Traumatic Cardiac Arrest Patients Research Articles

Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers.

Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA. We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process. A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS. TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.

Resuscitative Thoracotomy for Traumatic Cardiac Arrest: Potential Impact of Resource Constraint on Outcomes and Blood Product Utilization

IntroductionResuscitative thoracotomy (RT) in the setting of traumatic arrest serves as a vital but resource-intensive intervention. The COVID-19 pandemic has created critical shortages, sharpening the focus on efficient resource utilization. This study aims to compare RT performance and blood product utilization before and after the onset of the COVID-19 pandemic for patients in traumatic cardiac arrest. MethodsAll patients undergoing RT for traumatic cardiac arrest in the emergency department at our American College of Surgeons–verified Level 1 trauma center (August 01, 2017-July 31, 2022) were included in this retrospective observational study. Study groups were dichotomized into pre-COVID (before October 03, 2020) versus COVID (from October 03, 2020 on) based on patient arrival date demographics, clinical/injury data, and outcomes were collected. The primary outcome was blood product transfusion <4 h after presentation. Results445 RTs (2% of 23,488 trauma encounters) were performed over the study period: Pre-COVID, n = 209 (2%) versus COVID, n = 236 (2%) (P = 0.697). Survival to discharge was equivalent Pre-COVID versus COVID (n = 22, 11% versus n = 21, 9%, P = 0.562). RT patients during COVID consumed a median of 1 unit less packed red blood cells at the 4 h measurement (3.0 [1.8-7.0] versus 3.9 [2.0-10.0] units, P = 0.012) and 1 unit less of platelets at the 4 h measurement (4.3 [2.6-10.0] versus 5.7 [2.9-14.4] units, P = 0.012) compared to Pre-COVID. These findings were persistent after performing multivariable negative binomial regression. ConclusionsRates of RT and survival after RT remained consistent during the pandemic. Despite comparable RT frequency, packed red blood cells and platelet transfusions were reduced, likely reflecting resource expenditure minimization during the severe blood shortages that occurred during the pandemic. RT performance for patients in traumatic arrest may, therefore, be feasible during global pandemics at prepandemic frequencies as long as particular attention is paid to resource expenditure.

Abstract 254: Patients With Signs of Life on Hospital Arrival Have a Higher Chance of Survival and Favorable Neurological Outcomes Following Traumatic Cardiac Arrest

Introduction: The clinical impact of signs of life (SOL) in traumatic cardiac arrest (TCA) remain to be elucidated. A previous study compared TCA patients with pulseless electrical activity (PEA) to those with asystole, but survival was not significantly different between the groups. Other obvious SOL (i.e., fine extremity/eye movement, light reflection, agonal respiration) have not yet been examined in TCA. Hypothesis: We hypothesized that TCA patients with SOL on hospital arrival have a higher chance of survival and good neurological outcomes. Aim: To examine survival and neurological outcomes in TCA patients with or without SOL. Methods: Retrospective review of data from the Japan Trauma Data Bank (2019-2021). The inclusion criteria were patients with TCA on arrival. The exclusion criteria were patients with burns, abbreviated injury scale score&gt; 6 in any region, and missing survival or SOL data. SOL was defined as follows: extremity or eye movement, light reflex, gasping, pulseless electrical activity with electrical heart activity &gt; 40 beats per minute. The primary outcome was survival at discharge. The secondary outcome was favorable neurological outcome (Glasgow Outcome Scale score of 4 or 5) at hospital discharge. Patients with and without SOL were compared using univariable analysis. Results were described with odds ratio (ORs) and 95% confidence intervals (CI). Results: A total of 2,136 patients (121 with SOL and 2,015 without SOL) were included. The characteristics of patients with or without SOL were as follows: age (median age 60.5 years old [interquartile range: 42-80 years] vs. 55.2 [38-75]), gender (male: 83/121 (68.6%) vs. 1,321/2,015 (65.9%), Injury Severity Score (32.9 [22-43] vs. 33.7 [22-41]), blunt trauma (97/121 (82.2%) vs. 1,711/2,015 (84.9%)), and transportation time (15.1 min [7-18] vs. 13.3 [7-16]). The patients with SOL showed higher survival compared with the patients without SOL (11/121 (8.5%) vs. 24/2015 (1.2%), OR 1.9 [CI 1.38-2.85]). A similar trend was observed for favorable neurological outcomes (5/95 (5.3%) vs. 7/1,440 (0.5%), OR 2.41 [CI 1.26-3.60]). Conclusions: TCA patients with SOL at arrival showed higher survival and favorable neurological outcomes at hospital discharge compared with TCA patients without SOL.

A Contemporary Study of Pre-hospital Traumatic Cardiac Arrest: Distinguishing Exsanguination From Non-exsanguination Arrest With a Review of Current Literature.

Background Traumatic cardiac arrest (TCA) remains a challenging problem in terms of diagnosis and management. This is due to difficulty distinguishing the TCA cause and therefore understanding the pathophysiology. The goal of this study was to analyze a contemporary series of TCA patients and classify the causes of TCA into exsanguination (EX) arrest and non-exsanguination (non-EX) arrest. Methods This was a retrospective review of patients suffering TCA during 2019 at a level I trauma center. We excluded patients whose arrests were from medical causes such as ventricular fibrillation, ventricular tachycardia, pulmonary embolus, etc., hanging, drowning, thermal injury, outside transfer, and pediatric patients (age <13 as this is our institutional definition for pediatric trauma patients). We reviewed pre-hospital run-sheets, hospital charts including autopsy findings, and classified patients into EX and non-EX TCA. We defined a witnessed arrest (WA) using the traditional outside hospital cardiac (non-trauma) arrestdefinition. Outcomes included the incidence of EX arrest, survival to discharge, and hospital costs. Descriptive statistics were used.Significancewas set atp< 0.05. Results After exclusion, 54 patients suffered TCA with a mean age of 45.9 (±19.8) years.Eighty-three percent of patients were male. The average cost per TCA was ~$16,000. Of the 54 TCAs, 26 (48%) were WA, with one (1.85%) survivor (no non-WA TCA patients survived). Twenty-two (41%) patients died from EX-arrest; 59% penetrating vs. 28% blunt (p= 0.03). The one EX-arrest survivor was a 19-year-old gunshot wound to the leg whose arrest was witnessed, with a short downtime, and the cause of arrest (bleeding leg wound) was quickly reversible. Conclusion We classified 41% of TCAs to have died from EX-arrest with only a 1.85% survival rate. This study calls for a TCA pre-hospital registry with accurate and consistent data definitions and collection. The registry should capture the cause of arrest for future research, management decision-making, and prognostication.

No frequency change of prehospital treatments by emergency medical services workers for traumatic cardiac arrest patients before and after the COVID-19 pandemic in Korea: a case series

Purpose: 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. Methods: 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. Results: 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. Conclusions: 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.

Traumatic cardiac arrest – a nationwide Danish study

BackgroundCardiac 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).MethodsThis 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.ResultsA 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].ConclusionSurvival 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.

Impact of the 2015 European guidelines for resuscitation on traumatic cardiac arrest outcomes and prehospital management: A French nationwide interrupted time-series analysis

AimTo evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on patient outcomes following traumatic cardiac arrest (TCA) and on advanced life support interventions carried out by physician-staffed ambulances. MethodsData of TCA patients aged ≥18 years were extracted from the French nationwide cardiac arrest registry. A pre- (2011–2015) and a post-publication period (2016–2020) were defined. In the guidelines, a specific TCA management algorithm was introduced to prioritise the treatment of reversible causes. Its impact was evaluated using adjusted interrupted time series analysis. Results4,980 patients were treated (2,145 during the pre-publication period and 2,739 during the post-publication period). There was no significant change in the rates of prehospital ROSC (22.4% vs. 20.2%, p = 0.07 in the pre- and post- intervention respectively), survival (1.4% vs. 1.4%, p = 0.87) or good neurological outcome (71.4% vs. 66.7%, p = 0.93) or in the incidence of organ donation (1.6% vs. 1.3%, p = 0.50). There were nonsignificant changes in the adjusted temporal trend for ROSC (aOR 0.88; 95% CI [0.77; 1.00]), survival (aOR 1.34; 95% CI [0.83;2.17]), good neurological outcome (aOR 1.57; 95% CI [0.82;3.05]), and organ donation (aOR 1.06; 95% CI [0.71;1.60]). The use of intraosseous catheters (13.0% vs. 19.2%, p < 0.001), external haemorrhage control measures (23.9% vs. 64.8%, p < 0.001), bilateral chest decompression (13.7% vs. 16.5%, p = 0.009), and packed red cell transfusion (2.7% vs. 6.5%, p < 0.001) increased in the post-publication period. ConclusionsDespite the increased frequency of trauma rescue interventions performed by on-scene physicians, no change in patient-centred outcomes was associated with the publication of the 2015 ERC guidelines in France.

Outcomes in traumatic cardiac arrest patients who underwent advanced life support.

Survival following a traumatic cardiac arrest (TCA) remains poor despite research focused on specific management and guideline adaptation. Previous research has identified factors including age, arresting rhythm, injury severity and distance from hospital to be associated with prehospital TCA outcomes. The present study aimed to review the local incidence of TCA to inform local practice within a mature trauma system. A retrospective trauma database review from 2008 to 2021 was conducted at the Royal Brisbane and Women's Hospital. Patients were categorised by prehospital and in-hospital arrest, prehospital return of spontaneous circulation (ROSC), and year in relation to TCA management protocol changes. Descriptive comparative analysis was performed with the primary outcome of interest being survival to hospital discharge. Survival to hospital discharge was similar in patients in whom TCA occurred in the prehospital environment and hospital (24 vs 29%). Mechanism of injury, response to intervention and location of cardiac arrest were important outcome associations. Patients with a positive focused assessment with sonography in trauma scan were less likely to achieve ROSC but more likely to survive to discharge. The frequency of prehospital interventions remained similar after the guideline changes; with more patients arriving to the hospital with improved haemodynamic parameters and increased survival. These results support the identification and immediate management of TCA. No patients survived if they did not achieve ROSC by hospital arrival, questioning the role for aggressive management beyond the ED in this cohort. Future research will focus on the identification of patients with potentially positive survival outcomes and further define futile intervention factors.

Comparison of in-hospital and out-of-hospital cardiac arrest of trauma patients in Qatar

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.

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.

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

BackgroundCirculatory 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.MethodsThis 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.ResultsThirty-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 a physician was available on scene and 38.0% if no physician was available. Only non-shockable rhythm was associated with a higher mortality (RR 1.12, p = 0.06).ConclusionApproximately 1 in 20 patients with prehospital TCA will survive; about 40% of survivors have favorable neurological outcome.

A 6-year case series of resuscitative thoracotomies performed by a helicopter emergency medical service in a mixed urban and rural area with a comparison of blunt versus penetrating trauma

BackgroundResuscitative thoracotomy (RT) is an intervention that can be performed in the prehospital setting for relieving cardiac tamponade and/or obtaining vascular control of suspected sub-diaphragmatic haemorrhage in patients in traumatic cardiac arrest. The aim of this retrospective case study is to compare the rates of return of spontaneous circulation (ROSC) in RTs performed for both penetrating and blunt trauma over 6 years in a mixed urban and rural environment.MethodsThe electronic records of a single helicopter emergency medical service were reviewed between 1st June 2015 and 31st May 2021 for RTs. Anonymised data including demographics were extracted for relevant cases. Data were analysed with independent t-tests and Χ2 tests. A p value < 0.05 was considered statistically significant.ResultsForty-four RTs were preformed within the 6 years (26 for blunt trauma). Eleven ROSCs were achieved (nine blunt, two penetrating) but no patient survived to discharge. In contrast to RTs for penetrating trauma, twelve of the RTs for blunt trauma had a cardiac output present on arrival of the prehospital team (p = 0.01). Two patients had an RT performed in a helicopter (one ROSC) and two on a helipad (both achieving ROSC), likely due to the longer transfer times seen in a more rural setting. Four of the RTs for blunt trauma (15%) were found to have a cardiac tamponade versus seven (39%) of the penetrating trauma RTs.ConclusionPrehospital RT remains a procedure with low rates of survival but may facilitate a ROSC to allow patients to reach hospital and surgery, particularly when distances to hospitals are greater. A higher-than-expected rate of cardiac tamponade was seen in RTs for blunt trauma, although not caused by a right ventricular wound but instead due to underlying vessel damage.

Association between calcium administration and outcomes during adult cardiopulmonary resuscitation at the emergency department.

OBJECTIVES:Calcium administration during cardiac arrest is limited in some circumstances, mainly due to lack of consistent evidence. This study aims to investigate whether calcium therapy administered during cardiac arrest at the Emergency Department is associated with good outcomes, including the probability of return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge, and favorable neurological outcome at discharge.METHODS:We retrospectively reviewed 599 consecutive adult cardiac arrest events between 2016 and 2018. The primary outcome was the ROSC rate. Secondary outcomes included survival to hospital admission, survival to hospital discharge, and favorable neurologic outcome at hospital discharge. Multivariable logistic regression with inverse probability of treatment weighting was analyzed to examine the association between calcium administration and outcomes.RESULTS:Of 599 events, calcium was administered in 72 (12%) cases. The use of calcium during cardiopulmonary resuscitation (CPR) after adjusting for confounding factors was not associated with any better outcomes, including ROSC (adjusted odds ratio (aOR) 0.53, 95% confidence interval [CI] 0.24–1.17), survival to hospital admission (aOR 1.07, 95% CI 0.47–2.41), survival to hospital discharge (aOR 1.93, 95% CI 0.43–8.56), and favorable neurological outcome (aOR 6.60, 95% CI 0.72–60.74). Besides, calcium use in traumatic cardiac arrest patients was associated with unfavorable outcomes, including ROSC (aOR 0.02, 95% CI 0.00–0.09) and survival to hospital admission (aOR 0.16, 95% CI 0.03–0.84).CONCLUSION:The use of calcium during an adult cardiac arrest was not associated with better outcomes. Although associations drawn from this study did not indicate the causality, given calcium during CPR was linked to poorer outcomes in traumatic cardiac arrest patients, including ROSC and survival to hospital admission.

Impact of Specific Emergency Measures on Survival in Out-of-Hospital Traumatic Cardiac Arrest

The management of out-of-hospital traumatic cardiac arrest (TCA) for professional rescuers entails Advanced Life Support (ALS) with specific actions to treat the potential reversible causes of the arrest: hypovolemia, hypoxemia, tension pneumothorax (TPx), and tamponade. The aim of this study was to assess the impact of specific rescue measures on short-term outcomes in the context of resuscitating patients with a TCA. This retrospective study concerns all TCA patients treated in two emergency medical units, which are part of the Northern French Alps Emergency Network (RENAU), from January 2004 through December 2017. Utstein variables and specific rescue measures in TCA were compiled: fluid expansion, pelvic stabilization, tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at Day 30 with good neurological status (Cerebral Performance Category [CPC] score CPC 1 and CPC 2). In total, 287 resuscitation attempts in TCA were included and 279 specific interventions were identified: 262 fluid expansions, 41 pelvic stabilizations, five tourniquets, and 175 bilateral thoracostomies (including 44 with TPx). Among the standard resuscitation measures to treat the reversible causes of cardiac arrest, this study found that bilateral thoracostomy and tourniquet application on a limb hemorrhage improve survival in TCA. A larger sample for pelvic stabilization is needed.

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

AimPoint-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. MethodsWe 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. ResultsWe 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. ConclusionsPatients 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.

Abstract 363: Just Another Post-Arrest?: Predicting Outcomes in Traumatic Arrest and Hemorrhagic Shock

Introduction: Traumatic cardiac arrest is a challenging presentation at trauma centers globally, with a high mortality and subsequent morbidity among survivors. For those who do obtain return of spontaneous circulation (ROSC), there is even less clarity with respect to how best to prognosticate outcomes. The previously derived and validated Pittsburgh Cardiac Arrest Categories (PCAC) have demonstrated value in predicting functional outcome and survival to hospital discharge in non-traumatic arrest. It is a 1 to 4 categorical score wherein a higher category is correlative to a worse clinical outcome. We hypothesized that the PCAC would be able to accurately predict outcomes in a trauma cohort. Methods: Utilizing the Pennsylvania Trauma Outcome System registry, 30 patients from 2018-2020 presented to a single, urban, tertiary trauma center with traumatic arrest. Demographics, vital statistics, injury patterns, and hospital course were abstracted and matched with subsequent PCAC scoring in accordance with previously published methods. Results: Population was predominantly male 16 (80%), black (75%) with a mean age 33 y (SD 13) . Penetrating trauma comprised 76% with average injury severity score of 38 (SD 22). Six (30%) were discharged alive with 5 requiring inpatient rehabilitation. Average length of hospital stay was 16 days (SD 18) with approximately 11 ventilator free days (SD 9). Average GFR at time of discharge was 44mg/dl (SD 31). The majority, 12 (57%), were PCAC 4 on arrival owing to predominant evidence of coma, 61%. By post-arrest day 1, there was a more even distribution between PCAC categories with category 2 (28%) and 3 (28%) each having 3 survivors and PCAC 4 (28%) having 2. By day 3, PCAC scores were less normally distributed with PCAC 1 having 6 survivors (42%) and PCAC 4 having 5 (35%). Day 1 and 3 categories continued to be driven principally be median Coma scores 0 (IQR: 0-8) but with regression of median SOFA cardiopulmonary scores 4 (IQR:0-6). SOFA Renal scores in survivors predictably increased from no injury to moderate dysfunction across this same period (IQR:1-4). Conclusion: PCAC scores in traumatic cardiac arrest patients who achieve ROSC do not predict multisystem organ failure but do predict neurologic outcome.

Mechanisms of traumatic cardiac arrest in Kuwait: A retrospective study.

The objective of this study is to describe the epidemiology and causes of traumatic cardiac arrest (TCA) in Kuwait aiming to provide a preliminary background to update the current guidelines and improve patients’ management.This is a retrospective analysis of TCA cases retrieved from emergency medical services archived data between 1 January and 31 December 2017. The TCA cases were sub-grouped based on mechanism of injury then compared in terms of patient demographics, vital signs, patterns of injuries, resuscitation practices, and outcomes.Outcomes; On scene mortality rate and pre-hospital return of spontaneous circulation.Among the 204 TCA patients, 140 patients met the inclusion criteria. This whole group was then divided in to 4 subgroups: road traffic accident (RTA) 76% (n=106), fall from height (FFH) 13% (n = 18), slip/fall 4% (n = 6), and assaults 7% (n = 10). There was significant difference between the four mechanisms in: mean age (P = < .001), type of injury (P = .005), head injury (P = .005), chest injury (P = .003), GCS score < 9 (P = .004) and initial hypertension (P = < .001). Initial hypertension and GCS score < 9 were only documented in head injuries of RTA and slip/fall groups. Significant difference was also seen in cardiopulmonary resuscitation (P = .006), airway management (P = .035) and on scene mortality rate (P = .003). All patients who had isolated head injury in FFH were pronounced dead on scene, 60%.Not all TCA incidents are the same, there are different pattern of injuries in each TCA mechanism. Head injuries are predominantly seen in RTA, FFH, slip /falls and chest injuries are seen in assaults. This can influence emergency medical services personals resuscitation plan. Further research is required to address the resuscitation of TCA of different mechanisms.

Decision making in prehospital traumatic cardiac arrest; A qualitative study

BackgroundDespite improving survival of patients in prehospital traumatic cardiac arrest (TCA), initiation and/or discontinuation of resuscitation of TCA patients remains a subject of debate among prehospital emergency medical service providers. The aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with TCA. MethodsTwenty-five semi-structured interviews were conducted with experienced ambulance nurses, HEMS nurses and HEMS physicians individually, followed by a focus group discussion. Participants had to be currently active in prehospital medicine in the Netherlands. Interviews were encoded for analysis using ATLAS.ti. Using qualitative analysis, different themes around decision making in TCA were identified. ResultsEight themes were identified as being important factors for decision making during prehospital TCA. These themes were: (1) factual information (e.g., electrocardiography rhythm or trauma mechanism); (2) fear of providing futile care or major impairment if return of spontaneous circulation was obtained; (3) potential organ donation; (4) patient age; (5) suspicion of attempted suicide; (6) presence of bystanders or family; (7) opinions of other team members; and (8) training and education. Several ambulance nurses reported they do not feel adequately supported by the current official national ambulance guidelines on TCA, nor did they feel sufficiently trained to perform pre-hospital interventions such as endotracheal intubation or needle thoracocentesis on these patients. ConclusionEight themes were identified as being important for decision making during prehospital TCA. While guidelines based on prognostic factors are important, it should be recognized that decision making in TCA is impacted by more than factual information alone. This should be reflected in educational programs and future guidelines.

P104: Can patients suffering traumatic cardiac arrest be identified using the National Ambulatory Care Reporting System (NACRS) database?

Introduction: Trauma is a common cause of mortality across all age groups and is projected to become the third greatest contributor to global disease burden. Recent studies have demonstrated that survival from traumatic cardiac arrest (TCA) is more favourable than once believed and further research on this population is being encouraged. Currently, it is unclear whether existing databases, such as the National Ambulatory Care Reporting system (NACRS), which includes all emergency department visits, could be used to identify TCAs for population-based studies. We aimed to determine the accuracy of NACRS administrative codes in identifying TCA patients. Methods: This retrospective validation study used data acquired from NACRS and our institutional Patient Care System. We identified a number of International Classification of Diseases, tenth revision (ICD-10) diagnostic, procedural and cause of injury codes that we hypothesized would be consistent with TCA. NACRS was subsequently searched for patients meeting the diagnostic code criteria (January 1 - December 31, 2015). The following inclusion criteria were: an eligible ICD-10 diagnostic code or a qualifying Canadian Classification of Health Interventions (CCI) procedure code and an eligible ICD-10 external cause of injury code. Electronic medical records for these patients were then reviewed to determine whether true TCAs had occurred. Results: Eighty-five patients met the inclusion criteria and one was excluded from analysis due to inaccessible health records, leaving 84 patients eligible for chart review. Overall, 55% (n = 46) of patients were found to have true TCA, 35% (n = 29) sustained a cardiac arrest of non-traumatic etiology and 11% (n = 9) were considered “unclear” (i.e. could not determine whether it was a true TCA based on the medical records). We found that true TCA patients were most accurately identified using a combination of ICD-10 CA cardiac arrest and external cause of injury codes (Positive predictive value: 70.6%, 95% CI 46.9-86.7). Conclusion: TCA patients were identified with moderate accuracy using the NACRS database. Further efforts to integrate specific data fields for TCA cases within existing population databases and trauma registries is necessary to facilitate future studies focused on this patient population.

Out-of-hospital cardiac arrest following trauma: What does a helicopter emergency medical service offer?

IntroductionHelicopter emergency medical services (HEMS) are often dispatched to patients in traumatic cardiac arrest (TCA) as they can provide treatments and advanced interventions in the pre-hospital environment that have the potential to contribute to an increased survival. This study, aimed to investigate the added value of HEMS in the treatment of TCA. MethodsWe performed a retrospective cohort study of all patients with a pre-hospital TCA who were attended by a non-urban HEMS (Kent, Surrey and Sussex Air Ambulance trust) between July 1st 2013 and May 1st 2018. We investigated how many patients got return of spontaneous circulation (ROSC) at scene, which HEMS specific advanced interventions were performed in these patients, and how these interventions were related to ROSC. ResultsDuring the study period 263 patients with a TCA were attended by HEMS with an average response time of 30 min [range 13–109]. 51 patients (20%) regained ROSC at scene (28 before- and 23 after arrival of HEMS). The HEMS specific interventions of blood product administration (OR 8.54 [2.84–25.72]), and RSI (2.95 [1.32–6.58]) were positively associated with ROSC. Most patients who had a ROSC had one or more HEMS specific interventions being performed – RSI (n = 19, 37%), blood product administration (n = 32, 62%), thoracostomies (n = 36, 71%) and thoracotomy (n = 1, 2%). HEMS also delivered other important interventions to these patients as IV/IO access (n = 20, 39.2%) and endotracheal intubation without drugs (n = 9, 17.6%). ConclusionHEMS teams should be involved in the treatment of patients with a TCA, even in non-urban areas with prolonged response times, as they provide knowledge and skills that contribute to regaining and maintaining a sustained ROSC in this critically ill and injured cohort of patients.