Traumatic cardiac arrest outcomes

February 25, 2013 by  
Filed under All Updates, EMS, ICU, Kids, Resus, Trauma

simEver heard anyone spout dogma along the lines of: “it’s a traumatic cardiac arrest – resuscitation is futile as the outcome is hopeless: survival is close to zero per cent”?

I have. Less frequently in recent years, I’ll admit, but you still hear it spout forth from the anus of some muppet in the trauma team. Here’s some recent data to add to the existing literature that challenges the ‘zero per cent survival’ proponents. A Spanish study retrospectively analysed 167 traumatic cardiac arrests (TCAs). 6.6% achieved a complete neurological recovery (CNR), which increased to 9.4% if the first ambulance to arrive contained an advanced team including a physician. Rhythm and age were important: CNR was achieved in 36.4% of VFs, 7% of PEAs, and 2.7% of those in asystole; survival rate by age groups was 23.1% in children, 5.7% in adults, and 3.7% in the elderly.

Since traumatic arrest tends to affect a younger age group than medical arrests, the authors suggest:

Avoiding the potential decrease in life expectancy in this kind of patient justifies using medical resources to their utmost potential to achieve their survival

Since 2.7% of the asystolic patients achieved a CNR, the authors challenge the practice proposed by some authors that Advanced Life Support be withheld in TCA patients with asystole as the initial rhythm:

had that indication been followed, three of our patients who survived neurologically intact would have been declared dead on-scene.”

I’d like to know what interventions were making the difference in these patients. They describe what’s on offer as:


In our EMS, all TCA patients receive ALS on-scene, which includes intubation, intravenous access, fluid and drug therapy, point-of-care blood analysis, and procedures such as chest drain insertion, pericardiocentesis, or Focused Assessment with Sonography for Trauma ultrasonography to improve the treatment of the cause of the TCA.

It appears that crystalloids and colloids are their fluid therapy of choice; unlike many British and Australian physician-based prehospital services they made no mention of the administration of prehospital blood products.

Traumatic cardiac arrest: Should advanced life support be initiated?
J Trauma Acute Care Surg. 2013 Feb;74(2):634-8


BACKGROUND: 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).

METHODS: This is a cohort study (2006-2009) of treatment benefits.

RESULTS: 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).

CONCLUSION: 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.

Comments

10 Responses to “Traumatic cardiac arrest outcomes”

  1. Christopher on February 25th, 2013 11:18

    In the absence of available US, chest tubes, and pericardiocentesis, coupled with transport times in the best case of 10 minutes or greater, is it still reasonable to attempt resus of TCA with a presenting rhythm of PEA/Asystole? Most American EMS systems lack the means to treat the H’s/T’s in TCA appropriately, beyond needle decomp of PTX (PEA would get bilateral needle decomp if indicated).

  2. Sebastian Mayanz on February 25th, 2013 14:48

    Dear Cliff, the study is from Spain and not France. The spanish prehospital system (specificaly SAMUR in Madrid) has excelent results. They have done great things last years. Congrats to them !

  3. Cliff on February 25th, 2013 17:05

    Oops you’re right – thanks for the correction. I confused SAMU and SAMUR. I have corrected it now.

  4. Tom W on February 25th, 2013 19:38

    I can’t access the full paper so just going off the abstract but…isn’t blunt vs penetrating a pretty important distinction here? Was that broken down at all in the paper or exclusion criteria? Also interesting that pericardiocentesis mentioned as a treatment, I thought current thinking was against this

  5. Mat Oliver on February 25th, 2013 21:03

    Interesting how they break it down by cardiac rhythm rather than mechanism.
    It would have been nice to see what there outcomes with blunt vs. penetrating are as we know penetrating do better.
    Also would have been interesting to see what rhythms were caused by which mechanism.

  6. Chris on March 2nd, 2013 02:40

    In a mixed urban/rural system in close (no more than 40min by ground from multiple Level 1 Trauma Centers) we don’t work blunt-trauma arrests. Penetrating trauma is worked at the provider’s discretion. I think the etiology of the arrest is important to distinguish- penetrating trauma seems more likely to cause correctable issues (reversible hemorrhage, tension pneumo, airway obstruction) than blunt trauma (uncompressible hemorrhage, aortic shearing, TBI)

  7. Cliff on March 2nd, 2013 09:46

    Tension pneuno is pretty common in blunt trauma too

  8. Sebastian on March 4th, 2013 07:02

    “40.1% were caused by road traffic accidents; 15.6% were caused by assaults, stab wounds, or GSWs; 16.8% were caused by falls from a height; and the rest were grouped together as other causes such as drowning, electrocution, self- harm, railroad or underground accidents, and so on.”
    I’m emailing the authors to see if they can give us some details on survival depending of mechanism of trauma…

  9. Cliff on March 4th, 2013 10:29

    Thanks Sebastian – please let me know what they say
    Cliff

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