Traumatic Cardiac Arrest Patients Research Articles

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.

Emergency medical dispatch recognition, clinical intervention and outcome of patients in traumatic cardiac arrest from major trauma: an observational study

ObjectivesThe aim of this study is to describe the demographics of reported traumatic cardiac arrest (TCA) victims, prehospital resuscitation and survival to hospital rate.SettingHelicopter Emergency Medical Service (HEMS) in south-east...

Traumatic cardiac arrest and resuscitative endovascular balloon occlusion of the aorta (REBOA): a preliminary analysis utilizing high fidelity invasive blood pressure recording and videography.

Aortic occlusion (AO) increases proximal perfusion and may improve rates of return of spontaneous circulation (ROSC). The objective of this study was to investigate the hemodynamic effects of cardiopulmonary resuscitation (CPR) and AO by REBOA on patients in traumatic cardiac arrest. Patients admitted between February 2013 and May 2017at a tertiary center who suffered traumatic arrest, had an arterial line placed during resuscitation, and received CPR and REBOA which were included. In-hospital CPR data were obtained from videography. Arterial waveforms were recorded at 240Hz. 11 consecutive patients were included, 82% male; mean (± SD) age 37 ± 19years. 55% suffered blunt trauma and the remaining penetrating injuries. 64% arrested out of hospital. During compressions with AO, the mean systolic blood pressure (SBP) was 70 ± 22mmHg, mean arterial pressure (MAP) 43 ± 19mmHg, and diastolic blood pressure (DBP) 26 ± 17mmHg. Nine (82%) had ROSC, with eight having multiple periods of ROSC and arrest in the initial period. In-hospital mortality was 82%. Cardiac ultrasonography was used during arrest in 73%. In two patients with arterial line data before and after AO, SBP (mmHg) improved from 51 to 73 and 55 to 96 during arrest after AO. High-quality chest compressions coupled with aortic occlusion may generate adequate perfusion pressures to increase the rate of ROSC. New technology capable of transducing central arterial pressure may help us to understand the effectiveness of CPR with and without aortic occlusion. REBOA may be a useful adjunct to high-quality chest compressions during arrest.

Factors associated with outcomes in traumatic cardiac arrest patients without prehospital return of spontaneous circulation

BackgroundPrognostic factors for the outcomes in traumatic cardiac arrest (TCA) patients transported to hospitals without prehospital return of spontaneous circulation (ROSC) remain uncertain. The aim of this study is to investigate factors associated with outcomes in TCA patients without prehospital ROSC. MethodsWe conducted a retrospective cohort study using a multi-institutional, 5-year database. Only TCA patients without prehospital ROSC were included. The primary outcome was ROSC in the emergency department (ED), and the secondary outcome was 30-day survival. Logistic regression analysis was performed to determine the factors associated with primary and secondary outcomes. ResultsAmong 463 TCA patients, 73 (16%) had ROSC during ED resuscitation, and among those with sustained ROSC, 10 (14%) survived for at least 30 days. Injury severity score ≧ 16 (OR, 0.06; 95% CI: 0.02–0.20), trauma center admission (OR, 2.69; 95% CI: 1.03–7.03), length of ED resuscitation (OR, 0.98; 95% CI: 0.96-0.99), and total resuscitation length > 20 min (OR, 0.21; 95% CI: 0.08–0.54) were associated with ROSC. ConclusionsIn TCA patients transported to hospitals without prehospital ROSC, resuscitation attempts could be beneficial. We should aim to resuscitate patients as soon as possible with appropriate treatments for trauma patients, early activation of trauma team, and then, as a result, shorter resuscitation time will be achieved.

Survival rate variation among different types of hospitalized traumatic cardiac arrest: A retrospective and nationwide study.

Studies regarding the prognostic factors for survival conditions and the proportions of survival to discharge among different types of hospitalized traumatic cardiac arrest (TCA) during the period of postresuscitation are limited.This nationwide study was designed to determine certain parameters and clarify the effect of various injuries on the survival of hospitalized TCA patients to discharge.Data were retrieved from the National Health Insurance Research Database (NHIRD) from 2007 to 2013 in Taiwan. We reviewed patients with a diagnosis of TCA using International Classification of Disease Clinical Modification, 9th revision codes (ICD-9-CM codes). Patients identified for analysis were simultaneously coded in traumatic etiology (ICD-9-CM codes: 800-999) and cardiac arrest (ICD-9-CM codes: 427.41 or 427.5). The determinants and effects of different types of injury on survival were evaluated by SPSS 22.0 (IBM, Armonk, NY).A total of 3481 cases of hospitalized TCA were selected from the NHIRD. The overall rate of survival to discharge was 22.1%. The results indicated a decreased adjusted odds ratio (aOR) of survival to discharge with higher numbers of organ failure (aOR: 0.82; 95% confidence interval [CI]: 0.73-0.92). Patients with ventricular fibrillation had a better discharge rate (aOR: 4.33; 95% CI: 3.29-5.70). Two parameters, transfer to another hospital and the number of intensive care unit beds, were positively correlated with survival. Compared with traffic accidents, different injuries associated with survival to discharge were identified; the aOR (95% CI) was 1.89 (1.12-3.19) for poisoning, 1.63 (1.13-2.36) for falls, and 2.00 (1.36-2.92) for drowning/suffocation.This study has shown that hospitalized TCA patients with multiple organ failure may be less likely to be discharged from the hospital. The presence of ventricular fibrillation rhythm on admission increased the odds of survival to discharge. In the phase of postcardiac arrest care, the number of intensive care unit beds and transfer to another hospital were positively correlated with survival. Those events attributed to traffic accidents have a much worse influence on the main outcome.

Organ donation in trauma victims: A systematic review and meta-analysis

Although trauma patients represent a large pool of potential organ donors (PODs), the donor conversion rates (DCRs) in this population are unclear. Our primary objective was to synthesize published evidence on DCRs in trauma patients. As a secondary objective, we investigated factors that affect organ donation (OD) in the trauma population. We searched four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) and gray literature for articles on OD in trauma patients (PROSPERO 2017: CRD42017070388). Articles were excluded if it was not possible to calculate the DCR (actual organ donors divided by PODs). We pooled DCRs and performed subgroups analysis by trauma subpopulation, patients' age, and study publication date. We identified 27 articles with a total of 123,142 participants. Cohorts ranged in size from 28 to 120,512 patients (median, 132), with most studies performed in the United States. Conversion rates among individual studies ranged from 14.0% to 75.2% (median, 49.3%). All 27 studies were included in the meta-analysis. We found a pooled DCR of 48.1% using the random effects model. There was a high level of heterogeneity between studies (I = 97.4%). Upon subgroup analysis, we found DCRs were higher in head trauma patients compared with traumatic cardiac arrest patients (45.3% vs 20.9%, p < 0.001), in pediatric patients compared with adults (61.0% vs 38.0%, p = 0.018), and in studies published after 2007 compared with those published before (50.8% vs 43.9%, p < 0.001). Few studies assessed for factors associated with OD in trauma patients. We found variation in DCRs among trauma patients (range, 14.0-75.2%) and estimated a pooled DCR of 48.1%. Our results are limited by heterogeneity across studies, which may be attributable to differences in study design and population, definitions of a POD, and in the institutional criteria and processes regarding OD. Systematic reviews and meta-analyses level III.

The outcome of patients in traumatic cardiac arrest presenting to deployed military medical treatment facilities: data from the UK Joint Theatre Trauma Registry

BackgroundThe UK military was continuously engaged in armed conflict in Iraq and Afghanistan between 2003 and 2014, resulting in 629 UK fatalities. Traumatic cardiac arrest (TCA) is a precursor to...

Association between spinal immobilization and survival at discharge for on-scene blunt traumatic cardiac arrest: A nationwide retrospective cohort study

IntroductionSpinal immobilization has been indicated for all blunt trauma patients suspected of having cervical spine injury. However, for traumatic cardiac arrest (TCA) patients, rapid transportation without compromising potentially reversible causes is necessary. Our objective was to investigate the temporal trend of spinal immobilization for TCA patients and to examine the association between spinal immobilization and survival. MethodsWe conducted a retrospective cohort study using the Japan Trauma Data Bank 2004–2015 registry data. Our study population consisted of adult blunt TCA patients encountered at the scene of a trauma. The primary outcome was the survival proportion at hospital discharge, and the secondary outcome was the proportion achieving return of spontaneous circulation (ROSC). We examined the association between spinal immobilization and these outcomes using a logistic regression model based on imputed data sets with the multiple imputation method to account for missing data. ResultsAmong 4313 patients who met the inclusion criteria, 3307 (76.7%) were immobilized. The proportion of patients that underwent spinal immobilization gradually decreased from 82.7% in 2004–2006 to 74.0% in 2013–2015. 1.0% of immobilized and 0.9% of non-immobilized patients had severe cervical spine injury. Spinal immobilization was significantly associated with lower survival at discharge (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.42 to 0.98) and ROSC by admission (OR, 0.48; 95%CI, 0.27 to 0.87). There was no significant sub-group difference of the association between spinal immobilization and survival at discharge by patients with or without cervical spine injury (p for interaction 0.73). ConclusionSpinal immobilization is widely used even for blunt TCA patients, even though it is associated with a lower rate of survival at discharge and ROSC by admission. According to these results, we suggest that spinal immobilization should not be routinely recommended for all blunt TCA patients.

Epidemiology of traumatic cardiac arrest in patients presenting to emergency department at a level 1 trauma center.

Introduction:There is a paucity of literature on prehospital care and epidemiology of traumatic cardiac arrest (TCA) in India. This study highlights the profile and characteristics of TCA.Methods:A retrospective cohort study was conducted to study epidemiological profile of TCA patients ≥1 year presenting to a level 1 trauma center of India.Results:One thousand sixty-one patients were recruited in the study. The median age (interquartile range) was 32 (23–45) years (male:female ratio of 5.9:1). Asystole (253), pulseless electrical activity (11), ventricular fibrillation (six), and ventricular tachycardia (five) were initial arrest rhythm. Road traffic crash (RTC) (57.16%), fall from height (18.52%), and assault (10.51%) were modes of injury. Prehospital care was provided by police (36.59%), ambulance (10.54%), relatives (45.40%), and bystanders (7.47% cases). Return of spontaneous circulation was seen in 69 patients, of which only three survived to hospital discharge.Conclusion:RTC in young males was a major cause of TCA. Asystole was the most common arrest rhythm. Police personnel were major prehospital service provider. Prehospital care needs improvement including the development of robust TCA registry.

Challenging the dogma of traumatic cardiac arrest management: a military perspective

Attempts to resuscitate patients in traumatic cardiac arrest (TCA) have, in the past, been viewed as futile. However, reported outcomes from TCA in the past five years, particularly from military...

Clamshell thoracotomy and open heart massage—A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study

AimsSelected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. MethodsWe adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. ResultsThe mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167s (02:47min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. ConclusionClamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment.

Traumatic cardiac arrest

Traumatic cardiac arrest is known to have a poor outcome, and some authors have stated that attempted resuscitation from traumatic cardiac arrest is futile. However, advances in damage control resuscitation and understanding of the differences in pathophysiology of traumatic cardiac arrest compared to medical cardiac arrest have led to unexpected survivors. Recently published data have suggested that outcome from traumatic cardiac arrest is no worse than that for medical causes of cardiac arrest, and in some groups may be better. This review highlights key areas of difference between traumatic cardiac arrest and medical cardiac arrest, and outlines a strategy for the management of patients in traumatic cardiac arrest. Standard Advanced Life Support algorithms should not be used for patients in traumatic cardiac arrest.

271 Traumatic Cardiac Arrests in Asystole Managed by French Out-of-Hospital Emergency Medical Service: A Nationwide Survey

The prognostic of traumatic cardiac arrest (TCA) patients is considered to be extremely pejorative and the resuscitation attempt to be futile when the victim presents an asystole at EMS arrival. The aim of this study is to describe, in the out-of-hospital medical system in France, the TCA in asystole and to compare this population with non-traumatic cardiac arrests which initial pace is also asystole at emergency medical service (EMS) arrival. French multicentric (221 EMS), prospective, comparative study based on the data gathered in the RéAC registry framework between July 1, 2011 and December 10, 2013. Among 15982 registered CA with asystole as initial rhythm, 13892 were medical CA and 2090 TCA. TCA occurred in younger patients (48 ± 21 versus 66,9 ± 21; P<.04). They also happen in a more masculine population than in non-traumatic CA (76,6% versus 62,8%; P<10-4). The other variables concerning care and prognostic are set out in Table. Out-of-hospital resuscitation maneuvers was significantly less attempted in TCA victims and yet 8% of them are admitted to hospital with a spontaneous circulation. At Day 30, 2% of them survived and half of them had a Cerebral Performance Category score. We observe a survival odd significantly inferior in TCA victims than in non-traumatic CA population. However, the survival rates of TCA patients in asystole suggest that out-of-hospital resuscitation is not futile. Some complementary studies are requested to identify the factors of good functional prognostic.TableCardiac arrest in asystole: comparison of care and outcome between traumatic and medical cardiac arrestsMedical CA(n=13892)Traumatic CA(n=2090)P valueWitness’ presence when CA occured56,7%37,8%<10-4EMS arrival delay (min)21min ± 15min19min ± 18min<10-4Bystander BLS initiated31,2%22,6%<10-4BLS initiated at MERS arrival83%70%<10-4ACLS initiation62,3%56,4%<10-4ROSC14,3%10,1%<10-4ROSC delay (min)16min ± 14min22min ± 43min=.241Transport with non-beating heart13,1%8,6%=.002Admission survival10%8,2%=.009Day 30 survival4,7%2,1%<10-4BLS, Basic Life Support; ACLS, Advanced Cardiac Life Support; ROSC, Return of Spontaneous Circulation; min, minute. Open table in a new tab

Should prehospital resuscitative thoracotomy be incorporated in advanced life support after traumatic cardiac arrest?

The survival of traumatic cardiac arrest patients poses a challenge for Emergency Medical Services initiating advanced life support on-scene, especially with regard to having to decide immediately whether to initiate prehospital emergency thoracotomy. Although the necessity for carrying out the procedure remains a cause for debate, it can be life-saving when performed with the correct indications and approaches.

Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service

Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service

Sticking the knife in: Time to review management of tension pneumothorax

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.

Traumatic cardiac arrest

Several studies recommend not initiating advanced life support in traumatic cardiac arrest (TCA), mainly owing to the poor prognosis in several series that have been published. This study aimed to analyze the survival of the TCA in our series and to determine which factors are more frequently associated with recovery of spontaneous circulation (ROSC) and complete neurologic recovery (CNR). This is a cohort study (2006-2009) of treatment benefits. A total of 167 TCAs were analyzed. ROSC was obtained in 49.1%, and 6.6% achieved a CNR. Survival rate by age groups was 23.1% in children, 5.7% in adults, and 3.7% in the elderly (p < 0.05). There was no significant difference in ROSC according to which type of ambulance arrived first, but if the advanced ambulance first, 9.41% achieved a CNR, whereas only 3.7% if the basic ambulance first. We found significant differences between the response time and survival with a CNR (response time was 6.9 minutes for those who achieved a CNR and 9.2 minutes for those who died). Of the patients, 67.5% were in asystole, 25.9% in pulseless electrical activity (PEA), and 6.6% in VF. ROSC was achieved in 90.9% of VFs, 60.5% of PEAs, and 40.2% of those in asystole (p < 0.05), and CNR was achieved in 36.4% of VFs, 7% of PEAs, and 2.7% of those in asystole (p < 0.05). The mean (SD) quantity of fluid replacement was greater in ROSC (1,188.8 [786.7] mL of crystalloids and 487.7 [688.9] mL of colloids) than in those without ROSC (890.4 [622.4] mL of crystalloids and 184.2 [359.3] mL of colloids) (p < 0.05). In our series, 6.6% of the patients survived with a CNR. Our data allow us to state beyond any doubt that advanced life support should be initiated in TCA patients regardless of the initial rhythm, especially in children and those with VF or PEA as the initial rhythm and that a rapid response time and aggressive fluid replacement are the keys to the survival of these patients. Therapeutic study, level IV; epidemiologic study, level III.

Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service.

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.

Computed Tomography Evaluation of the Brain and Upper Cervical Spine in Patients With Traumatic Cardiac Arrest Who Achieved Return of Spontaneous Circulation

The outcomes of patients with traumatic cardiac arrest (TCA) have been dismal. However, imaging modalities are improving rapidly and are expected to play a role in treatment of patients with TCA. In this retrospective study, whether obtaining computed tomography (CT) immediately after resuscitation had any clinical value was evaluated. Among 145 patients with TCA admitted to our institution during 4 years, hemodynamically stable return of spontaneous circulation (ROSC) was achieved in 38 (26%). Brain and cervical spine CT was obtained prospectively, and the frequency and type of traumatic brain injury (TBI)/upper cervical spine injury (UCSI) were investigated. CT was performed uneventfully in all patients with an average door-to-CT time of 51.5 ± 18.6 min. Twenty (53%) had CT evidence of TBI. However, no patients underwent brain surgery because of lack of return of brainstem functions. Among the 18 patients without TBI, CT signs of hypoxia were present in 15 patients (39%), and CT was considered intact in 3 patients (8%). None of the 35 patients with abnormal CT findings survived, and the presence of such findings predicted fatality with high sensitivity and specificity. While 13 of the 38 patients (34%) had CT evidence of UCSI, concomitant TBI and USCI were uncommon. None of the 13 patients with UCSI underwent spine surgery because of lack of return of brainstem functions, and the presence of USCI might also be associated with fatality. Although obtaining CT was useful in the prognostication of TCA patients with ROSC, it did not have much impact in therapeutic decision making.