Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review

Emergency reflex action drill for traumatic cardiac arrest in a simulated pre-hospital setting; a one-group pre-post intervention study

BACKGROUND

Emergency Reflex Action Drills (ERADs) are meant to decrease stress-associated cognitive demand in high urgency situations. The aim of this study was to develop and test an ERAD for witnessed traumatic cardiac arrest (TCA), an event in which potentially reversible causes need to be systematically addressed and treated in a short period of time. We hypothesize that this ERAD (the TCA-Drill) helps ground Emergency Medical Services (EMS) nurses in overcoming performance decline during this specific high-pressure situation.

METHODS

This was a prospective, experimental one-group pre-post intervention study. Ground EMS nurses participated in a session of four simulated scenarios, with an in-between educational session to teach the TCA-Drill. Scenarios were video recorded, after which adherence and time differences were analyzed. Self-confidence on clinical practice was measured before and after the scenarios.

RESULTS

Twelve ground EMS nurses participated in this study. Overall median time to address reversible causes of TCA decreased significantly using the TCA-Drill (132 vs. 110 s; p = 0.030) compared with the conventional ALS strategy. More specifically, participants adhering to the TCA-Drill showed a significantly lower time needed for hemorrhage control (58 vs. 37 s; p = 0.012). Eight of 12 (67 %) ground EMS nurses performed the ERAD without protocol deviations. Reported self-confidence significantly increased on 11 of the 13 surveyed items.

CONCLUSIONS

The use of an ERAD for TCA (the TCA-Drill) significantly reduces the time to address reversible causes for TCA without delaying chest compressions in a simulated environment and can be easily taught to ground EMS nurses and increases self-confidence.

IMPLICATIONS FOR CLINICAL PRACTICE

The use of an ERAD for TCA (the TCA-Drill can significantly reduce the time to address reversible causes for TCA without delaying chest compression. This drill can be easily taught to ground EMS nurses and increases their self-confidence in addressing TCA-patients.

Survival of Out-of-Hospital Pediatric Blunt Traumatic Arrest With Full Neurologic Recovery: Case Report

We present the case of a 10-year-old previously healthy male who suffered an out-of-hospital cardiac arrest because of abdominal trauma and survived with excellent neurologic outcomes and near complete return to baseline functional status at hospital discharge. The rapid response and efficient mobilization of resources led to an excellent patient outcome despite the severity of injuries, including intra-abdominal injuries with expected mortality, out-of-hospital traumatic arrest, coagulopathy, and an extended pediatric intensive care unit stay. This case underscores the significance of timely advanced trauma life support interventions, especially early blood product administration, efficient transport, and airway management, while sharing a remarkable case of out-of-hospital pediatric traumatic arrest with near full recovery.

Sodium octanoate alleviates cardiac and cerebral injury after traumatic cardiac arrest in a porcine model

INTRODUCTION

Traumatic cardiac arrest (TCA) is a severe condition with a high mortality rate, and patients who survive from TCA face a poor prognosis due to post-resuscitation injury, including cardiac and cerebral injury, which remains a serious challenge. Sodium octanoate has shown protective effects against various diseases. The present study aims to investigate sodium octanoate's protective effects against cardiac and cerebral injury after TCA in a porcine model.

METHODS

The study included a total of 22 male domestic pigs divided into three groups: Sham group (n = 7), TCA group (n = 7), and sodium octanoate (SO) group (n = 8). Hemorrhage was initiated via the right femoral artery by a blood pump at a rate of 2 ml·kg-1·min-1 to establish TCA model. The Sham group underwent only endotracheal intubation and arteriovenous catheterization, without experiencing the blood loss/cardiac arrest/resuscitation model. At 5 min after resuscitation, the SO group received a continuous sodium octanoate infusion while the TCA group received the same volume of saline. General indicators were monitored, and blood samples were collected at baseline and at different time points after resuscitation. At 24 h after resuscitation, pigs were sacrificed, and heart and brain were obtained for cell apoptosis detection, iron deposition staining, oxidative stress detection, and the expression of ferroptosis-related proteins (ACSL4 and GPX4).

RESULTS

Sodium octanoate significantly improved mean arterial pressure, cardiac output and ejection fraction induced by TCA. Serum biomarkers of cardiac and cerebral injury were found to increase at all time points after resuscitation, while sodium octanoate significantly reduced their levels. The apoptosis rates of cardiomyocytes and cerebral cortex cells in the SO group were significantly lower than in the TCA group, along with a reduced area of iron deposition staining. The sodium octanoate also reduced oxidative stress and down-regulated ferroptosis which was indicated by protein level alteration of ACSL4 and GPX4.

CONCLUSION

Our study's findings suggest that early infusion of sodium octanoate significantly alleviates post-resuscitation cardiac and cerebral injury in a porcine model of TCA, possibly through inhibition of cell apoptosis and GPX4-mediated ferroptosis. Therefore, sodium octanoate could be a potential therapeutic strategy for patients with TCA.

Paramedics' Success and Complications in Prehospital Pediatric Intubation: A Meta-Analysis

BACKGROUND

Prehospital pediatric intubation is a potentially life-saving procedure in which paramedics are relied upon. However, due to the anatomical nature of pediatrics and associated adverse events, it is more challenging compared to adult intubation. In this study, the knowledge and attitude of paramedics was assessed by measuring their overall success rate and associated complications.

METHODS

An online search using PubMed, Scopus, Web of Science, and Cochrane CENTRAL was conducted using relevant keywords to include studies that assess success rates and associated complications. Studies for eligibility were screened. Data were extracted from eligible studies and pooled as risk ratio (RR) with a 95% confidence interval (CI).

RESULTS

Thirty-eight studies involving 14,207 pediatrics undergoing intubation by paramedics were included in this study. The prevalence of success rate was 82.5% (95% CI, 0.745-0.832) for overall trials and 77.2% (95% CI, 0.713-0.832) success rate after the first attempt. By subgrouping the patients according to using muscle relaxants during intubation, the group that used muscle relaxants showed a high overall successful rate of 92.5% (95% CI, 0.877-0.973) and 79.9% (95% CI, 0.715-0.994) success rate after the first attempt, more than the group without muscle relaxant which represent 78.9% (95% CI, 0.745-0.832) overall success rate and 73.3% (95% CI, 0.616-0.950) success rate after first attempt.

CONCLUSION

Paramedics have a good overall successful rate of pediatric intubation with a lower complication rate, especially when using muscle relaxants.

Reality of treatment for severely injured patients: are there age-specific differences?

BACKGROUND

Major trauma and its consequences are one of the leading causes of death worldwide across all age groups. Few studies have conducted comparative age-specific investigations. It is well known that children respond differently to major trauma than elderly patients due to physiological differences. The aim of this study was to analyze the actual reality of treatment and outcomes by using a matched triplet analysis of severely injured patients of different age groups.

METHODS

Data from the TraumaRegister DGU® were analyzed. A total of 56,115 patients met the following inclusion criteria: individuals with Maximum Abbreviated Injury Scale > 2 and < 6, primary admission, from German-speaking countries, and treated from 2011-2020. Furthermore, three age groups were defined (child: 3-15 years; adult: 20-50 years; and elderly: 70-90 years). The matched triplets were defined based on the following criteria: 1. exact injury severity of the body regions according to the Abbreviated Injury Scale (head, thorax, abdomen, extremities [including pelvis], and spine) and 2. level of the receiving hospital.

RESULTS

A total of 2,590 matched triplets could be defined. Traffic accidents were the main cause of severe injury in younger patients (child: 59.2%; adult: 57.9%). In contrast, low falls (from < 3 m) were the most frequent cause of accidents in the elderly group (47.2%). Elderly patients were least likely to be resuscitated at the scene. Both children and elderly patients received fewer therapeutic interventions on average than adults. More elderly patients died during the clinical course, and their outcome was worse overall, whereas the children had the lowest mortality rate.

CONCLUSIONS

For the first time, a large patient population was used to demonstrate that both elderly patients and children may have received less invasive treatment compared with adults who were injured with exactly the same severity (with the outcomes of these two groups being opposite to each other). Future studies and recommendations should urgently consider the different age groups.

Traumatic Cardiac Arrest-A Narrative Review

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.

Utility of Early Magnetic Resonance Imaging to Enhance Outcome Prediction in Critically Ill Children with Severe Traumatic Brain Injury

BACKGROUND

Many children with severe traumatic brain injury (TBI) receive magnetic resonance imaging (MRI) during hospitalization. There are insufficient data on how different patterns of injury on early MRI inform outcomes.

METHODS

Children (3-17 years) admitted in 2010-2021 for severe TBI (Glasgow Coma Scale [GCS] score < 9) were identified using our site's trauma registry. We used multivariable modeling to determine whether the hemorrhagic diffuse axonal injury (DAI) grade and the number of regions with restricted diffusion (subcortical white matter, corpus callosum, deep gray matter, and brainstem) on MRI obtained within 7 days of injury were independently associated with time to follow commands and with Functional Independence Measure for Children (WeeFIM) scores at the time of discharge from inpatient rehabilitation. We controlled for the clinical variables age, preadmission cardiopulmonary resuscitation, pupil reactivity, motor GCS score, and fever (> 38 °C) in the first 12 h.

RESULTS

Of 260 patients, 136 (52%) underwent MRI within 7 days of injury at a median of 3 days (interquartile range [IQR] 2-4). Patients with early MRI were a median age of 11 years (IQR 7-14), 8 (6%) patients received cardiopulmonary resuscitation, 19 (14%) patients had bilateral unreactive pupils, the median motor GCS score was 1 (IQR 1-4), and 82 (60%) patients had fever. Grade 3 DAI was present in 46 (34%) patients, and restricted diffusion was noted in the corpus callosum in 75 (55%) patients, deep gray matter in 29 (21%) patients, subcortical white matter in 23 (17%) patients, and the brainstem in 20 (15%) patients. After controlling for clinical variables, an increased number of regions with restricted diffusion, but not hemorrhagic DAI grade, was independently associated with longer time to follow commands (hazard ratio 0.68, 95% confidence interval 0.53-0.89) and worse WeeFIM scores (estimate β - 4.67, 95% confidence interval - 8.33 to - 1.01).

CONCLUSIONS

Regional restricted diffusion on early MRI is independently associated with short-term outcomes in children with severe TBI. Multicenter cohort studies are needed to validate these findings and elucidate the association of early MRI features with long-term outcomes in children with severe TBI.

Favourable neurological outcome following paediatric out-of-hospital cardiac arrest: a retrospective observational study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in children is rare and can potentially result in severe neurological impairment. Our study aimed to identify characteristics of and factors associated with favourable neurological outcome following the resuscitation of children by the Swiss helicopter emergency medical service.

MATERIALS AND METHODS

This retrospective observational study screened the Swiss Air-Ambulance electronic database from 01-01-2011 to 31-12-2021. We included all primary missions for patients ≤ 16 years with OHCA. The primary outcome was favourable neurological outcome after 30 days (cerebral performance categories (CPC) 1 and 2). Multivariable linear regression identified potential factors associated with favourable outcome (odd ratio - OR).

RESULTS

Having screened 110,331 missions, we identified 296 children with OHCA, which we included in the analysis. Patients were 5.0 [1.0; 12.0] years old and 61.5% (n = 182) male. More than two-thirds had a non-traumatic OHCA (67.2%, n = 199), while 32.8% (n = 97) had a traumatic OHCA. Thirty days after the event, 24.0% (n = 71) of patients were alive, 18.9% (n = 56) with a favourable neurological outcome (CPC 1 n = 46, CPC 2 n = 10). Bystander cardiopulmonary resuscitation (OR 10.34; 95%CI 2.29-51.42; p = 0.002) and non-traumatic aetiology (OR 11.07 2.38-51.42; p = 0.002) were the factors most strongly associated with favourable outcome. Factors associated with an unfavourable neurological outcome were initial asystole (OR 0.12; 95%CI 0.04-0.39; p < 0.001), administration of adrenaline (OR 0.14; 95%CI 0.05-0.39; p < 0.001) and ongoing chest compression at HEMS arrival (OR 0.17; 95%CI 0.04-0.65; p = 0.010).

CONCLUSION

In this study, 18.9% of paediatric OHCA patients survived with a favourable neurologic outcome 30 days after treatment by the Swiss helicopter emergency medical service. Immediate bystander cardiopulmonary resuscitation and non-traumatic OHCA aetiology were the factors most strongly associated with a favourable neurological outcome. These results underline the importance of effective bystander and first-responder rescue as the foundation for subsequent professional treatment of children in cardiac arrest.

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

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.

ECMO in adult patients with severe trauma: a systematic review and meta-analysis

BACKGROUND

Severe trauma can result in cardiorespiratory failure, and when conventional treatment is ineffective, extracorporeal membrane oxygenation (ECMO) can serve as an adjunctive therapy. However, the indications for ECMO in trauma cases are uncertain and clinical outcomes are variable. This study sought to describe the prognosis of adult trauma patients requiring ECMO, aiming to inform clinical decision-making and future research.

METHODS

A comprehensive search was conducted on Pubmed, Embase, Cochrane, and Scopus databases until March 13, 2023, encompassing relevant studies involving over 5 trauma patients (aged ≥ 16 years) requiring ECMO support. The primary outcome measure was survival until discharge, with secondary measures including length of stay in the ICU and hospital, ECMO duration, and complications during ECMO. Random-effects meta-analyses were conducted to analyze these outcomes. The study quality was assessed using the Joanna Briggs Institute checklist, while the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

The meta-analysis comprised 36 observational studies encompassing 1822 patients. The pooled survival rate was 65.9% (95% CI 61.3-70.5%). Specifically, studies focusing on traumatic brain injury (TBI) (16 studies, 383 patients) reported a survival rate of 66.1% (95% CI 55.4-76.2%), while studies non-TBI (15 studies, 262 patients) reported a survival rate of 68.1% (95% CI 56.9-78.5%). No significant difference was observed between these two survival comparisons (p = 0.623). Notably, studies utilizing venoarterial extracorporeal membrane oxygenation (VA ECMO) (15 studies, 39.0%, 95% CI 23.3-55.6%) demonstrated significantly lower survival rates than those using venovenous extracorporeal membrane oxygenation (VV ECMO) (23 studies, 72.3%, 95% CI 63.2-80.7%, p < 0.001). The graded assessment of evidence provided a high degree of certainty regarding the pooled survival.

CONCLUSIONS

ECMO is now considered beneficial for severely traumatized patients, improving prognosis and serving as a valuable tool in managing trauma-related severe cardiorespiratory failure, haemorrhagic shock, and cardiac arrest.

Potential harms of emergency department thoracotomy in patients with persistent cardiac arrest following trauma: a nationwide observational study

Emergency department thoracotomy (EDT) was incorporated into traumatic out-of-hospital cardiac arrest (t-OHCA) resuscitation. Although current guidelines recommend EDT with survival predictors, futility following EDT has been demonstrated and the potential risks have not been thoroughly investigated. This study aimed to elucidate the benefits and harms of EDT for persistent cardiac arrest following injury until hospital arrival. This retrospective cohort study used a nationwide trauma registry (2019-2021) and included adult patients with t-OHCA both at the scene and on hospital arrival. Survival to discharge, hemostatic procedure frequency, and transfusion amount were compared between patients treated with and without EDT. Inverse probability weighting using a propensity score was conducted to adjust age, sex, comorbidities, mechanism of injury, prehospital resuscitative procedure, prehospital physician presence, presence of signs of life, degree of thoracic injury, transportation time, and institutional characteristics. Among 1289 patients, 374 underwent EDT. The longest transportation time for survivors was 8 and 23 min in patients with and without EDT, respectively. EDT was associated with lower survival to discharge (4/374 [1.1%] vs. 22/915 [2.4%]; adjusted odds ratio [OR], 0.43 [95% CI 0.22-0.84]; p = 0.011), although patients with EDT underwent more frequent hemostatic surgeries (46.0% vs. 5.0%; adjusted OR, 16.39 [95% CI 12.50-21.74]) and received a higher amount of transfusion. Subgroup analyses revealed no association between EDT and lower survival in patients with severe chest injuries (1.0% vs. 1.4%; adjusted OR, 0.72 [95% CI 0.28-1.84]). EDT was associated with lower survival till discharge in trauma patients with persistent cardiac arrests after adjusting for various patient backgrounds, including known indications for EDT. The idea that EDT is the last resort for t-OHCA should be reconsidered and EDT indications need to be deliberately determined.Trial registration This study is retrospectively registered at University Hospital Medical Information Network (UMIN ID: UMIN000050840).

Physician-staffed prehospital units: a retrospective follow-up from an urban area in Scandinavia

BACKGROUND

The aim of this study was to determine when and how rapid response vehicles (RRVs) make a difference in prehospital care by investigating the number and kinds of RRV assignment dispatches and the prehospital characteristics and interventions involved.

METHODS

This retrospective cohort study was based on data from a quality assurance system where all assignments are registered. RRV staff register every assignment directly at the site, using a smartphone, tablet, or computer. There is no mandatory information requirement or time limit for registration. The study includes data for all RRVs operating in Region Stockholm, three during daytime hours and one at night - from January 1, 2021 to December 31, 2021.

RESULTS

In 2021, RRVs in Stockholm were dispatched on 11,283 occasions, of which 3,571 (31.6%) resulted in stand-downs. In general, stand-downs were less common for older patients. The most common dispatch category was blunt trauma (1,584 or 14.0%), which accounted for the highest frequency of stand-downs (676 or 6.0%). The second most common category was cardiac arrest (1,086 or 9.6%), followed by shortness of breath (691 or 6.1%), medical not specified (N/S) (596 or 5.3%), and seizures (572 or 5.1%).

CONCLUSION

The study findings confirm that RRVs provide valuable assistance to the ambulance service in Stockholm, especially for cardiac arrest and trauma patients. In particular, RRV personnel have more advanced medical knowledge and can administer medications and perform interventions that the regular ambulance service cannot provide.

Traumatic cardiac arrest - a nationwide Danish study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Management of Intraoperative Cardiac Arrest

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology ultimately leading to better outcomes. This article reviews the most probable causes of intraoperative arrest and their management.

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Out-of-hospital cardiac arrests in the city of Cape Town metropole of the Western Cape province of South Africa: a spatio-temporal analysis

BACKGROUND

The incidence of out-of-hospital cardiac arrest (OHCA) is expected to increase in sub-Saharan Africa along with the incidence of cardiovascular disease. In low-resource settings (LRS), OHCA carries a negligible survival rate. Interventions to improve OHCA survival might not be cost effective for many LRS, and therefore need to be targeted to areas of high incidence. The aim of this study was to describe the temporal and geographic distribution of OHCA in the City of Cape Town, South Africa, and their proximity to percutaneous coronary intervention (PCI) resources.

METHODS

In this retrospective study, OHCA data between 1 January and 31 December 2018 were extracted from public and one private emergency medical services in the Western Cape. For temporal analysis, distribution of OHCA according to time of day, day of the week and month of the year were subjected to chi-squared testing. For geospatial analysis, cluster and outlier, and hotspot analyses were performed. Proximity analysis was employed to determine the driving time from OHCA location to the closest PCI-capable facility.

RESULTS

A total of 929 patients with OHCA received an emergency medical services response in the City of Cape Town, corresponding to an annual prevalence of 23.2 per 100 000 persons. The distribution of OHCA incidence was not explained by month of the year (p = 0.08) or day of the week (p = 0.67). A statistically significant variation in OHCA incidence was explained by time of day (p < 0.01) with 30% (n = 279) of all OHCAs occurring from 05:00 to 09:59. Geospatial analysis yielded a large area of hotspots (99% confidence interval) over the centre of the metropole, Cape Flats and southern suburbs. The median (interquartile range) driving time from the incident to the closest PCI-capable facility was 10:22 (08:05) minutes.

CONCLUSIONS

Incidents of OHCA occurred predominantly at home during the mid-morning, with hotspots around the city centre and residential suburbs of Cape Town. While the incidents occurred close to PCI-capable facilities, some areas remained underserved and access to PCI for OHCA victims may be impossible due to socio-economic factors. With an increase in OHCA incidence expected, it is essential that contextual, cost-effective management interventions be developed and implemented.

Prehospital Ultrasound Use to Guide Resuscitative Thoracotomy in Blunt Traumatic Cardiac Arrest

Traumatic cardiac arrest is frequently encountered in the air medical transport environment, and resuscitative thoracotomy is a procedure that is sometimes performed in an attempt to salvage these critically injured patients. Focused assessment with sonography for trauma (FAST) is a point-of-care ultrasound protocol commonly used in trauma patients to detect the presence of free fluid in the intraperitoneal and pericardial spaces. The authors present a case of an adult female victim of a motor vehicle collision whose prehospital FAST scan revealed significant hemoperitoneum without hemopericardium. When she developed cardiac arrest, these ultrasound findings aided in the decision to perform resuscitative thoracotomy and helped guide the sequence of maneuvers with prioritization given to cross-clamping the aorta. This case highlights the utility of prehospital ultrasound in yielding timely, actionable diagnostic information that can inform the performance of a high-acuity low-occurrence procedure in the air medical transport environment.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Contribution of the Technical Efficiency of Public Health Programs to National Trends and Regional Disparities in Unintentional Childhood Injury in Japan

To achieve the Sustainable Development Goals, strengthening investments in health service inputs has been widely emphasized, but less attention has been paid to tackling variation in the technical efficiency of services. In this study, we estimated the technical efficiency of local public health programs for the prevention of unintentional childhood injury and explored its contribution to national trend changes and regional health disparities in Japan. Efficiency scores were estimated based on the Cobb-Douglas and translog production functions using a true fixed effects model in a stochastic frontier analysis to account for unobserved time-invariant heterogeneity across prefectures. Using public data sources, we compiled panel data from 2001 to 2017 for all 47 prefectures in Japan. We treated disability-adjusted life years (DALYs) as the output, coverage rates of public health programs as inputs, and caregivers' capacity and environmental factors as constraints. To investigate the contribution of efficiency to trend changes and disparities in output, we calculated the predicted DALYs with several measures of inefficiency scores (2001 average, yearly average, and prefecture-year-specific estimates). In the translog model, mean efficiency increased from 0.62 in 2001 to 0.85 in 2017. The efficiency gaps among prefectures narrowed until 2007 and then remained constant until 2017. Holding inefficiency score constant, inputs and constraints contributed to improvements in average DALYs and widened regional gaps. Improved efficiency over the years further contributed to improvements in average DALYs. Efficiency improvement in low-output regions and stagnated improvement in high-output regions offset the trend of widening regional health disparities. Similar results were obtained with the Cobb-Douglas model. Our results demonstrated that assessing the inputs, constraints, output, and technical efficiency of public health programs could provide policy leverage relevant to region-specific conditions and performance to achieve health promotion and equity.

Traumatic Cardiac Arrest: Scoping Review of Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm and may also be used for patients with traumatic cardiac arrest (TCA). Resuscitative thoracotomy with aortic cross clamping (RT-ACC) maneuver was traditionally performed for patients with TCA due to hemorrhagic shock; however, REBOA has been substituted for RT-ACC in selected TCA cases. During cardiopulmonary resuscitation (CPR) in TCA, REBOA increases cerebral and coronary perfusion, and temporary bleeding control. Both animal and clinical studies have reported the efficacy of REBOA for TCA, and a recent observational study suggested that REBOA may contribute to the return of spontaneous circulation after TCA. Although multiple questions remain unanswered, REBOA has been applied to trauma fields as a novel technology.

Accuracy of prehospital clinicians' perceived prognostication of long-term survival in critically ill patients: a nationwide retrospective cohort study on helicopter emergency service patients

OBJECTIVES

Prehospital critical care physicians regularly attend to patients with poor prognosis and may limit the advanced therapies. The aim of this study was to evaluate the accuracy of poor prognosis given by prehospital critical care clinicians.

DESIGN

Cohort study.

SETTING

We performed a retrospective cohort study using the national helicopter emergency medical services (HEMS) quality database.

PARTICIPANTS

Patients classified by the HEMS clinician to have survived until hospital admission solely because of prehospital interventions but evaluated as having no long-term survival by prehospital clinician, were included.

PRIMARY AND SECONDARY OUTCOME

The survival of the study patients was examined at 30 days, 1 year and 3 years.

RESULTS

Of 36 715 patients encountered by the HEMS during the study period, 2053 patients were classified as having no long-term survival and included. At 30 days, 713 (35%, 95% CI 33% to 37%) were still alive and 69 were lost to follow-up. Furthermore, at 1 year 524 (26%) and at 3 years 267 (13%) of the patients were still alive. The deceased patients received more often prehospital rapid sequence intubation and vasoactives, compared with patients alive at 30 days. Patients deceased at 30 days were older and had lower initial Glasgow Coma Scores. Otherwise, no clinically relevant difference was found in the prehospital vital parameters between the survivors and non-survivors.

CONCLUSIONS

The prognostication of long-term survival for critically ill patients by a prehospital critical care clinician seems to fulfil only moderately. A prognosis based on clinical judgement must be handled with a great degree of caution and decision on limitation of advanced care should be made cautiously.

Comparison of Jaw-Thrust Maneuver and Standard Method for Airway Management with Laryngeal Mask Airway by Paramedics during Chest Compression: A Randomized, Crossover, Manikin Study

INTRODUCTION

The first priority of the primary survey of trauma care is airway management. For patients who have a known or suspected cervical spine injury, using the jaw-thrust maneuver is critical. It was hypothesized that the jaw-thrust maneuver would ease the insertion of the laryngeal mask airway (LMA) by moving the tongue forward from the palate and posterior pharyngeal wall.

STUDY OBJECTIVES

The aim of the study was to evaluate the effect of jaw-thrust maneuver on LMA insertion times of the paramedics with or without chest compression and with or without cervical stabilization in a manikin.

METHODS

Eleven experienced paramedics inserted LMA in jaw-thrust position and standard position in chest compression without cervical stabilization scenario, chest compression with cervical stabilization scenario, cervical stabilization without chest compression scenario, and the scenario where neither cervical stabilization nor chest compression were performed. The primary outcome of the study was the comparison of LMA insertion times for each method. The secondary outcome measures were first-pass success rates and the comparison of the difficulty level of each method.

RESULTS

During the LMA placement, performing the jaw-thrust maneuver instead of the standard method did not shorten the LMA insertion times. Adding chest compression and/or cervical stabilization did not complicate the LMA insertion. All of the LMA insertion attempts during the jaw-thrust maneuver and standard method were successful.

CONCLUSION

The findings of this study suggest that LMA insertion might be attempted both during the jaw-thrust maneuver and standard position in patients with or without chest compression and with or without cervical stabilization.

Prehospital traumatic cardiac arrest: a systematic review and meta-analysis

BACKGROUND

Circulatory arrest after trauma is a life-threatening situation that mandates urgent action. The aims of this systematic review and meta-analysis on prehospital traumatic cardiac arrest (TCA) were to provide an updated pooled mortality rate for prehospital TCA, to investigate the impact of the time of patient inclusion and the type of prehospital trauma system on TCA mortality rates and neurological outcome, and to investigate which pre- and intra-arrest factors are prognostic for prehospital TCA mortality.

METHODS

This review was conducted in accordance with the PRISMA and CHARMS guidelines. Databases were searched for primary studies published about prehospital TCA patients (1995-2020). Studies were divided into various EMS-system categories. Data were analyzed using MedCalc, Review Manager, Microsoft Excel, and Shinyapps Meta Power Calculator software.

RESULTS

Thirty-six studies involving 51.722 patients were included. Overall mortality for TCA was 96.2% and a favorable neurological outcome was seen in 43.5% of the survivors. Mortality rates were 97.2% in studies including prehospital deaths and 92.3% in studies excluding prehospital deaths. Favorable neurological outcome rates were 35.8% in studies including prehospital deaths and 49.5% in studies excluding prehospital deaths. Mortality rates were 97.6% if no physician was available at the prehospital scene and 93.9% if a physician was available. Favorable neurological outcome rates were 57.0% if no physician was available at the prehospital scene and 38.0% if a physician was available. Only non-shockable rhythm was associated with a higher mortality (RR 1.12, p = 0.06).

CONCLUSION

Approximately 1 in 20 patients with prehospital TCA will survive; about 40% of survivors have favorable neurological outcome.

Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Prognostic and epidemiologic, Level III.

Epidemiology and Outcome of Pediatric Out-of-Hospital Cardiac Arrest after Traffic Collision in Japan: A Population-Based Study

The epidemiological and clinical characteristics, treatments, and outcomes of patients with traumatic out-of-hospital cardiac arrests (OHCAs) following traffic collisions have not been adequately investigated in Japan. We analyzed the All-Japan Utstein Registry data of 918 pediatric patients aged < 20 years with OHCAs following traffic collisions who were resuscitated by bystanders or emergency medical service personnel and were subsequently transported to hospitals between 2013 and 2019. Multiple logistic regression analysis was used to assess factors potentially associated with 1-month survival after OHCA. The 1-month survival rate was 3.3% (30/918), and the rate of neurologically favorable outcomes was 0.7% (60/918). The proportion of 1-month survival of all OHCAs after traffic collision origin did not significantly increase (from 1.9% (3/162) in 2013 to 4.5% (5/111) in 2019), and the adjusted odds ratio (OR) for a 1-year increment was 1.13 (95% confidence interval (CI) 0.93 to 1.37). In a multivariate analysis, ventricular fibrillation arrests and pulseless electrical activity (PEA) were significant predictors of 1-month outcome after OHCAs due to traffic collision. From a large OHCA registry in Japan, we demonstrated that 1-month survival after OHCAs due to traffic collision origin was approximately 3%, and some children even gained full recovery of neurological function.

Chest trauma in children-what an anesthesiologist should know

Injury is the leading cause of death in children, with chest trauma accounting for 25% of this mortality. In addition, these patients often present with multiple system injuries, which require simultaneous management. These concurrent injuries can lead to challenges when prioritizing tasks in the resuscitation room and during anesthetic management. In addition, changes from spontaneous ventilation to positive pressure ventilation can impact lung physiology. Therefore, a clear communication plan with careful monitoring and vigilance is needed for intubation and ventilation in these children. These injuries also require specific strategies to prevent barotrauma which could lead to complications such as respiratory failure, pneumonia, sepsis, and acute respiratory distress syndrome. This educational review aims to guide clinicians managing pediatric chest trauma through some of the critical decision-making regarding intubation, ventilation, and subsequent management of injuries.

Cardiopulmonary resuscitation in pediatric patients under palliative home care - A multicenter retrospective study

Introduction: Patients under palliative home care have special needs for their end-of-life support, which in general does not automatically include cardiopulmonary resuscitation. However, emergency medical services (EMS) respond to emergencies in children under palliative care that lead to cardiopulmonary resuscitation. To understand the underlying steps of decision-making, this retrospective, cross-sectional, multicenter study aimed to analyze pediatric patients under palliative home care who had been resuscitated. Methods: This study included patients from three spezialized pediatric palliative home care (SHPC) teams. The primary study parameters were the prevalence of cardiopulmonary resuscitation and the decision-making for carrying out pediatric advanced life support (PALS). Further analyses included the causes of cardiac arrest, the type of CPR (basic life support, advanced life support), the patient´s outcome, and involvement of the SHPC in the resuscitation. Descriptive statistical analysis was performed. Results: In total, 880 pediatric patients under palliative home care were included over 8.5 years, of which 17 patients were resuscitated once and two patients twice (overall, 19 events with CPR, 21.6 per 1,000 cases). In 10 of the 19 incidents (52.6%), cardiac arrest occurred suddenly without being predictable. The causes of cardiac arrest varied widely. PALS was performed in 78.9% of the cases by EMS teams. In 12 of 19 events (63.2%) resuscitation was performed on explicit wish of the parents. However, from a medical point of view, only four resuscitation attempts were reasonable. In total 7 of 17 (41.2%) patients survived cardiac arrest with a comparable quality of life. Discussion: Overall, resuscitation attempts were rare events in children under home palliative therapy, but if they occur, EMS are often the primary caregivers. Most resuscitation attempts occurred on explicit wish of the parents independently of the meaningfulness of the medical procedure. Despite the presence of a life-limiting disease, survival with a similar quality was achieved in one third of all resuscitated patients. This study indicates that EMS should be trained for advanced life support in children under home palliative therapy and SHPC should address the scenario of cardiac arrest also in early stages of palliative treatment. These results underline that advance care planning for these children is urgently needed.

Association of Nights and Weekends with Survival of Traumatic Out-of-Hospital Cardiac Arrest following Traffic Collisions: Japanese Registry-Based Study

BACKGROUND

The process of care for traumatic out-of-hospital cardiac arrest (OHCA) may be different at night and on the weekend. However, little is known about whether the rate of survival after OHCA is affected by the time of day and day of the week.

METHODS

This observational study analyzed the Japanese government-led nationwide population-based registry data of OHCA patients. Patients who experienced traumatic OHCA following traffic collisions from 2013 to 2017 were included in the study. A multivariable logistic regression model was used to examine the association of both time of day (day/evening vs. night) and day of the week (weekday vs. weekend) with outcomes after traumatic OHCA. Night was defined as 23:00 p.m. to 6:59 a.m., and weekends were defined as Saturday and Sunday. The primary outcome was one-month survival.

RESULTS

A total of 8500 patients (mean [SD] age, 57.7 [22.3] years; 68.6% male) were included. 2267 events (26.7%) occurred at night, and 2482 events (29.2%) occurred on weekends. Overall, 173 patients (2.0%) survived one month after OHCA. After adjusting for potential confounders, one-month survival during the day/evening (148/6233 [2.4%]) was significantly higher than during the night (25/2267 [1.1%]) (adjusted OR, 1.95 [95%CI, 1.24-3.07]), whereas there was no significant difference in one-month survival between weekdays (121/6018 [2.0%]) and weekends (52/2482 [2.1%]) (adjusted OR, 0.97 [95%CI, 0.69-1.38]).

CONCLUSIONS

One-month survival after traumatic OHCA was significantly lower during the night than during the day/evening, although there was no difference in one-month survival between weekdays and weekends. Further studies are warranted to investigate the underlying mechanisms of decreased survival at night.

Neurological outcomes after traumatic cardiopulmonary arrest: a systematic review

Background

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

Objectives

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

Data sources

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

Study eligibility criteria

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

Participants and interventions

Patients who were resuscitated following traumatic cardiac arrest.

Study appraisal and synthesis methods

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

Results

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

Limitations

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

Conclusions or implications of key findings

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

Level of evidence

Systematic review, level IV.

PROSPERO registration number

CRD42020198482.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association between emergency medical service transport time and survival in patients with traumatic cardiac arrest: a Nationwide retrospective observational study

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.

Is point-of-care ultrasound a reliable predictor of outcome during traumatic cardiac arrest? A systematic review and meta-analysis from the SHoC investigators

AIM

Point-of-care ultrasound (POCUS) has been shown to assist in predicting outcomes in cardiac arrest. We evaluated the test characteristics of POCUS in predicting poor outcomes: failure of return of spontaneous circulation (ROSC), survival to hospital admission (SHA), survival to hospital discharge (SHD) and neurologically intact survival to hospital discharge (NISHD) in adult and paediatric patients with blunt and penetrating traumatic cardiac arrest (TCA) in out-of-hospital or emergency department settings.

METHODS

We conducted a systematic review and meta-analysis using the PRISMA guidelines. We searched Clinicaltrials.gov, CINAHL, Cochrane library, EMBASE, Medline and the World Health Organization-International Clinical Trials Registry from 1974 to November 9, 2020. Risk of bias was assessed using QUADAS-2 tool. We used a random-effects meta-analysis model with 95% confidence intervals with I² statistics for heterogeneity.

RESULTS

We included 8 studies involving 710 cases of TCA. For all blunt and penetrating TCA patients who failed to achieve ROSC, the specificity (proportion of patients with cardiac activity on POCUS who achieved ROSC) was 98% (95% CI 0.13 to 1.0). The sensitivity (proportion of patients with cardiac standstill on POCUS who failed to achieve ROSC) was 91% (95% CI 0.67 to 0.98). No patient with cardiac standstill survived. Substantial level of heterogeneity was noted.

CONCLUSIONS

Patients in TCA without cardiac activity on POCUS have a high likelihood of death and negligible chance of SHD. The numbers of patients included in published studies remains too low for practice recommendations for termination of resuscitation based solely upon the absence of cardiac activity on POCUS.

Out-of-hospital cardiac arrests in the city of Cape Town, South Africa: a retrospective, descriptive analysis of prehospital patient records

OBJECTIVES

While prospective epidemiological data for out-of-hospital cardiac arrest (OHCA) exists in many high-income settings, there is a dearth of such data for the African continent. The aim of this study was to describe OHCA in the Cape Town metropole, South Africa.

DESIGN

Observational study with a retrospective descriptive design.

SETTING

Cape Town metropole, Western Cape province, South Africa.

PARTICIPANTS

All patients with OHCA for the period 1 January 2018-31 December 2018 were extracted from public and private emergency medical services (EMS) and described.

OUTCOME MEASURES

Description of patients with OHCA in terms of demographics, treatment and short-term outcome.

RESULTS

A total of 929 patients with OHCA received an EMS response in the Cape Town metropole, corresponding to an annual prevalence of 23.2 per 100 000 persons. Most patients were adult (n=885; 96.5%) and male (n=526; 56.6%) with a median (IQR) age of 63 (26) years. The majority of cardiac arrests occurred in private residences (n=740; 79.7%) and presented with asystole (n=322; 34.6%). EMS resuscitation was only attempted in 7.4% (n=69) of cases and return of spontaneous circulation (ROSC) occurred in 1.3% (n=13) of cases. Almost all patients (n=909; 97.8%) were declared dead on the scene.

CONCLUSION

To our knowledge, this was the largest study investigating OHCA ever undertaken in Africa. We found that while the incidence of OHCA in Cape Town was similar to the literature, resuscitation is attempted in very few patients and ROSC-rates are negligible. This may be as a consequence of protracted response times, poor patient prognosis or an underdeveloped and under-resourced Chain of Survival in low- to middle-income countries, like South Africa. The development of contextual guidelines given resources and disease burden is essential.

[Cardiac arrest under special circumstances]

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

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

prognostic study, level III.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

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

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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