Traumatic cardiac arrest

Outcomes from traumatic cardiac arrest are poor ( Lockey et al. 2006 ; Soar et al, 2010 ). Those who do survive tend to have had a quickly reversible cuase for their arrest ( Vanden Hoek et al, 2010 ). One such mechanism is tension pneumothorax; and in a retrospective database review of London HEMS traumatic arrests six patients regained cardiac output immediately following decompression of a tension pneumothorax ( Lockey et al. 2006 ). Had their tension pneumothoraces not been rapidly decompressed successfully prior to transport to hospital, the continuation of positive pressure ventilation during CPR would likely have further increased intrathoracic pressure. This would render chest compressions ineffective and almost certainly lead to death. There is currently much doubt surrounding the effectiveness of needle decompression for tension pneumothoraces, and needle decompression without release of air certainly does not rule out this important reversible cause of cardiac arrest ( Rojas et al. 1983 ). In order to improve the outcomes for patients in traumatic cardiac arrest in the UK there is an argument for introducing finger thoracostomy to a paramedics skill set as a safe and effective method of both draining and ruling out tension pneumothorax in the limited setting of traumatic cardiac arrest.

Resuscitative thoracotomy: a practical approach

BackgroundCardiac arrests in admitted hospital patients with trauma have not been described in the literature. We defined “in-hospital cardiac arrest of a trauma” (IHCAT) patient as “cessation of circulatory activity in a trauma patient confirmed by the absence of signs of circulation or abnormal cardiac arrest rhythm inside a hospital setting, which was not cardiac re-arrest.” This study aimed to compare epidemiology, clinical presentation, and outcomes between in- and out-of-hospital arrest resuscitations in trauma patients in Qatar. It was conducted as a retrospective cohort study including IHCAT and out-of-hospital trauma cardiac arrest (OHTCA) patients from January 2010 to December 2015 utilizing data from the national trauma registry, the out-of-hospital cardiac arrest registry, and the national ambulance service database.ResultsThere were 716 traumatic cardiac arrest patients in Qatar from 2010 to 2015. A total of 410 OHTCA and 199 IHCAT patients were included for analysis. The mean annual crude incidence of IHCAT was 2.0 per 100,000 population compared to 4.0 per 100,000 population for OHTCA. The univariate comparative analysis between IHCAT and OHTCA patients showed a significant difference between ethnicities (p=0.04). With the exception of head injury, IHCAT had a significantly higher proportion of localization of injuries to anatomical regions compared to OHTCA; spinal injury (OR 3.5, 95% CI 1.5–8.3, p<0.004); chest injury (OR 2.62, 95% CI 1.62–4.19, p<0.00), and abdominal injury (OR 2.0, 95% CI 1.0–3.8, p<0.037). IHCAT patients had significantly higher hypovolemia (OR 1.66, 95% CI 1.18–2.35, p=0.004), higher mean Glasgow Coma Scale (GCS) score (OR 1.4, 95% CI 1.3–1.6, p<0.00), and a greater proportion of initial shockable rhythm (OR 3.51, 95% CI 1.6–7.7, p=0.002) and cardiac re-arrest (OR 6.0, 95% CI 3.3–10.8, p=<0.00) compared to OHTCA patients. Survival to hospital discharge was greater for IHCAT patients compared to OHTCA patients (OR 6.3, 95% CI 1.3–31.2, p=0.005).Multivariable analysis for comparison after adjustment for age and gender showed that IHCAT was associated with higher odds of spinal injury, abdominal injury, higher pre-hospital GCS, higher occurrence of cardiac re-arrest, and better survival than for OHTCA patients.IHCAT patients had a greater proportion of anatomically localized injuries indicating solitary injuries compared to greater polytrauma in OHTCA. In contrast, OHTCA patients had a higher proportion of diffuse blunt non-localizable polytrauma injuries that were severe enough to cause immediate or earlier onset of cardiac arrest.ConclusionIn traumatic cardiac arrest patients, IHCAT was less common than OHTCA and might be related to a greater proportion of solitary localized anatomical blunt injuries (head/abdomen/chest/spine). In contrast, OHTCA patients were associated with diffuse blunt non-localizable polytrauma injuries with increased severity leading to immediate cardiac arrest. IHCAT was associated with a higher mean GCS score and a higher rate of initial shockable rhythm and cardiac re-arrest, and improved survival rates.

Out-of-hospital traumatic cardiac arrest (TCA) often has a poor prognosis despite rescue efforts. Although the incidence and mortality of out-of-hospital cardiac arrest have increased, bystander cardiopulmonary resuscitation (CPR) has decreased in some countries during the COVID-19 pandemic. In the prehospital setting, immediate treatment of cardiac arrest is required without knowing the patient's COVID-19 status. Because COVID-19 is usually transmitted through the respiratory tract, airway management can put medical personnel at risk for infection. This study explored whether on-scene treatments involving CPR for TCA patients changed during the COVID-19 pandemic in Korea. This retrospective study used data from emergency medical services (EMS) run sheets in Gangwon Province from January 2019 to December 2021. Patients whose initial problem was cardiac arrest and who received CPR were included. Data in 2019 were classified as pre-COVID-19 and all subsequent data (from 2020 and 2021) as post-COVID-19. Age, sex, possible cause of cardiac arrest, and treatments including airway maneuvers, oropharyngeal airway (OPA) or i-gel insertion, endotracheal intubation (ETI), bag-valve mask (BVM) ventilation, intravenous (IV) line establishment, neck collar application, and wound dressing with hemostasis were investigated. During the study period, 2,007 patients received CPR, of whom 596 patients had TCA and 367 had disease-origin cardiac arrest (DCA). Among the patients with TCA, 192 (32.2%) were pre-COVID-19 and 404 (67.8%) were post-COVID-19. In the TCA group, prehospital treatments did not decrease. The average frequencies were 59.7% for airway maneuvers, 47.5% for OPA, 57.4% for BVM, and 51.3% for neck collar application. The rates of ETI, i-gel insertion, and IV-line establishment increased. The treatment rate for TCA was significantly higher than that for DCA. Prehospital treatments by EMS workers for patients with TCA did not decrease during the COVID-19 pandemic. Instead, the rates of ETI, i-gel insertion, and IV-line establishment increased.

Objectives While epinephrine is widely used for medical cardiac arrests, there is a knowledge gap regarding its utility for traumatic arrests. Traumatic arrests result from hypovolemia, hypoxia, or anatomic impairment of cardiac function such that the inotropic and vasoconstrictive effects of epinephrine may be ineffective or harmful. We hypothesized that epinephrine does not improve survival among patients with traumatic cardiac arrest. Methods This was a multicenter retrospective cohort study of trauma patients sustaining prehospital cardiac arrest who were treated at seven level I and II trauma centers over 6 years (2011–2017), ascertained via trauma registry data and chart abstraction. The primary outcome was survival to hospital discharge; patients treated with or without epinephrine were compared. Multivariable analyses were performed using Poisson regression. Time to event analyses were conducted using Cox proportional hazard models. Results We included 1631 adult and pediatric trauma patients with prehospital cardiac arrest. Prehospital epinephrine was administered to 844 (52%). The median age was 35 years, 335 (21%) were female, 712 (44%) sustained blunt trauma, and 58 (4%) had a shockable initial rhythm. Survival to hospital discharge was significantly lower in the prehospital epinephrine cohort compared to the no epinephrine cohort in univariable analysis [43/844 (5%) vs. 125/787 (16%), p < 0.001]. Among patients with blunt mechanism, survival was significantly lower in the prehospital epinephrine cohort [12/382 (3%) vs. 54/330 (16%), p < 0.001]. Among patients with penetrating mechanism, survival was not statistically different [10/276 (4%) with epinephrine vs. 22/374 (6%) without, p = 0.19]. In multivariable analyses adjusting for age, sex, mechanism, and initial rhythm, epinephrine was associated with lower likelihood of survival in the overall and blunt cohorts; there was no significant difference in the penetrating cohort (overall aRR 0.33, 95% CI 0.23–0.46; blunt aRR 0.20, 95% CI 0.11–0.37; penetrating aRR 0.62, 95% CI 0.30–1.28). Adjusted and unadjusted time to event analyses across each of these cohorts showed that epinephrine was associated with either statistically inferior or indistinct hazard ratios. Conclusions Epinephrine was not associated with improved survival following traumatic cardiac arrest, and in multiple subanalyses, it was associated with inferior outcomes. These results may inform prehospital traumatic arrest protocols.

Objectives. Pediatric cardiac arrest patients andadult traumatic arrest patients are perceived as more difficult to endotracheally intubate than adult cardiac arrest patients. The study hypothesis was that these populations were at higher risk of endotracheal intubation failure compared with adult cardiac arrest patients andthat paramedics would more frequently defer attempts to intubate these patients. Methods. This was a retrospective, observational study analyzing oral endotracheal intubations on pediatric cardiac arrest, adult traumatic arrest, andadult cardiac arrest patients over 66 months. Homogeneity of intubation nonattempt andendotracheal intubation failure was studied with chi-square analysis. Relative risks (RRs) with 95% confidence intervals (CIs) were used to compare pediatric cardiac arrest with adult traumatic arrest with adult cardiac arrest nonattempt rates andendotracheal intubation failure rates. Results. 2,669 oral endotracheal intubations were included. There was a significant difference in intubation nonattempts andintubation failure between the combined pediatric cardiac arrest andadult traumatic arrest groups andthe adult cardiac arrest cohort (RR 7.24, 95% CI 5.73, 9.16 for nonattempt; RR = 2.33, 95% CI 1.93, 2.83 for intubation failure). Both groups individually showed significant risk for intubation nonattempt andendotracheal intubation failure compared with adult cardiac arrest, with the pediatric cohort at higher risk for failure andthe adult traumatic arrest cohort at higher risk for nonattempt. Conclusions. There was significant risk of intubation nonattempt andintubation failure in the pediatric cardiac arrest andadult traumatic arrest cohorts compared with the adult cardiac arrest population, with the pediatric cohort being at particularly high risk for intubation failure andthe adult traumatic arrest cohort at higher risk for nonattempt.

BackgroundResuscitative thoracotomy (RT) is a critical intervention for patients in traumatic cardiac arrest or hemorrhagic shock, where survival is highly dependent on the time required to perform the procedure. Despite its urgency, RT is still conducted using traditional thoracic retractors originally designed for scheduled surgeries, which pose challenges in emergency settings. To address these limitations, we developed a novel thoracic retractor optimized for RT and evaluated its performance compared to a conventional model.MethodsThe novel retractor was designed with an arrow-shaped hook for improved intercostal insertion and a continuously rotatable handle to enhance procedural efficiency. A comparative study using excised porcine thoraxes was conducted to assess its performance. Six cm incisions were made in the intercostal spaces bilaterally before retractor insertion. Evaluators inserted the device, performed three handle rotations, and repeated the procedure using the other retractor on the contralateral side. The primary outcome was the time required for three rotations, while secondary outcomes included ease of insertion, ease of rotation, and hook stability, rated on a 6-point scale by evaluators.ResultsTen surgeons (n = 10) performed thoracotomy using both the novel and conventional retractors. Comparison of the time required for three handle rotations between the novel and conventional retractors demonstrated a statistically significant reduction with the novel retractor. The median time to complete three rotations was 16.0 [11.7–19.1] seconds with the novel retractor, compared to 7.0 [5.3–8.5] seconds with the conventional model (P < 0.01). The ease of insertion was rated significantly higher with the novel retractor compared to the conventional model (6.0 [5.5–6.0] vs. 2.5 [2.0–3.0], P < 0.01). The ease of rotation was also rated significantly higher with the novel retractor than with the conventional model (5.5 [5.0–6.0] vs. 2.5 [1.0–3.5], P < 0.01). In the evaluation of the hook stability, no significant difference was observed between the novel and conventional retractors (P = 1.0).ConclusionsThe novel thoracic retractor enables faster and easier thoracotomy compared to conventional model. Given the strong association between time and RT prognosis, this device is well-suited for RT procedures requiring rapid execution.

For decades, survival rates of cardiac arrest following trauma were reported between 0 and 2 %. Since 2005, survival rates have increased with awide range up to 39 % and good neurological recovery in every second person injured for unknown reasons. Especially in children, high survival rates with good neurologic outcomes are published. Resuscitation following traumatic cardiac arrest differs significantly from nontraumatic causes. Paramount is treatment of reversible causes, which include massive bleeding, hypoxia, tension pneumothorax, and pericardial tamponade. Treatment of reversible causes should be simultaneous. Chest compression is inferior following traumatic cardiac arrest and should never delay treatment of reversible causes of the traumatic cardiac arrest. In massive bleeding, bleeding control has priority. Damage control resuscitation with permissive hypotension, aggressive coagulation therapy, and damage control surgery represent the pillars of initial treatment. Cardiac arrest due to hypoxia should be resolved by airway management and ventilation. Tension pneumothorax should be decompressed by finger thoracostomy, pericardial tamponade by resuscitative thoracotomy. In addition, resuscitative thoracotomy allows direct and indirect bleeding control. Untreated impact brain apnea may rapidly lead to cardiac arrest and requires quick opening of the airway and effective oxygenation. Established algorithms for treatment of cardiac arrest following trauma enable asafe, structured, and effective management.

BackgroundTrauma is a main cause of death among young adults worldwide. Patients experiencing a traumatic cardiac arrest (TCA) certainly have a poor prognosis but population-based studies are sparse. Primarily to describe characteristics and 30-day survival following a TCA as compared with a medical out-of-hospital cardiac arrest (medical CA).MethodsA cohort study based on data from the nationwide, prospective population-based Swedish Registry for Cardiopulmonary Resuscitation (SRCR), a medical cardiac arrest registry, between 1990 and 2016. The definition of a TCA in the SRCR is a patient who is unresponsive with apnoea where cardiopulmonary resuscitation and/or defibrillation have been initiated and in whom the Emergency Medical Services (EMS, mainly a nurse-based system) reported trauma as the aetiology. Outcome was overall 30-day survival. Descriptive statistics as well as multivariable logistic regression models were used.ResultsIn all, between 1990 and 2016, 1774 (2.4%) cases had a TCA and 72,547 had a medical CA. Overall 30-day survival gradually increased over the years, and was 3.7% for TCAs compared to 8.2% following a medical CA (p < 0.01). Among TCAs, factors associated with a higher 30-day survival were bystander witnessed and having a shockable initial rhythm (adjusted OR 2.67, 95% C.I. 1.15–6.22 and OR 8.94 95% C.I. 4.27-18.69, respectively).DiscussionAssociation in registry-based studies do not imply causality but TCA had short time intervals in the chain of survival as well as high rates of bystander-CPR.ConclusionIn a medical CA registry like ours, prevalence of TCAs is low and survival is poor. Registries like ours might not capture the true incidence. However, many individuals do survive and resuscitation in TCAs should not be seen futile.

Survival rates following traumatic cardiac arrest (TCA) are known to be poor but resuscitation is not universally futile. There are a number of potentially reversible causes to TCA and a well-defined group of survivors. There are distinct differences in the pathophysiology between medical cardiac arrests and TCA. The authors present some of the key differences and evidence related to resuscitation in TCA, and suggest a separate algorithm for the management of out-of-hospital TCA attended by a highly trained physician and paramedic team.

The management of traumatic cardiac arrest (TCA) focuses on the immediate treatment of reversible causes, including bilateral thoracostomy. In our prehospital emergency service, bilateral thoracostomy has been recommended since 2012 for the management of TCA. We sought to analyse the prehospital management and clinical course of patients with TCA, focusing on changes over time in the use of thoracostomy. In this single-centre retrospective observational study, we included patients with TCA managed by physicians of the prehospital service of Lausanne University Hospital from 2012 to 2024. The primary outcome was the annual rate of bilateral thoracostomy. Secondary outcomes included the rate of additional on-site measures, such as pelvic binder placement and airway management, and follow-up at 48h. Among 3206 cardiac arrests during the study period, 473 (15%) were TCAs. Among the 247 patients with resuscitation attempts, thoracostomy was judged as indicated in 223 (90%) and performed in 148 (66%). Twenty-seven (18%) patients who had a thoracostomy were alive on arrival at hospital, with 9 (6.1%) still alive at 48h. The mean annual proportion of patients in whom a thoracostomy was performed was 68% (range 0-100%) and increased significantly over the years (p<0.001). The annual rate of thoracostomy in TCA patients increased significantly in the period 2012 to 2024. Larger studies are required to determine the impact of thoracostomy on survival.

Pre-hospital CPR after traumatic arrest: Outcomes at a level 1 pediatric trauma center

BackgroundDespite advances in trauma care, traumatic cardiac arrest (TCA) shows significantly poorer outcomes compared to non-traumatic cardiac arrest, with mortality rates exceeding 96%. However, no standardized protocol exists for appropriate cardiopulmonary resuscitation (CPR) duration in TCA. This study aimed to establish evidence-based CPR duration thresholds and identify factors associated with return of spontaneous circulation (ROSC) in TCA patients.MethodsWe conducted a retrospective observational study using a single-centre trauma registry of adult patients with TCA between January 2021 and December 2023. Univariate analysis was used to identify differences in the baseline and outcome variables between the ROSC and no-ROSC groups. We performed multivariable logistic regression analysis to identify factors independently associated with ROSC. We also investigated the appropriate cutoff time of pre-hospital and total CPR duration for ROSC (the CPR duration that has maximum sensitivity and specificity for ROSC).ResultsIn total, 422 patients with TCA were included, of whom 250 were eligible for analysis. The proportion of patients with ROSC was 22.4% (n = 56), and trauma bay/emergency department mortality and in-hospital mortality rates were 80.8% (n = 202) and 97.2% (n = 243), respectively. Factors associated with ROSC included alert mental status in the field, as indicated by verbal response (adjusted odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01–1.12; p = 0.06), pain response (OR, 0.03; 95% CI, 0.01–0.43; p = 0.009), and unresponsiveness (OR, 0.04; 95% CI, 0.01–0.44; p = 0.009) and non-asystolic initial rhythms, such as pulseless electrical activity (OR, 4.26; 95% CI, 1.92–9.46; p < 0.001), shockable rhythm (OR, 14.26; 95% CI, 1.44–141.54; p = 0.023), pre-hospital CPR duration (OR, 0.90; 95% CI, 0.85–0.95), and total CPR duration (OR, 0.88; 95% CI, 0.84–0.92; p < 0.001). The upper limits of pre-hospital and total CPR durations for achieving a probability of ROSC < 1% were 23 and 30 min, respectively, whereas those for a cumulative portion of ROSC > 99% were 27 and 38 min, respectively. Among the survivors (n = 7), six had favourable functional outcomes at discharge.ConclusionsThis study provides evidence-based CPR duration thresholds in TCA, demonstrating that resuscitation efforts beyond 27 min in prehospital settings and 38 min in total were futile. Additionally, an alert mental status in the field and non-asystolic initial rhythm were identified as positive predictors of ROSC. These findings may help guide appropriate duration of resuscitation efforts in TCA.

Objective: In this study, we aimed to evaluate the datas about cardio pulmoner resusitation performed at Hatay Mustafa Kemal University hospital emergency department. by investigate of hospital data system and to make the most appropriate resuscitation planning. Material and Methods: 109 patients who underwent CPR at Hatay Mustafa Kemal University Emergency Department were retrospectively analysed. pH and lactate values of patients in blood samples taken on arrival of patients analysed. Results: In emergency department admissions 50 (45.9%) İHCA and 59 (54.1%) OHCA cases was observed. 26 (23.9%) of patients who underwent CPR in emergency department ROSC and admitted to intensive care following the CPR. 7(26.9%) patients in the intensive care unit were discharged and 10 (38.5%) patients exitus on the first day of hospitalisation. 102 patients (93,6%) were exitus. Mean lactate in OHCA patients (10.44±4.52 mmol/L) was significantly higher than the IHCA patients mean lactate (7.6±4.97 mmol/L) (p=0.002). In the ROC analysis, the AUC was 0.627 (0.514 0.740) (p=0.040). A lactate value above 10.65 mmol/L was determined as the cut-off point for mortality prediction. sensitivity 0.470 specificity of 0.808. Survival was not observed in traumatic cardiac arrests. Conclusion: While no significant difference was observed for survival in IHCA and OHCA, ROSC close to the literature was observed, but survival in traumatic cardiac arrest patients was far behind the literature. Resuscitation is a rescue chain that starts with ''bystander CPR'' and consists of detection of the cause of arrest in emergency services, maintenance of CPR and post-CPR care. Survival rate can be increased by strengthening each link of this chain.

Traumatic cardiac arrest (TCA) presents a critical challenge in trauma care, often occurring rapidly after injury before effective interventions are available. To evaluate the association of prehospital resuscitative thoracotomy with survival outcomes for TCA. This retrospective cohort study examined all cases of prehospital resuscitative thoracotomy for TCA in London from January 1999 to December 2019. Data were analyzed from July 2022 to July 2023. Prehospital resuscitative thoracotomy for TCA. The primary outcome was survival to hospital discharge. Secondary outcomes included survival to hospital admission and neurological status at discharge. Prehospital resuscitative thoracotomy was undertaken in 601 patients with out-of-hospital TCA. The median (IQR) age was 25 (20-37) years; 538 (89.5%) were male and 63 (10.5%) female. A total of 529 patients (88.0%) had a penetrating mechanism of injury. TCA occurred at a median (IQR) of 12 (6-22) minutes after the emergency call, with 491 arrests (81.7%) before the advanced trauma team's arrival. TCA was the result of cardiac tamponade (105 patients, 17.5%), exsanguination (418 patients, 69.6%), and exsanguination combined with cardiac tamponade (72 patients, 12.0%). Thirty patients (5.0%) survived to hospital discharge, with a favorable neurological outcome observed in 23 survivors (76.6%). Survival varied significantly with the cause of TCA: 22 of 105 patients (21%) with cardiac tamponade, 8 of 418 patients (1.9%) with exsanguination, and none of the 72 patients with combined or other pathologies survived. There were no survivors beyond 15 minutes of TCA for cardiac tamponade and 5 minutes after exsanguination. Multivariable analysis revealed that the cause of TCA (adjusted odds ratio [aOR], 21.1; 95% CI, 8.1-54.7; P < .001), duration of TCA (aOR, 20.9; 95% CI, 4.4-100.6, P < .001), and absence of the need for internal cardiac massage (AOR, 0.2; 95% CI, 0.06-0.5; P = .001) were independently associated with survival. TCA occurs soon after injury, with only a brief window available for effective intervention. This study found that resuscitative thoracotomy is feasible in a mature, physician-led, urban prehospital system and is associated with improved survival for patients with out-of-hospital TCA, particularly when caused by cardiac tamponade, in situations where other treatment options are limited.