and type and severity of trauma should be taken into account clinically.
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Affiliation(s)
- Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan.
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Takashi Yorifuji
- Dentistry and Pharmaceutical Sciences, Department of Epidemiology, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Tsuyoshi Nojima
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Hirotsugu Yamamoto
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Taihei Yamada
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Kohei Tsukahara
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Mototaka Inaba
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Takeshi Nishimura
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan.,Hyogo Emergency Medical Center, Department of Emergency and Critical Care Medicine, Kobe, Hyogo, Japan
| | - Takenori Uehara
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan.,Dentistry and Pharmaceutical Sciences, Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
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29
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Lyng JW, Braithwaite S, Abraham H, Brent CM, Meurer DA, Torres A, Bui PV, Floccare DJ, Hogan AN, Fairless J, Larrimore A. Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA. PREHOSP EMERG CARE 2021; 25:854-873. [PMID: 34388053 DOI: 10.1080/10903127.2021.1967534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Air medical services involves providing medical care in transit while using either fixed wing (airplane) or rotor wing (helicopter) aircraft to move patients between locations. The modern use and availability of air medical services has expanded access to various health system resources, including specialty care. While this is generally beneficial, such expansion has also contributed to the complexity of health care delivery systems.(1, 2) Since the publication of the 2013 joint position statement Appropriate and Safe Utilization of Helicopter Emergency Medical Services,(3) research has shown that patient benefit is gained from the clinical care capabilities of air medical services independent of potential time saved when transporting patients.(4-6) Because the evidence basis for utilization of air medical services continues to evolve, NAEMSP, ACEP, and AMPA believe that an update regarding the appropriate utilization of air medical services is warranted, and that such guidance for utilization can be divided into three major categories: clinical considerations, safety considerations, and system integration and quality assurance considerations.
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Affiliation(s)
- John W Lyng
- University of Minnesota School of Medicine, Department of Emergency Medicine (NAEMSP)
| | - Sabina Braithwaite
- Washington University in Saint Louis School of Medicine, Department of Emergency Medicine (NAEMSP)
| | | | - Christine M Brent
- University of Michigan, Department of Emergency Medicine (NAEMSP, AMPA)
| | - David A Meurer
- University of Florida College of Medicine, Department of Emergency Medicine (NAEMSP)
| | - Alexander Torres
- Cleveland Clinic Florida, Department of Emergency Medicine (NAEMSP)
| | - Peter V Bui
- Augusta University, Department of Emergency Medicine (NAEMSP)
| | - Douglas J Floccare
- Maryland Institute for EMS Systems (MIEMSS), Maryland State Police Aviation Command, University of Maryland, Department of Emergency Medicine (AMPA)
| | - Andrew N Hogan
- UT Southwestern Medical Center, Department of Emergency Medicine (AMPA)
| | - Justin Fairless
- Texas Christian University and University of North Texas Health Science Center School of Medicine, Department of Emergency Medicine (ACEP)
| | - Ashley Larrimore
- The Ohio State University, Department of Emergency Medicine (NAEMSP)
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30
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
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).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Abdou H, Madurska MJ, Edwards J, Patel N, Richmond MJ, Galvagno S, Kundi R, DuBose JJ, Scalea TM, Morrison JJ. A technique for open chest selective aortic arch perfusion. J Trauma Acute Care Surg 2021; 90:e158-e162. [PMID: 33496546 DOI: 10.1097/ta.0000000000003092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hossam Abdou
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
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Shen P, Xu JF, Gao YZ, Xia SL, Liu SY, Zhang M. Establishment of a swine model of traumatic cardiac arrest induced by haemorrhage and ventricular fibrillation. J Int Med Res 2021; 48:300060520931260. [PMID: 32588703 PMCID: PMC7325463 DOI: 10.1177/0300060520931260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To establish and evaluate a swine model of traumatic cardiac arrest (TCA) induced by haemorrhage and ventricular fibrillation. METHODS Thirteen male pigs were divided into a sham group (n = 5) and TCA group (n = 8). Animals in the sham-operated group underwent intubation and monitoring but not haemorrhage and resuscitation, while animals in the TCA group underwent 40% blood volume haemorrhage over 20 min followed by 5 min of ventricular fibrillation and 5 min of cardiopulmonary resuscitation with fluid resuscitation. RESULTS Restoration of spontaneous circulation was achieved in seven of eight animals in the TCA group. After resuscitation, the heart rate was significantly increased while the mean arterial pressure and ejection fraction were significantly decreased in the TCA group. The TCA group had significant cardiac and neurological injuries post-resuscitation and had higher serum creatinine and blood lactic acid levels and lower PaO2 than the sham group. Animals in the TCA group also exhibited significantly higher apoptotic indices and caspase-3 protein levels in the heart, brain and kidney than the sham group. CONCLUSION Animals in this swine model of TCA exhibited high rates of successful resuscitation, significant vital organ injury and prolonged survival. The model is suitable for use in further TCA research.
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Affiliation(s)
- Peng Shen
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China.,Department of Intensive Care Unit, The First Hospital of Jiaxing, Jiaxing, Zhejiang Province, China
| | - Jie-Feng Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China.,Department of Emergency Medicine, Yuyao People's Hospital, Medical School of Ningbo University, Ningbo, Zhejiang Province, China
| | - Yu-Zhi Gao
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Sen-Lin Xia
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Shao-Yun Liu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 299] [Impact Index Per Article: 99.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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The Safety and Utility of Ground Transport of Traumatic Cardiopulmonary Arrest Patients by Helicopter Emergency Medical Services Crews. Air Med J 2021; 40:108-111. [PMID: 33637272 DOI: 10.1016/j.amj.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/30/2020] [Indexed: 11/22/2022]
Abstract
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.
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Alqudah Z, Nehme Z, Williams B, Oteir A, Bernard S, Smith K. Impact of a trauma-focused resuscitation protocol on survival outcomes after traumatic out-of-hospital cardiac arrest: An interrupted time series analysis. Resuscitation 2021; 162:104-111. [PMID: 33631292 DOI: 10.1016/j.resuscitation.2021.02.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/10/2021] [Accepted: 02/06/2021] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Zainab Alqudah
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Allied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan.
| | - Ziad Nehme
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Brett Williams
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Alaa Oteir
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Allied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Alfred Hospital, Prahran, Victoria, Australia
| | - Karen Smith
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
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Zhao Z, Liang JJ, Wang Z, Winans NJ, Morris M, Doyle S, Fry A, Fiore SM, Mofakham S, Mikell CB. Cardiac arrest after severe traumatic brain injury can be survivable with good outcomes. Trauma Surg Acute Care Open 2021; 6:e000638. [PMID: 33634211 PMCID: PMC7880094 DOI: 10.1136/tsaco-2020-000638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/12/2020] [Accepted: 01/17/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Zirun Zhao
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Justine J Liang
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Zhe Wang
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Nathan J Winans
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Matthew Morris
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Stephen Doyle
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Adam Fry
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Susan M Fiore
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Sima Mofakham
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Charles B Mikell
- Department of Neurosurgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
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Alqudah Z, Nehme Z, Williams B, Oteir A, Bernard S, Smith K. Impact of temporal changes in the epidemiology and management of traumatic out-of-hospital cardiac arrest on survival outcomes. Resuscitation 2020; 158:79-87. [PMID: 33253769 DOI: 10.1016/j.resuscitation.2020.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/07/2020] [Accepted: 11/11/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Zainab Alqudah
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Allied Medical Sciences, Applied Medical Sciences College, Jordan University of Science and Technology, Irbid, Jordan.
| | - Ziad Nehme
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Brett Williams
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Alaa Oteir
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Allied Medical Sciences, Applied Medical Sciences College, Jordan University of Science and Technology, Irbid, Jordan
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Alfred Hospital, Prahran, Victoria, Australia
| | - Karen Smith
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
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Schön CA, Gordon L, Hölzl N, Milani M, Paal P, Zafren K. Determination of Death in Mountain Rescue: Recommendations of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Wilderness Environ Med 2020; 31:506-520. [PMID: 33077333 DOI: 10.1016/j.wem.2020.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 11/27/2022]
Abstract
Determination of death requires specific knowledge, training, and experience in most cases. It can be particularly difficult when external conditions, such as objective hazards in mountains, prevent close physical examination of an apparently lifeless person, or when examination cannot be accomplished by an authorized person. Guidelines exist, but proper use can be difficult. In addition to the absence of vital signs, definitive signs of death must be present. Recognition of definitive signs of death can be problematic due to the variability in time course and the possibility of mimics. Only clear criteria such as decapitation or detruncation should be used to determine death from a distance or by laypersons who are not medically trained. To present criteria that allow for accurate determination of death in mountain rescue situations, the International Commission for Mountain Emergency Medicine convened a panel of mountain rescue doctors and a forensic pathologist. These recommendations are based on a nonsystematic review of the literature including articles on determination of death and related topics.
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Affiliation(s)
- Corinna A Schön
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; Institute of Forensic Medicine, University of Bern, Bern, Switzerland.
| | - Les Gordon
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; University Hospitals, Morecambe Bay Trust, Royal Lancaster Infirmary, Lancaster, United Kingdom
| | - Natalie Hölzl
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; Department of Anaesthesiology and Intensive Care, Klinikum Immenstadt, Germany
| | - Mario Milani
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - Peter Paal
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA; Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK
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Abstract
Evaluating and treating traumatic cardiac arrest remains a challenge to the emergency medicine provider. Guidelines have established criteria for patients who can benefit from treatment and resuscitation versus those who will likely not survive. Patient factors that predict survival are penetrating injury, signs of life with emergency medical services or on arrival to the Emergency Department, short length of prehospital cardiopulmonary resuscitation, cardiac motion on ultrasound, pediatric patients, and those with reversible causes including pericardial tamponade and tension pneumothorax. Newer technologies such as resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, and extracorporeal membrane oxygenation may improve outcomes, but remain primarily investigational.
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Affiliation(s)
- William Teeter
- Department of Emergency Medicine, University of Maryland, 22 South Greene Street, T1R51, Baltimore, MD 21201, USA.
| | - Daniel Haase
- Department of Emergency Medicine, University of Maryland, 22 South Greene Street, T1R51, Baltimore, MD 21201, USA
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Kelly GS, Clare D. Improving out-of-hospital notification in traumatic cardiac arrests with novel usage of smartphone application. J Am Coll Emerg Physicians Open 2020; 1:618-623. [PMID: 33000080 PMCID: PMC7493493 DOI: 10.1002/emp2.12146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Timely out-of-hospital notifications in patients with traumatic cardiac arrest are associated improvements in mortality. Details surrounding these events are often limited, and decisions to perform advanced resuscitative procedures must be made based on limited data. This study evaluated the ability of a mobile application (app) called Citizen (sp0n Inc., New York, NY) to address these issues by providing a novel, secondary source of out-of-hospital information in traumatic cardiac arrest. Citizen sends notifications to mobile devices in response to nearby detected public safety events, and we sought to evaluate its utility in prenotification for traumatic cardiac arrest. METHODS This was a retrospective observational study. Patients ≥ 15 years of age with traumatic cardiac arrest attributed to penetrating trauma were included. The 2 coprimary outcomes observed were the time difference between the app notification and emergency medical services notification, and the app's success rate in generating a notification for each patient in traumatic cardiac arrest. RESULTS From February 2, 2019 to October 10, 2019, there were 43 patients who met the criteria for this study. On average, the Citizen app notification arrived 12.9 minutes before emergency medical services radio notification (95% confidence interval, 9.2-16.6; P < 0.001). Citizen generated a notification for 36 of 43 patients (84%). CONCLUSION The Citizen app generates earlier notifications in traumatic cardiac arrest compared with standard radio communications. It also provides a previously unavailable secondary source of information for making rapid resuscitative decisions upon the arrival of the arresting patient to the emergency department. Further research is needed to determine how to optimally integrate the app into existing trauma systems.
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Affiliation(s)
- Geoffrey S. Kelly
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Drew Clare
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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The Cardiac Physiology Underpinning Exsanguination Cardiac Arrest: Targets for Endovascular Resuscitation. Shock 2020; 55:83-89. [PMID: 33337788 DOI: 10.1097/shk.0000000000001607] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Exsanguination leading to cardiac arrest is the terminal phase of uncontrolled hemorrhage. Resuscitative interventions have focused on preload and afterload support. Outcomes remain poor due to several factors but poor coronary perfusion undoubtedly plays a role. The aim of this study is to characterize the relationship between arterial pressure and flow during hemorrhage in an effort to better describe the terminal phases of exsanguination.Male swine weighing 60 kg to 80 kg underwent splenectomy and instrumentation followed by a logarithmic exsanguination until asystole. Changes in hemodynamic parameters over time were compared using one-way, repeated measures analysis of variance.Nine animals weighing 69 ± 15 kg were studied. Asystole occurred at 53 ± 13 min when 52 ± 11% of total blood volume has been shed. The greatest fall in mean hemodynamic indices were noted in the first 15 min: SBP (80-42 mm Hg, P = 0.02), left ventricular end-diastolic volume (94-52 mL, P = 0.04), cardiac output (4.8-2.4 L/min, P = 0.03), coronary perfusion pressure (57-30 mm Hg, P = 0.01), and stroke volume (60-25 mL, P = 0.02). This corresponds to the greatest rate of exsanguination. Organized cardiac activity was observed until asystole without arrythmias. Coronary flow was relatively preserved throughout the study, with a precipitous decline once mean arterial pressure was less than 20 mm Hg, leading to asystole.In this model, initial hemodynamic instability was due to preload failure, with asystole occurring relatively late, secondary to failure of coronary perfusion. Future resuscitative therapies need to directly address coronary perfusion failure if effective attempts are to be made to salvage these patients.
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Kim OH, Go SJ, Kwon OS, Park CY, Yu B, Chang SW, Jung PY, Lee GJ. Part 2. Clinical Practice Guideline for Trauma Team Composition and Trauma Cardiopulmonary Resuscitation from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Tran A, Fernando SM, Rochwerg B, Vaillancourt C, Inaba K, Kyeremanteng K, Nolan JP, McCredie VA, Petrosoniak A, Hicks C, Haut ER, Perry JJ. Pre-arrest and intra-arrest prognostic factors associated with survival following traumatic out-of-hospital cardiac arrest - A systematic review and meta-analysis. Resuscitation 2020; 153:119-135. [PMID: 32531405 DOI: 10.1016/j.resuscitation.2020.05.052] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/04/2020] [Accepted: 05/31/2020] [Indexed: 01/16/2023]
Abstract
AIM To summarize the prognostic associations of pre- and intra-arrest factors with return of spontaneous circulation (ROSC) and survival (in-hospital or 30 days) after traumatic out-of-hospital cardiac arrest. METHODS We conducted this review in accordance with the PRISMA and CHARMS guidelines. We searched Medline, Pubmed, Embase, Scopus, Web of Science and the Cochrane Database of Systematic Reviews from inception through December 1st, 2019. We included English language studies evaluating pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA. Risk of bias was assessed using the QUIPS tool. We pooled unadjusted odds ratios using random-effects models and presented adjusted odds ratios with 95% confidence intervals. We used the GRADE method to describe certainty. RESULTS We included 53 studies involving 37,528 patients. The most important predictors of survival were presence of cardiac motion on ultrasound (odds ratio 33.91, 1.87-613.42, low certainty) or a shockable initial cardiac rhythm (odds ratio 7.29, 5.09-10.44, moderate certainty), based on pooled unadjusted analyses. Importantly, mechanism of injury was not associated with either ROSC (odds ratio 0.97, 0.51-1.85, very low certainty) or survival (odds ratio 1.40, 0.79-2.48, very low certainty). CONCLUSION This review provides very low to moderate certainty evidence that pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA predict ROSC and survival. This evidence is primarily based on unadjusted data. Further well-designed studies with larger cohorts are warranted to test the adjusted prognostic ability of pre- and intra-arrest factors and guide therapeutic decision-making.
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Affiliation(s)
- Alexandre Tran
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Christian Vaillancourt
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Kenji Inaba
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada; Institute du Savoir, Montfort, Ottawa, ON, Canada
| | - Jerry P Nolan
- Anesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom; Warwick Clinical Trials Unit, University of Warwick, United Kingdom
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Toronto Western Hospital, University Health Network, Toronto, ON, Canada; Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrew Petrosoniak
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christopher Hicks
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Department of Anesthesiology and Critical Care, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore MD, USA; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Jeffrey J Perry
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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Turner S, Lang ES, Brown K, Franke J, Workun-Hill M, Jackson C, Roberts L, Leyton C, Bulger EM, Censullo EM, Martin-Gill C. Systematic Review of Evidence-Based Guidelines for Prehospital Care. PREHOSP EMERG CARE 2020; 25:221-234. [PMID: 32286899 DOI: 10.1080/10903127.2020.1754978] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Introduction: Multiple national organizations have identified a need to incorporate more evidence-based medicine in emergency medical services (EMS) through the creation of evidence-based guidelines (EBGs). Tools like the Appraisal of Guidelines for Research and Evaluation (AGREE) II and criteria outlined by the National Academy of Medicine (NAM) have established concrete recommendations for the development of high-quality guidelines. While many guidelines have been created that address topics within EMS medicine, neither the quantity nor quality of prehospital EBGs have been previously reported. Objectives: To perform a systematic review to identify existing EBGs related to prehospital care and evaluate the quality of these guidelines using the AGREE II tool and criteria for clinical guidelines described by the NAM. Methods: We performed a systematic search of the literature in MEDLINE, EMBASE, PubMED, Trip, and guidelines.gov, through September 2018. Guideline topics were categorized based on the 2019 Core Content of EMS Medicine. Two independent reviewers screened titles for relevance and then abstracts for essential guideline features. Included guidelines were appraised with the AGREE II tool across 6 domains by 3 independent reviewers and scores averaged. Two additional reviewers determined if each guideline reported the key elements of clinical practice guidelines recommended by the NAM via consensus. Results: We identified 71 guidelines, of which 89% addressed clinical aspects of EMS medicine. Only 9 guidelines scored >75% across AGREE II domains and most (63%) scored between 50 and 75%. Domain 4 (Clarity of Presentation) had the highest (79.7%) and domain 5 (Applicability) had the lowest average score across EMS guidelines. Only 38% of EMS guidelines included a reporting of all criteria identified by the NAM for clinical practice guidelines, with elements of a systematic review of the literature most commonly missing. Conclusions: EBGs exist addressing a variety of topics in EMS medicine. This systematic review and appraisal of EMS guidelines identified a wide range in the quality of these guidelines and variable reporting of key elements of clinical guidelines. Future guideline developers should consider established methodological and reporting recommendations to improve the quality of EMS guidelines.
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Selective aortic arch perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of noncompressible torso hemorrhage. J Trauma Acute Care Surg 2020; 87:263-273. [PMID: 31348400 DOI: 10.1097/ta.0000000000002315] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhage-induced traumatic cardiac arrest (HiTCA) has a dismal survival rate. Previous studies demonstrated selective aortic arch perfusion (SAAP) with fresh whole blood (FWB) improved the rate of return of spontaneous circulation (ROSC) after HiTCA, compared with resuscitative endovascular balloon occlusion of the aorta and cardiopulmonary resuscitation (CPR). Hemoglobin-based oxygen carriers, such as hemoglobin-based oxygen carrier (HBOC)-201, may alleviate the logistical constraints of using FWB in a prehospital setting. It is unknown whether SAAP with HBOC-201 is equivalent in efficacy to FWB, whether conversion from SAAP to extracorporeal life support (ECLS) is feasible, and whether physiologic derangement post-SAAP therapy is reversible. METHODS Twenty-six swine (79 ± 4 kg) were anesthetized and underwent HiTCA which was induced via liver injury and controlled hemorrhage. Following arrest, swine were randomly allocated to resuscitation using SAAP with FWB (n = 12) or HBOC-201 (n = 14). After SAAP was initiated, animals were monitored for a 20-minute prehospital period prior to a 40-minute damage control surgery and resuscitation phase, followed by 260 minutes of critical care. Primary outcomes included rate of ROSC, survival, conversion to ECLS, and correction of physiology. RESULTS Baseline physiologic measurements were similar between groups. ROSC was achieved in 100% of the FWB animals and 86% of the HBOC-201 animals (p = 0.483). Survival (t = 320 minutes) was 92% (11/12) in the FWB group and 67% (8/12) in the HBOC-201 group (p = 0.120). Conversion to ECLS was successful in 100% of both groups. Lactate peaked at 80 minutes in both groups, and significantly improved by the end of the experiment in the HBOC-201 group (p = 0.001) but not in the FWB group (p = 0.104). There was no significant difference in peak or end lactate between groups. CONCLUSION Selective aortic arch perfusion is effective in eliciting ROSC after HiTCA in a swine model, using either FWB or HBOC-201. Transition from SAAP to ECLS after definitive hemorrhage control is feasible, resulting in high overall survival and improvement in lactic acidosis over the study period.
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Kang BH, Choi D, Huh Y, Kwon J, Jung K, Lee JCJ, Moon J. Sign of Life is Associated with Return of Spontaneous Circulation After Resuscitative Thoracotomy: Single Trauma Center Experience of Republic of Korea. World J Surg 2019; 43:1519-1524. [PMID: 30737554 DOI: 10.1007/s00268-019-04939-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Resuscitative thoracotomy (RT) can be a lifesaving treatment, but it has not yet been performed in Korea. In this study, we review our experience of RT after a regional trauma center was constructed. METHODS This is a retrospective study of RT conducted at a single Korean trauma center from May 2014 to March 2018. The primary outcome was survival, and the secondary outcome was return of spontaneous circulation (ROSC). The clinical characteristics of the patients were compared between the ROSC and non-ROSC groups. Survivors were also reviewed. RESULTS A total of 62 patients were reviewed, and 60 patients had experienced blunt injury. Thirty-nine patients had ROSC. The ROSC group had short cardiopulmonary resuscitation (CPR) time (6 [2-10] min vs 11 [8-12] min, p < 0.001), the presence of sign of life at the trauma bay [32 (86.5%) vs 7 (28.0%), p < 0.001], and a low Injury Severity Score [26 (25-39) vs 37 (30-75), p = 0.038] compared to the non-ROSC group. On multivariate analysis, only the presence of sign of life was significantly associated with ROSC [11.297 (1.496-85.309) OR (95% CI), p = 0.019]. The 24-h survival rate was 8.1%, and the successful discharge rate was 4.8%. CONCLUSION The outcome of RT in a Korean trauma center was favorable. ROSC after RT was strongly associated with the presence of sign of life, and RT may be performed in the presence of sign of life regardless of prehospital CPR time.
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Affiliation(s)
- Byung Hee Kang
- Department of Trauma Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Donghwan Choi
- Department of Trauma Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Yo Huh
- Department of Trauma Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Junsik Kwon
- Department of Trauma Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Kyoungwon Jung
- Department of Trauma Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - John Cook-Jong Lee
- Department of Trauma Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Jonghwan Moon
- Department of Trauma Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea.
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Shibahashi K, Sugiyama K, Hamabe Y. Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest After Traffic Accidents and Termination of Resuscitation. Ann Emerg Med 2019; 75:57-65. [PMID: 31327568 DOI: 10.1016/j.annemergmed.2019.05.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE We describe the characteristics and outcomes of pediatric traumatic out-of-hospital cardiac arrest after traffic accidents and validate the termination of resuscitation clinical criteria for adult traumatic out-of-hospital cardiac arrest in pediatrics. METHODS We analyzed the records of pediatric (≤18 years) traumatic out-of-hospital cardiac arrest cases after traffic accidents in a prospectively collected nationwide database (2012 to 2016). Endpoints were 1-month favorable neurologic outcomes and 1-month survival. Validation of termination of resuscitation criteria, cardiac arrest at the scene, and unsuccessful resuscitation after cardiopulmonary resuscitation (CPR) greater than 15 minutes was performed based on specificity and positive predictive value. RESULTS Of the 582 patients who were eligible for analyses, 8 (1.4%) and 20 (3.4%) had 1-month favorable neurologic outcome and survival, respectively. All patients with favorable neurologic outcomes had out-of-hospital return of spontaneous circulation, and the duration of CPR was significantly shorter than for those with unfavorable neurologic outcomes (4 versus 23 minutes; absolute difference -21.9 minutes; 95% confidence interval -36.3 to -7.4 minutes). The duration of out-of-hospital CPR beyond which the possibility of favorable neurologic outcomes and survival diminished to less than 1% was 15 minutes. For predicting unfavorable neurologic outcomes, the termination of resuscitation criteria provided a specificity of 1.00 (95% confidence interval 0.52 to 1.00) and a positive predictive value of 1.00 (95% confidence interval 0.99 to 1.00). CONCLUSION The outcomes of pediatric patients with traumatic out-of-hospital cardiac arrest after traffic accidents were as poor as those of adults in previous studies. Out-of-hospital return of spontaneous circulation was a significant indicator of favorable outcomes, and the duration of out-of-hospital CPR beyond which the possibility of favorable neurologic outcomes and survival diminished to less than 1% was 15 minutes. Termination of resuscitation criteria provided an excellent positive predictive value for 1-month unfavorable neurologic outcomes after out-of-hospital cardiac arrest.
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Affiliation(s)
- Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Stifkens F, Dami F, Feiner AS, Dubois M, Pasquier M. Prehospital Simple Thoracostomy for Traumatic Cardiac Arrest: Does the Cardiac Arrest Rhythm Matter? J Emerg Med 2019; 56:457. [PMID: 30979403 DOI: 10.1016/j.jemermed.2018.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 09/22/2018] [Indexed: 12/01/2022]
Affiliation(s)
- François Stifkens
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Fabrice Dami
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Adam-Scott Feiner
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Margaux Dubois
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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Kang WS, Park YC, Jo YG. Laparotomy following cardiopulmonary resuscitation after traumatic cardiac arrest: is it futile? Eur J Trauma Emerg Surg 2019; 46:657-661. [PMID: 30949739 DOI: 10.1007/s00068-019-01118-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 03/27/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE The outcome of cardiopulmonary resuscitation (CPR) after traumatic cardiac arrest is very poor. Moreover, some consider laparotomy for abdominal trauma after CPR futile. This study aimed to investigate the outcomes of trauma patients who were pulseless and received CPR followed by laparotomy. METHOD We conducted a retrospective review of 28,255 trauma patients from our hospital from January 2009 to November 2017. Patient demographics, injury severity scores, duration of CPR, operative data, and mortality of patients with laparotomy after CPR were collected and analyzed. RESULT We identified 120 trauma patients (0.42%) who underwent CPR at admission. Twenty-three patients (0.08%) underwent laparotomy following CPR. Of these, 19 patients (82.6%) died after laparotomy. Of four survivors after laparotomy, three (13.0%) survived with a good neurologic outcome. One survivor required rehabilitation due to poor neurologic outcome. All patients had suffered a blunt injury. CONCLUSION The survival rate for laparotomy following CPR after traumatic cardiac arrest was very poor. However, laparotomy following CPR is not always futile.
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Affiliation(s)
- Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, 61469, Korea.,Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, 61469, Korea.
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, 61469, Korea
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