Association of Prehospital Epinephrine Administration With Survival Among Patients With Traumatic Cardiac Arrest Caused By Traffic Collisions

Prehospital Management of Adults With Traumatic Out-of-Hospital Circulatory Arrest-A Joint Position Statement

The National Association of Emergency Medical Services Physicians (NAEMSP), American College of Surgeons Committee on Trauma (ACS-COT), and American College of Emergency Physicians (ACEP) believe that evidence-based, pragmatic, and collaborative protocols addressing the care of patients with traumatic out-of-hospital circulatory arrest (TOHCA) are needed to optimize patient outcomes and clinician safety. When the etiology of arrest is unclear, particularly without clear signs of life-threatening trauma, standard basic and advanced cardiac life support (BCLS/ACLS) treatments for medical cardiac arrest are appropriate. Traumatic circulatory arrest may result from massive hemorrhage, airway obstruction, obstructive shock, respiratory disturbances, cardiogenic causes, or massive head trauma. While resuscitation and/or transport is appropriate for some populations, it is appropriate to withhold or discontinue resuscitation attempts for TOHCA patients for whom these efforts are nonbeneficial. This position statement and resource document were written as an update to the 2013 joint position statements. NAEMSP, ACEP, and ACS-COT recommend.

Epinephrine in Prehospital Traumatic Cardiac Arrest-Life Saving or False Hope?

OBJECTIVES

While epinephrine is widely used for medical cardiac arrests, there is a knowledge gap regarding its utility for traumatic arrests. Traumatic arrests result from hypovolemia, hypoxia, or anatomic impairment of cardiac function such that the inotropic and vasoconstrictive effects of epinephrine may be ineffective or harmful. We hypothesized that epinephrine does not improve survival among patients with traumatic cardiac arrest.

METHODS

This was a multicenter retrospective cohort study of trauma patients sustaining prehospital cardiac arrest who were treated at seven level I and II trauma centers over 6 years (2011-2017), ascertained via trauma registry data and chart abstraction. The primary outcome was survival to hospital discharge; patients treated with or without epinephrine were compared. Multivariable analyses were performed using Poisson regression. Time to event analyses were conducted using Cox proportional hazard models.

RESULTS

We included 1631 adult and pediatric trauma patients with prehospital cardiac arrest. Prehospital epinephrine was administered to 844 (52%). The median age was 35 years, 335 (21%) were female, 712 (44%) sustained blunt trauma, and 58 (4%) had a shockable initial rhythm. Survival to hospital discharge was significantly lower in the prehospital epinephrine cohort compared to the no epinephrine cohort in univariable analysis [43/844 (5%) vs. 125/787 (16%), p < 0.001]. Among patients with blunt mechanism, survival was significantly lower in the prehospital epinephrine cohort [12/382 (3%) vs. 54/330 (16%), p < 0.001]. Among patients with penetrating mechanism, survival was not statistically different [10/276 (4%) with epinephrine vs. 22/374 (6%) without, p = 0.19]. In multivariable analyses adjusting for age, sex, mechanism, and initial rhythm, epinephrine was associated with lower likelihood of survival in the overall and blunt cohorts; there was no significant difference in the penetrating cohort (overall aRR 0.33, 95% CI 0.23-0.46; blunt aRR 0.20, 95% CI 0.11-0.37; penetrating aRR 0.62, 95% CI 0.30-1.28). Adjusted and unadjusted time to event analyses across each of these cohorts showed that epinephrine was associated with either statistically inferior or indistinct hazard ratios.

CONCLUSIONS

Epinephrine was not associated with improved survival following traumatic cardiac arrest, and in multiple subanalyses, it was associated with inferior outcomes. These results may inform prehospital traumatic arrest protocols.

Pre-hospital Associated Factors of Survival in Traumatic Out-of-hospital Cardiac Arrests: An 11-Year Retrospective Cohort Study

Introduction

Traumatic out-of-hospital cardiac arrest (TOHCA) presents significant public health challenges. The high accident rates and variability in prehospital management in Thailand further complicate TOHCA treatment. This study aimed to analyze prehospital prognostic factors of survival in TOHCA cases.

Methods

This study is a retrospective cohort study utilizing data from the Information Technology of Emergency Medicine System (ITEMS) from January 2012 to December 2022. It included TOHCA patients who received prehospital care and were transported to the emergency department (ED). We used an exploratory approach, incorporating all prognostic variables into a multivariable logistic regression model. Results are presented as odds ratios (OR) with 95% confidence intervals (CIs) and p-values.

Results

Over an 11-year period, 35,724 patients with the mean age of 39.69±20.53 (range: 1-99) years were included in the final analysis (78.69% male). Of these, 6,590 (18.45%) survived to hospital admission, while 29,134 (81.55%) died in the ED. Prehospital management factors significantly increasing the likelihood of survival to hospital admission included stopping bleeding (OR=1.38, 95% CI=1.24-1.54, P<0.001), endotracheal intubation (ETT) (OR=2.09, 95% CI=1.74-2.50, P<0.001), intravenous fluid administration (OR=1.66, 95% CI=1.35-2.05, P<0.001), defibrillation (OR = 2.35, 95% CI=1.96-2.81, P<0.001), age (aOR = 0.99, 95% CI = 0.98-0.99, P < 0.001), closed fracture (aOR = 0.59, 95% CI = 0.53-0.66, P < 0.001), open fracture (aOR = 0.54, 95% CI = 0.48-0.61, P < 0.001), dislocation (aOR = 0.60, 95% CI = 0.45-0.81, P = 0.001), and on scene time <10 min (aOR = 0.63, 95% CI = 0.54-0.75, P < 0.001).

Conclusions

To improve survival to hospital admission in TOHCA, several factors should be prioritized. These include administering intravenous fluid boluses, controlling external bleeding, delivering defibrillation when indicated, and performing ETT.

2024 RECOVER Guidelines: Advanced Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

OBJECTIVE

To systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps.

DESIGN

Standardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.

SETTING

Transdisciplinary, international collaboration in university, specialty, and emergency practice.

RESULTS

Seventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats.

CONCLUSIONS

These updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.

Trauma Anesthesiology Perioperative Management Update

Anesthesia for patients with life-threatening injuries is an essential part of post-accident care. Unfortunately, there is variability in trauma anesthesia care and numerous nonstandardized methods of working with patients remain. Uncertainty exists as to when and how best to intubate trauma patients, the use of vasopressors, and the appropriate management of severe traumatic brain injury. Some physicians recommend prehospital rapid sequence intubation, whereas others use bag-mask ventilation at lower pressures with no cricoid pressure and early transport to a trauma center. Overall, the absence of uniformity in trauma anesthesia care underlines the need for continued study and dialogue to define best practices and optimize patient outcomes.

Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries

Abstract

Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.

Graphical Abstract

Association between Timing of Epinephrine Administration and Outcomes of Traumatic Out-of-Hospital Cardiac Arrest following Traffic Collisions

The effects of epinephrine administration timing on patients with out-of-hospital cardiac arrest (OHCA) following traffic collisions are unknown. We analyzed the 2013-2019 All-Japan Utstein Registry data of 2024 such patients aged ≥18 years who were resuscitated by emergency medical service (EMS) personnel or bystanders and then transported to medical institutions. Time from 119 call to epinephrine administration was classified into quartiles: Q1 (6-21 min), Q2 (22-26 min), Q3 (27-34 min), and Q4 (35-60 min). Multivariable logistic regression analysis was used to assess the effects of epinephrine administration timing on one-month survival after OHCA. Overall, the one-month survival rates were 3.2% (15/466) in Q1, 1.1% (5/472) in Q2, 1.9% (11/577) in Q3, and 0.2% (1/509) in Q4. Additionally, the one-month survival rate decreased significantly in the Q4 group (adjusted odds ratio, 0.07; 95% confidence interval, 0.01-0.57) compared with the Q1 group, and the probability of one-month survival decreased as the time from the EMS call to epinephrine administration increased (p-value for trend = 0.009). Only four patients (0.9% [4/466]) with the earliest epinephrine administration showed a good neurological outcome.

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

BACKGROUND

Circulatory 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.

METHODS

This 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.

RESULTS

Thirty-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 no physician was available at the prehospital scene and 38.0% if a physician was available. Only non-shockable rhythm was associated with a higher mortality (RR 1.12, p = 0.06).

CONCLUSION

Approximately 1 in 20 patients with prehospital TCA will survive; about 40% of survivors have favorable neurological outcome.

Survival Trends in Adults with Out-of-Hospital Cardiac Arrests after Traffic Collisions in Japan: A Population-Based Study

The 1-month survival rate from out-of-hospital cardiac arrest (OHCA) of cardiac origin has reportedly improved recently, at ≥5%. However, the characteristics of patients with OHCA after a traffic collision have not been adequately evaluated in Japan. We analyzed the All-Japan Utstein Registry data of 12,577 adult patients aged ≥ 20 years with OHCA due to traffic collisions who were resuscitated by emergency medical service personnel or bystanders and were then transported to medical institutions between 2013 and 2019. Multiple logistic regression analysis was used to assess factors potentially associated with the 1-month survival rate after OHCA. The 1-month survival rate was 1.4% (174/12,577). The proportion of 1-month survival of all OHCAs after a traffic collision origin did not increase significantly (from 1.6% [30/1919] in 2013 to 1.8% [25/1702] in 2019), and the adjusted odds ratio for 1-year increments was 1.04 (95% confidence interval, 0.96-1.12). In multivariate analysis, men who received ventricular fibrillation, pulseless electrical activity, intravenous fluid replacement, or early emergency medical service response and had a traffic collision during daytime had significantly favorable 1-month outcomes. In Japan, the 1-month survival after OHCA of a traffic collision origin was lower than that of a cardiac origin and remains stable.

Treatment Outcomes of Epinephrine for Traumatic Out-of-hospital Cardiac Arrest: A Systematic Review and Meta-analysis

INTRODUCTION

Despite the standard guidelines stating that giving epinephrine for patients with cardiac arrest is recommended, the clinical benefits of epinephrine for patients with traumatic out-of-hospital cardiac arrest (OHCA) are still limited. This study aims to evaluate the benefits of epinephrine administration in traumatic OHCA patients.

METHODS

We searched four electronic databases up to June 30, 2020, without any language restriction in research sources. Studies comparing epinephrine administration for traumatic OHCA patients were included. Two independent authors performed the selection of relevant studies, data extraction, and assessment of the risk of bias. The primary outcome was inhospital survival rate. Secondary outcomes included prehospital return of spontaneous circulation (ROSC), short-term survival, and favorable neurological outcome. We calculated the odds ratios (ORs) of those outcomes using the Mantel-Haenszel model and assessed the heterogeneity using the I2 statistic.

RESULTS

Four studies were included. The risk of bias of the included studies was low, except for one study in which the risk of bias was fair. All included studies reported the inhospital survival rate. Epinephrine administration during traumatic OHCA might not demonstrate a benefit for inhospital survival (OR: 0.61, 95% confidence interval [CI]: 0.11-3.37). Epinephrine showed no significant improvement in prehospital ROSC (OR: 4.67, 95% CI: 0.66-32.81). In addition, epinephrine might not increase the chance of short-term survival (OR: 1.41, 95% CI: 0.53-3.79).

CONCLUSION

The use of epinephrine for traumatic OHCA may not improve either inhospital survival or prehospital ROSC and short-term survival. Epinephrine administration as indicated in standard advanced life support algorithms might not be routinely used in traumatic OHCA.

Survival outcomes in emergency medical services witnessed traumatic out-of-hospital cardiac arrest after the introduction of a trauma-based resuscitation protocol

AIM

In this study, we examine the impact of a trauma-based resuscitation protocol on survival outcomes following emergency medical services (EMS) witnessed traumatic out-of-hospital cardiac arrest (OHCA).

METHODS

We included EMS-witnessed OHCAs arising from trauma and occurring between 2008 and 2019. In December 2016, a new resuscitation protocol for traumatic OHCA was introduced prioritising the treatment of potentially reversible causes before conventional cardiopulmonary resuscitation. The effect of the new protocol on survival outcomes was assessed using adjusted multivariable logistic regression models.

RESULTS

Paramedics attempted resuscitation on 490 patients, with 341 (69.6%) and 149 (30.4%) occurring during the control and intervention periods, respectively. A reduction in the proportion of cases receiving cardiopulmonary resuscitation and epinephrine administration were found in the intervention period compared to the control period, whereas trauma-based interventions increased significantly, including blood administration (pre-arrest: 17.9% vs 3.7%; intra-arrest: 24.1% vs 2.7%), splinting (pre-arrest: 38.6% vs 17.1%; intra-arrest: 20.7% vs 5.2%), and finger thoracostomy (pre-arrest: 13.1% vs 0.6%; intra-arrest: 22.8% vs 0.9%), respectively, with p-values < 0.001 for all comparisons. After adjustment, the trauma-based resuscitation protocol was not associated with an improvement in survival to hospital discharge (AOR 1.29, 95% CI: 0.51-3.23), event survival (AOR 0.72, 95% CI: 0.41-1.28) or prehospital return of spontaneous circulation (AOR 0.63, 95% CI: 0.39-1.03).

CONCLUSION

In our region, the introduction of a trauma-based resuscitation protocol led to an increase in the delivery of almost all trauma interventions; however, this did not translate into better survival outcomes following EMS-witnessed traumatic OHCA.

Association between emergency medical service transport time and survival in patients with traumatic cardiac arrest: a Nationwide retrospective observational study

Background

Patients with traumatic cardiac arrest (TCA) are known to have poor prognoses. In 2003, the joint committee of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma proposed stopping unsuccessful cardiopulmonary resuscitation (CPR) sustained for > 15 min after TCA. However, in 2013, a specific time-limit for terminating resuscitation was dropped, due to the lack of conclusive studies or data. We aimed to define the association between emergency medical services transport time and survival to demonstrate the survival curve of TCA.

Methods

A retrospective review of the Japan Trauma Data Bank. Inclusion criteria were age ≥ 16, at least one trauma with Abbreviated Injury Scale score (AIS) ≥ 3, and CPR performed in a prehospital setting. Exclusion criteria were burn injury, AIS score of 6 in any region, and missing data. Estimated survival rate and risk ratio for survival were analyzed according to transport time for all patients. Analysis was also performed separately on patients with sustained TCA at arrival.

Results

Of 292,027 patients in the database, 5336 were included in the study with 4141 sustained TCA. Their median age was 53 years (interquartile range (IQR) 36–70), and 67.2% were male. Their median Injury Severity Score was 29 (IQR 22–41), and median transport time was 11 min (IQR 6–17). Overall survival after TCA was 4.5%; however, survival of patients with sustained TCA at arrival was only 1.2%. The estimated survival rate and risk ratio for sustained TCA rapidly decreased after 15 min of transport time, with estimated survival falling below 1%.

Conclusion

The chances of survival for sustained TCA declined rapidly while the patient is transported with CPR support. Time should be one reasonable factor for considering termination of resuscitation in patients with sustained TCA, although clinical signs of life, and type and severity of trauma should be taken into account clinically.

Pre-arrest and intra-arrest prognostic factors associated with survival following traumatic out-of-hospital cardiac arrest - A systematic review and meta-analysis

AIM

To summarize the prognostic associations of pre- and intra-arrest factors with return of spontaneous circulation (ROSC) and survival (in-hospital or 30 days) after traumatic out-of-hospital cardiac arrest.

METHODS

We conducted this review in accordance with the PRISMA and CHARMS guidelines. We searched Medline, Pubmed, Embase, Scopus, Web of Science and the Cochrane Database of Systematic Reviews from inception through December 1st, 2019. We included English language studies evaluating pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA. Risk of bias was assessed using the QUIPS tool. We pooled unadjusted odds ratios using random-effects models and presented adjusted odds ratios with 95% confidence intervals. We used the GRADE method to describe certainty.

RESULTS

We included 53 studies involving 37,528 patients. The most important predictors of survival were presence of cardiac motion on ultrasound (odds ratio 33.91, 1.87-613.42, low certainty) or a shockable initial cardiac rhythm (odds ratio 7.29, 5.09-10.44, moderate certainty), based on pooled unadjusted analyses. Importantly, mechanism of injury was not associated with either ROSC (odds ratio 0.97, 0.51-1.85, very low certainty) or survival (odds ratio 1.40, 0.79-2.48, very low certainty).

CONCLUSION

This review provides very low to moderate certainty evidence that pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA predict ROSC and survival. This evidence is primarily based on unadjusted data. Further well-designed studies with larger cohorts are warranted to test the adjusted prognostic ability of pre- and intra-arrest factors and guide therapeutic decision-making.

Comment on epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: a post hoc analysis of prospective observational study

The aim of this Letter to the Editor was to report some important biases in a recently published Article. We agreed with the notion by Yamamoto et al. that the effects of epinephrine regarding was limited without hemostasis, however, this study had major limitations such as no information on etiology of traumatic cardiac arrest (hemorrhagic or on non-hemorrhagic) and on hemostatic treatment. The results of this study should be interpreted with caution and further analysis is necessary. Finally, we commented on the necessity of future study regarding another vasopressor (ie; vasopressin) on traumatic cardiac arrest based on current evidence.