Surviving traumatic cardiac arrest: Identification of factors associated with survival

Trauma center vs. nearest non-trauma center: direct transport or bypass approach for out-of-hospital traumatic cardiac arrest

BACKGROUND

Out-of-hospital traumatic cardiac arrest (TCA), a sudden loss of heart function caused by severe trauma such as blunt, penetrating, or other injuries, presents significant public health challenges due to its high severity and extremely low survival rates. Approximately 2.7% of trauma patients experience cardiac arrest at the scene, with an overall survival rate of less than 5%. The correlations of prognosis with various transport approach, such as hospital level with different distance, are yet to be clarified. Thus, we conducted this study to assess the association of transporting TCA patients to hospitals of different levels and distances on critical outcomes, including the return of spontaneous circulation (ROSC), survival to admission, and 30-day survival.

METHODS

This retrospective study included adults with TCA who were admitted to various emergency departments in Taoyuan City between January 2016 and December 2022. The patients were stratified by destination hospital into three groups: those transported to a trauma center (TC; TC group), those transported to the nearest non-TC (non-TC group), and those cross-regionally transported to a TC (cross-region TC group). Geographic information system (GIS) data were utilized to determine hospital locations and distances. The associations between various factors and key outcomes-any return of spontaneous circulation (ROSC), survival to admission, 24-h survival and 30-day survival-were analyzed. Multivariable logistic regression was used to determine the association of these outcomes based on transportation to hospitals of different levels.

RESULTS

This study included 557 patients with TCA (TC: 190 [direct transport: 72; cross-region transport: 118]; non-TC: 367). The TC and cross-region TC groups demonstrated significantly higher rates of ROSC at 30.6% and 30.5%, respectively, as well as lower mortality rates (95.8% for both), compared to the non-TC group, which had a ROSC rate of 12.0% and a mortality rate of 99.5%. Multivariable analysis revealed significant associations between favorable outcomes and transportation to a trauma center, either directly (aOR 2.91, 95% CI 1.54-5.49) or via cross-region transfer (aOR 2.05, 95% CI 1.01-4.15). Furthermore, blunt trauma was significantly associated with a poorer survival prognosis (aOR 0.31, 95% CI 0.08-0.78).

DISCUSSION

This study highlights the positive associations of direct or cross-region transportation to a TC on the outcomes of TCA. Our findings challenge the current EMT transport approach in Taiwan, which prioritizes transporting TCA patients to the nearest hospital regardless of its level, potentially leading to worse outcomes. Transport time and TC distance may not significantly influence prognosis.

CONCLUSION

Bypassing and directly transporting to a TC within the observed (10 km) distances are associated with better survival rates in patients with TCA. Furthermore, blunt TCA is associated with a poorer survival prognosis compared to other mechanisms of trauma-induced cardiac arrest.

Seat belt use and cardiac arrest immediately after motor vehicle collision: Nationwide observational study

Objective

Motor vehicle collisions (MVCs) are known to cause traumatic cardiac arrest; it is unclear whether seat belts prevent this. This study aimed to evaluate the association between seat belt use and immediate cardiac arrest in cases of MVCs.

Method

This cross-sectional observational study used data from a nationwide EMS-based severe trauma registry in South Korea. The sample comprised adult patients with EMS-assessed severe trauma due to MVCs between 2018 and 2019. The primary, secondary, and tertiary outcomes were immediate cardiac arrest, in-hospital mortality, and death or severe disability, respectively. We calculated the adjusted odds ratios (AORs) of immediate cardiac arrest with seat belt use after adjusting for potential confounders.

Results

Among the 8178 eligible patients, 6314 (77.2 %) and 1864 (29.5 %) were wearing and not wearing seat belts, respectively. Immediate cardiac arrest, mortality, and death/severe disability rates were higher in the "no seat belt use" group than in the "seat belt use" group (9.4 % vs. 4.0 %, 12.4 % vs. 6.2 %, 17.7 % vs. 9.9 %, respectively; p < 0.001). The former group was more likely to experience immediate cardiac arrest (AOR [95 %CI]: 3.29 [2.65-4.08]), in-hospital mortality (AOR [95 %CI]: 2.72 [2.26-3.27]), and death or severe disability (AOR [95 %CI]: 2.40 [2.05-2.80]).

Conclusion

There was an association between wearing seat belts during MVCs and a reduced risk of immediate cardiac arrest.

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

Lugnet, Viktor, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, and Peter Paal. Termination of cardiopulmonary resuscitation in mountain rescue: a scoping review and ICAR MedCom 2023 recommendations. High Alt Med Biol. 24:274-286, 2023. Background: In 2012, the International Commission for Mountain Emergency Medicine (ICAR MedCom) published recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue. New developments have necessitated an update. This is the 2023 update for termination of CPR in mountain rescue. Methods: For this scoping review, we searched the PubMed and Cochrane libraries, updated the recommendations, and obtained consensus approval within the writing group and the ICAR MedCom. Results: We screened a total of 9,102 articles, of which 120 articles met the inclusion criteria. We developed 17 recommendations graded according to the strength of recommendation and level of evidence. Conclusions: Most of the recommendations from 2012 are still valid. We made minor changes regarding the safety of rescuers and responses to primary or traumatic cardiac arrest. The criteria for termination of CPR remain unchanged. The principal changes include updated recommendations for mechanical chest compression, point of care ultrasound (POCUS), extracorporeal life support (ECLS) for hypothermia, the effects of water temperature in drowning, and the use of burial times in avalanche rescue.

Manual vs Mechanical Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest on a Ski Slope: A Pilot Study

INTRODUCTION

The quality of cardiopulmonary resuscitation (CPR) is critical in increasing the probability of survival with a good neurologic outcome after out-of-hospital cardiac arrest. In an austere environment with a potentially salvageable patient, bystanders or first responders may need to provide chest compressions for a prolonged duration or during physically challenging transportation scenarios. Consequently, they may be at risk of fatigue or injury, and chest compression quality may deteriorate. The study sought to assess whether or not access to and utilization of a mechanical compression device (Lund University Cardiopulmonary Assist System) was feasible and not inferior to manual compressions while extricating and transporting a patient from a ski slope.

METHODS

Variable 3-person ski patrol teams responded to a simulated patient with out-of-hospital cardiac arrest in a nonshockable rhythm. Using a mannequin and CPR quality monitor, performance during manual CPR was compared with that of a mechanical compression device. This is a prospective, crossover analysis of CPR quality during extrication from a ski slope. Across 8 total runs, chest compression fraction, which is the proportion of time without spontaneous circulation during which compressions occurred, and high-quality CPR, as measured by appropriate rate and depth, were compared between the 2 groups. Extrication times between the 2 groups were also measured.

RESULTS

There was no difference in compression fraction between the manual (91.4%; 95% CI [86.8-96.1]) and mechanical arms (92.8%; 95% CI [88.8-96.8]) (P=0.67). There was an increase in the time performing high-quality CPR in the mechanical group (58.5%; 95% CI [45.8-71.2]) vs that in the manual group (25.6%; 95% CI [13.5-37.8]) (P<0.001). There was a statistically significant difference in the extrication times between the 2 groups, 7.6 ± 0.5 min in the manual group vs 8.6 ± 0.4 min in the mechanical group (P=0.014).

CONCLUSIONS

Mechanical CPR devices are noninferior for use in ski areas during initial resuscitation and transportation. Compared with manual CPR, mechanical CPR would likely improve the fraction of time performing high-quality CPR.

Characterization of fatal blunt injuries using postmortem computed tomography

BACKGROUND

Rapid triage of blunt agonal trauma patients is necessary to maximize survival, but autopsy is uncommon, slow, and rarely informs resuscitation guidelines. Postmortem computed tomography (PMCT) can serve as an adjunct to autopsy in guiding blunt agonal trauma resuscitation.

METHODS

Retrospective cohort review of trauma decedents who died at or within 1 hour of arrival following blunt trauma and underwent noncontrasted PMCT. Primary outcome was the prevalence of mortal injury defined as potential exsanguination (e.g., cavitary injury, long bone and pelvic fractures), traumatic brain injury, and cervical spine injury. Secondary outcomes were potentially mortal injuries (e.g., pneumothorax) and misplacement airway devices. Patients were grouped by whether arrest occurred prehospital/in-hospital. Univariate analysis was used to identify differences in injury patterns including multiple-trauma injury patterns.

RESULTS

Over a 9-year period, 80 decedents were included. Average age was 48.9 ± 21.7 years, 68% male, and an average ISS of 42.3 ± 16.3. The most common mechanism was motor vehicle accidents (67.5%) followed by pedestrian struck (15%). Of all decedents, 62 (77.5%) had traumatic arrest prehospital while 18 (22.5%) arrived with pulse. Between groups there were no significant differences in demographics including ISS. The most common mortal injuries were traumatic brain injury (40%), long bone fractures (25%), moderate/large hemoperitoneum (22.5%), and cervical spine injury (25%). Secondary outcomes included moderate/large pneumothorax (18.8%) and esophageal intubation rate of 5%. There were no significant differences in mortal or potentially mortal injuries, and no differences in multiple-trauma injury patterns.

CONCLUSION

Fatal blunt injury patterns do not vary between prehospital and in-hospital arrest decedents. High rates of pneumothorax and endotracheal tube misplacement should prompt mandatory chest decompression and confirmation of tube placement in all blunt arrest patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Quantifying physician's bias to terminate resuscitation. The TERMINATOR Study

Context Deciding on "termination of resuscitation" (TOR) is a dilemma for any physician facing cardiac arrest. Due to the lack of evidence-based criteria and scarcity of the existing guidelines, crucial arbitration to interrupt resuscitation remains at the practitioner's discretion.

AIM

Evaluate with a quantitative method the existence of a physician internal bias to terminate resuscitation.

METHOD

We extracted data concerning OHCAs managed between January 2013 and September 2021 from the RéAC registry. We conducted a statistical analysis using generalized linear mixed models to model the binary TOR decision. Utstein data were used as fixed effect terms and a random effect term to model physicians personal bias towards TOR.

RESULTS

5,144 OHCAs involving 173 physicians were included. The cohort's average age was 69 (SD 18) and was composed of 62% of women. Median no-flow and low-flow times were respectively 6 (IQR [0,12]) and 18 (IQR [10,26]) minutes. Our analysis showed a significant (p<0.001) physician effect on TOR decision. Odds ratio for the "doctor effect" was 2.48 [2.13-2.94] for a doctor one SD above the mean, lower than that of dependency for activities of daily living (41.18 [24.69-65.50]), an age of more than 85 years (38.60 [28.67-51.08]), but higher than that of oncologic, cardiovascular, respiratory disease or no-flow duration between 10 to 20 minutes (1.60 [1.26-2.00]).

CONCLUSIONS

We demonstrate the existence of individual physician biases in their decision about TOR. The impact of this bias is greater than that of a no-flow duration lasting ten to twenty minutes. Our results plead in favor developing tools and guidelines to guide physicians in their decision.

Trauma in Pregnancy

Trauma is the leading cause of nonobstetric maternal death. Pregnant patients have a similar spectrum of traumatic injuries with a noted increase in interpersonal violence. A structured approach to trauma evaluation and management is recommended with several guidelines expanding on ATLS principles; however, evidence is limited. Optimal management requires understanding of physiologic changes in pregnancy, a team-based approach, and preparation for interventions that may including neonatal resuscitation. The principles of trauma management are the same in pregnancy with a systematic approach and initial maternal focused resuscitation..

Trauma deaths of hospitalized patients in Abu Dhabi Emirate: a retrospective descriptive study

AIM

To study the epidemiology and pattern of trauma-related deaths of hospitalized patients in Abu Dhabi Emirate, United Arab Emirates, in order to improve trauma management and injury prevention.

METHODS

The Abu Dhabi Trauma Registry prospectively collects data of all hospitalized trauma patients from seven major trauma centres in Abu Dhabi Emirate. We studied all patients who died on arrival or after admission to these hospitals from January 2014 to December 2019.

RESULTS

There were 453 deaths constituting 13.5% of all trauma deaths in the Abu Dhabi Emirate. The median (IQR) age of the patients was 33 (25-45) years, and 82% were males. 85% of the deaths occurred in the emergency department (ED) and the intensive care unit (ICU). Motor vehicle collision (63.8%) was the leading cause of death. 45.5% of the patients had head injury. Two of the seven hospitals admitted around 50% of all patients but accounted for only 25.8% of the total deaths (p < 0.001). Those who died in the ward (7%) were significantly older, median (IQR) age: of 65.5 (31.75-82.25) years, (p < 0.001), 34.4% of them were females (p = 0.09). The median (IQR) GCS of those who died in the ward was 15 (5.75-15) compared with 3 (3-3) for those who died in ED and ICU (P < 0.001).

CONCLUSIONS

Death from trauma predominantly affects young males with motor traffic collision as the leading cause. Over 85% of in-hospital deaths occur in the ICU and ED, mainly from head injuries. Injury prevention of traffic collisions through enforcement of law and improved hospital care in the ED and ICU will reduce trauma death.

Diagnostic Value of sIL-2R, TNF-α and PCT for Sepsis Infection in Patients With Closed Abdominal Injury Complicated With Severe Multiple Abdominal Injuries

OBJECTIVE

We aimed to evaluate the diagnostic value of soluble interleukin-2 receptor (sIL-2R), tumor necrosis factor-α (TNF-α), procalcitonin (PCT), and combined detection for sepsis infection in patients with closed abdominal injury complicated with severe multiple abdominal injuries.

PATIENTS AND METHODS

One hundred forty patients with closed abdominal injury complicated with severe multiple abdominal injuries who were diagnosed and treated from 2015 to 2020 were divided into a sepsis group (n = 70) and an infection group (n = 70).

RESULTS

The levels of sIL-2R, TNF-α, and PCT in the sepsis group were higher than those in the infection group (p < 0.05). The receiver operating characteristic (ROC) curve showed that the areas under the ROC curve (AUCs) of sIL-2R, TNF-α, PCT and sIL-2R+TNF-a+PCT were 0.827, 0.781, 0.821, and 0.846, respectively, which were higher than those of white blood cells (WBC, 0.712), C-reactive protein (CRP, 0.766), serum amyloid A (SAA, 0.666), and IL-6 (0.735). The AUC of the three combined tests was higher than that of TNF-α, and the difference was statistically significant (p < 0.05). There was no significant difference in the AUCs of sIL-2R and TNF-α, sIL-2R and PCT, TNF-α and PCT, the three combined tests and sIL-2R, and the three combined tests and PCT (p > 0.05). When the median was used as the cut point, the corrected sIL-2R, TNF-α, and PCT of the high-level group were not better than those of the low-level group (p > 0.05). When the four groups were classified by using quantile as the cut point, the OR risk values of high levels of TNF-α and PCT (Q4) and the low level of PCT (Q1) after correction were 7.991 and 21.76, respectively, with statistical significance (p < 0.05).

CONCLUSIONS

The detection of sIL-2R, TNF-α, and PCT has good value in the diagnosis of sepsis infection in patients with closed abdominal injury complicated with severe multiple abdominal injuries. The high concentrations of PCT and TNF-α can be used as predictors of the risk of septic infection.

Cardiopulmonary resuscitation in special circumstances

Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.