Traumatic Cardiac Arrest 7.5% survival!?

ExpatMedic0

ExpatMedic0

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For patients over 18, my protocols permit termination of resuscitation (TOR) subject to medical direction oversight for:
1) Blunt trauma patients if the patient is apenic, pulseless, and asystolic on ECG upon arrival on scene, and
2) Penetrating trauma patients if the patient is apneic, pulseless, and does not have any other signs of life (e.g. pupillary reflexes, spontaneous movement, ECG electrical activity).

That being said, if I find myself at a traumatic arrest, and I'm BLS...I'll probably start BLS measures until I get an ALS response (usually going to be within 5 minutes of my arrival on scene).
 
ExpatMedic0 said:
Whats your protocol for traumatic cardiac arrest? Do you work them? I found 2 studies published this year, which boast certain population groups have 5% and up to 7.5% survival rates. Thoughts?
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Sorry, forgot to address the third question!

With respect to the research, I don't have full article access...that being said, it seems like we may want to give more thought to resuscitating traumatic arrests. However, there are major caveats to this:
1) We should see what neurologically-intact survival rates are, and the same for neurologically-intact survival to discharge rates are. It makes little sense (indeed, it's cruel!) to work up somebody who will end up vent-dependent, etc.
2) What's the cost, and is it worth it? (I would posit that cost per QALY is much higher than our usual QALY thresholds of circa $50k/QALY.)
 
Most often no, but obviously they're case specific. Single penetrating chest traumatic arrests from low impact weapons (e.g., knives) probably have the biggest(?) chance of survivability, at least last time I checked that's what I was being told.

Our protocols dictate if we're greater than 10 minutes from our regional trauma center we consider pronouncement. Again, other variables can come into play at any given time, but the guy who takes a double barrell shotgun to the chest at point blank, is in an IVR, was most likely deceased before hitting the ground, and only 5 out from our level 2 probably won't get more than a 6-second strip from me before leaving it with LE for the coroner.

When in doubt, we're allowed to still work them, they like double darts in them if time permits, all that jazz, but again I personally can't live off of stats alone.
 
I tried to access the articles, but they are not yet posted to sciencedirect. It's tough to tell from the abstracts how exactly they calculated survival.

The first study is out of the UK and the 2nd out of Australia. Both countries have a low burden of ballistic trauma and as mentioned previously, a single stab wound is typically associated with the best survival (relatively speaking), and both countries, as far as I know, see more stabbings at least insofar as proportion of penetrating trauma. Also, at least in the UK, it is commonplace to have physicians not only respond, but to perform resuscitative thoracotomy for select cases of traumatic arrest. London HEMS has pretty much shown that their only survivors are those with a single cardiac stab wound. I know that in many area of Australia, it is also common to have HEMS staffed with a physician, but I do not know if thoracotomy is a procedure that they perform routinely for traumatic arrest.

I'm a resident at a trauma center that has ~2000 activations for which nearly 40-50% are penetrating. The trauma service performs approx 50 ED thoracotomies per year and are very liberal (penetrating wound below the neck and no pulse, you get opened). A very small number survive. I have seen short term survivors, but I personally have not cared for a patient that survived to D/C that I know of, but the trauma surgeons affirm that there are survivors.

Anyhow, I would not be surprised if the numbers are much lower when you look at all patients who at one point in the prehospital setting were pulseless 2/2 trauma. I suspect that 5% and 7.5% represents a subgroup of the all-comers.
 
For us if they are pulseless, without organized respiratory activity and after BLS airway maneuvers stay without organized respiratory effort and have no identifiable reversible causes (i.e. Tension pneumo or cardiac tamponade) we call for termination orders. Only time we really work traumatic arrests is if they're in VF/VT or if they have chest trauma and arrest in the presence of a credentialed system provider (fire or EMS) and we can perform a three hole punch (bilateral decompression and pericardiocentesis) within 5 minutes of loss of pulses we will do it then assess for changes. No positive changes and we call for termination orders.

Basically, if you're in traumatic arrest when we find you you probably will not be worked unless you've got a suspected tension pneumo and/or cardiac tamponade then we'll do a three hole punch and reassess.


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Interesting large-ish scale study done in Germany based on the German Resuscitation Registry. They end up with the following (for those patients who arrived with a pulse)...
7% of the patients survived until hospital discharge, and only 2% of the patients had good neurological outcome.
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Ironically enough, (and for the life of me I cannot find the episode, or think of the shows name) there was a kid who got stabbed on one of those trauma shows filmed in either Australia, or New Zealand.

Long story short, he codes, briefly dies, but makes a full neurological recovery. If anyone can find it, it's a remarkable case presentation; he had a pericadial tamponade I believe.
 
Cardiac arrest following trauma is not always futile. While most patients will die, there is some reasonable international experience (as noted here and elsewhere) that a subset of these patients can survive.

The "catch" is that the patient needs to have an immediately reversible cause that is recognised and treated very quickly; this means response times need to be short, clinical people need to be looking for and identifying what can be treated and treating it in a very few minutes, or taking the patient somewhere where it can be treated very quickly, and this place needs to be ready to receive the patient immediately and be very close.

So, in the real world; this would likely be the exception rather than the rule given most road ambulance personnel are probably some combination of not that good at recognising causes which can be immediately reversed either because the numbers of patients seen are small or ultrasound is not routinely carried and the travel time to somewhere which can treat these patients is more than a few minutes and/or even a hospital call before leaving the scene may not be able to get an appropriate doctor into ED within 5 or 10 minutes.

The EM consultants I know have never done a thoracotomy; indeed I'd say it is probably a never or once in a career event for even most general surgeons. I know they'd have a crack at it though if they are in the hospital.

In Auckland HEMSh can respond by road or air and has a Doctor on board but again, time to get them there.

Our new CPGs out this month have the following for cardiac arrest following trauma:

1. Compress arterial bleeding
2. Decompress a tension pneumothorax if present and ventilate at 8-10 min and not higher,
3. Give 2-3 litres of 0.9% NaCl and call for blood if available
4. Transport immediately
5. Do not routinely do CPR
 
We transport the following traumatic arrests:
1. Penetrating trauma with signs of life in the last 15 minutes
2. Blunt trauma with signs of life in 10 minutes
3. Extremity trauma with signs of life in 5 minutes

Pretty much everything else is a pronouncement, with the usual exceptions (like pregnancy).

I don't remember the numbers, but our trauma surgeons do a lot of ED thoracotomies.
 
Ensihoitaja said:
We transport the following traumatic arrests:
1. Penetrating trauma with signs of life in the last 15 minutes
2. Blunt trauma with signs of life in 10 minutes
3. Extremity trauma with signs of life in 5 minutes

Pretty much everything else is a pronouncement, with the usual exceptions (like pregnancy).

I don't remember the numbers, but our trauma surgeons do a lot of ED thoracotomies.
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This is interesting, what's the rationale?
 
VentMonkey said:
This is interesting, what's the rationale?
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I'm guessing it's a proximity thing.

Pretty much any traumatic arrest is going to meet those criteria in a large urban center.


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I have to admit, I was pretty shocked at the survival rates boasted in these studies. As others mentioned, it's difficult to really understand the reason because we only have access to the abstract. As someone mentioned above, there is also the question of bringing someone's body back on life support or just getting ROSC. That certainly puts the 7.5% figure from the UK into question in my opinion. However, what is interesting about the Aussie figure is that %5 lived until hospital discharge. Obviously, these are particular situations and populations groups. Regardless of this, I am still very surprised at the figures and how high they are. I have worked under protocols where we did not work traumatic arrest under almost any circumstance.
 
EpiEMS said:
Any particular evidence basis for those times that you're aware of? (Just curious!).
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We just had some CE with some of the trauma surgeons. I'm trying to remember if it was based on in house numbers or published research. I'll have to check.
 
The crude survival for the Australian study was 3.78% (25/660) for attempted resuscitations. 5% was after excluding patients with resusc time <10 min.

The English study had 705 patients, but 129 had an ED-only arrest, thus 576 w/ a prehospital arrest. Survival AT 30 DAYS was actually 8.3% for those who arrested out-of-hospital. But, 9 of the 30-day survivors apparently did not have a TBI or "severe" hemorrhagic injury, which makes me think they may have been medical arrests with subsequent trauma. Excluding those 9 would bring survival to 5.5%. 5 patients died after 30 days of hospitalization, so the actual survival to D/C was 6.8% (this includes the patients who arrested in the ED, unk if those 5 were OOH or ED arrests). Only 60% of overall patients received chest compressions. 191 patients were tended to by prehospital physicians. 99 resuscitative thoracotomies (unk breakdown for prehospital vs. ED or blunt vs. penetrating, but only 2 survived to 30 days).

Anyhow, I don't have anymore time to delve into the studies beyond that.
 
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