Revisiting traumatic cardiac arrest: should CPR be initiated?

Abstract

Traumatic cardiac arrest (TCA) represents a unique problem, and poses difficult challenges in the care of trauma patients. Although the literature has suggested that attempted resuscitation from TCA in trauma is futile and consumptive of medical and human resources, studies have recently demonstrated that the outcome of TCA is comparable cardiac arrest secondary to non-traumatic events. The objective of this study was to determine the incidence, predictors, and outcomes following TCA. We retrospectively reviewed 124 adult patients with TCA over a period of 5years (July 2010 to June 2014). Cardiopulmonary resuscitation (CPR) occurred either in the field, en route, or in the emergency department at our Level I Trauma Center. Patients' demographics, clinical data, CPR-related variables, and outcomes were extracted from both the electronic and paper medical records. The median age of the group was 37 (IQR 38), and the median ISS was 37 (IQR 50). The most common cardiac rhythm observed was pulseless electrical activity (PEA, 55%). While 31.4% of patients achieved a return of spontaneous circulation (ROSC), only 7.3% survived with a complete neurological recovery (CNR). In blunt injury patients, the mortality rate after CPR was higher in motor-vehicle-related injuries than falls from heights (93.1 vs 72.3%, OR 5.06, 95% CI 0.95-27.0, p < 0.05). In penetrating injuries, the mortality rate after CPR was higher in patients with trauma to the torsos than those suffering injuries to the head, neck, face, and extremities combined (100 vs 81.3%, OR 0.049, 95% CI 0.0024-1.008, p < 0.001). Two variables predicted failure of CPR were prolonged time interval hospital transport (OR 0.42, 95% CI 0.22-0.80, p < 0.01) and high injury severity score (OR 0.97, 95% CI 0.94-1.00, p < 0.05). However, CPR duration/location (out-of-hospital or in-hospital), head injury, and day/night shifts in ED were not associated with the above outcome. When comparing age groups, the mortality was significantly higher in patients < 65 years than those ≥ 65 years (OR 0.2619, 95% CI 0.09485-0.9703, p = 0.0182). Although survival after CPR among trauma patients continues to have dismal outcomes, advanced cardiac life support should be initiated regardless of the initial EKG rhythm. Ultimately, both a rapid response time and transport to the ED are of the utmost importance to survival.