Traumatic cardiac arrest in Sweden 1990-2016 - a population-based national cohort study

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.

Adherence to prehospital thoracostomy practice guidelines for traumatic cardiac arrest: A retrospective study

Objectives

The management of traumatic cardiac arrest (TCA) focuses on the immediate treatment of reversible causes, including bilateral thoracostomy. In our prehospital emergency service, bilateral thoracostomy has been recommended since 2012 for the management of TCA. We sought to analyse the prehospital management and clinical course of patients with TCA, focusing on changes over time in the use of thoracostomy.

Methods

In this single-centre retrospective observational study, we included patients with TCA managed by physicians of the prehospital service of Lausanne University Hospital from 2012 to 2024. The primary outcome was the annual rate of bilateral thoracostomy. Secondary outcomes included the rate of additional on-site measures, such as pelvic binder placement and airway management, and follow-up at 48 h.

Results

Among 3206 cardiac arrests during the study period, 473 (15%) were TCAs. Among the 247 patients with resuscitation attempts, thoracostomy was judged as indicated in 223 (90%) and performed in 148 (66%). Twenty-seven (18%) patients who had a thoracostomy were alive on arrival at hospital, with 9 (6.1%) still alive at 48 h. The mean annual proportion of patients in whom a thoracostomy was performed was 68% (range 0-100%) and increased significantly over the years (p < 0.001).

Conclusions

The annual rate of thoracostomy in TCA patients increased significantly in the period 2012 to 2024. Larger studies are required to determine the impact of thoracostomy on survival.

Effect of cardiopulmonary resuscitation on perfusion in a porcine model of severe hemorrhagic shock

BACKGROUND

Pulseless electrical activity from hemorrhagic shock has not been shown to benefit from cardiopulmonary resuscitation (CPR). Using a porcine model, our objective was to determine the effects of CPR on brain and skin oxygenation as a measure of perfusion in the setting of severe hemorrhagic shock.

METHODS

Adult swine randomized to non-CPR and CPR were anesthetized. Tissue oxygen sensors were inserted into the parietal cerebral parenchyma and skin. Controlled hemorrhagic shock with mean arterial pressure (MAP) <30 mm Hg was achieved and allowed to persist for 10 minutes. Animals were randomized to either receive automated CPR or no treatment. They were then autotransfused with sufficient blood to achieve MAP >60 mm Hg. Measurements were obtained before, during, and after shock state. Outcomes were modeled using mixed-effects lognormal models.

RESULTS

A total of 12 swine were used, and the results were analyzed (non-CPR, n = 5; CPR, n = 7). One animal in the CPR group died during shock. One cerebral probe sensor malfunctioned, and these data were excluded. Baseline characteristics were similar between groups. MAP during shock was similar between groups; however, the CPR group had significantly higher systolic blood pressure (62.8 vs. 48.8 mm Hg, p = 0.010) and lower diastolic blood pressure (12.8 vs. 27.8 mm Hg, p < 0.001). Both cerebral (pBO 2 ) and skin oxygenation (TcO 2 ) dropped significantly as a result of shock. The CPR group had lower overall measures of tissue perfusion during shock, but only TcO 2 at the shoulder was significantly lower during shock (11.5 vs. 21.1 mm Hg, p = 0.027) and recovery (33.3 vs. 62 mm Hg, p = 0.033).

CONCLUSION

Our model showed that adding CPR during hemorrhagic shock did not improve end-organ oxygenation/perfusion, but did significantly diminish skin perfusion. This experiment corroborates existing literature on the potential detrimental effects of CPR during hemorrhagic pulseless electrical activity, but further work is needed to confirm this observation.

Development of a prediction model for emergency medical service witnessed traumatic out-of-hospital cardiac arrest: A multicenter cohort study

BACKGROUND/PURPOSE

To develop a prediction model for emergency medical technicians (EMTs) to identify trauma patients at high risk of deterioration to emergency medical service (EMS)-witnessed traumatic cardiac arrest (TCA) on the scene or en route.

METHODS

We developed a prediction model using the classical cross-validation method from the Pan-Asia Trauma Outcomes Study (PATOS) database from 1 January 2015 to 31 December 2020. Eligible patients aged ≥18 years were transported to the hospital by the EMS. The primary outcome (EMS-witnessed TCA) was defined based on changes in vital signs measured on the scene or en route. We included variables that were immediately measurable as potential predictors when EMTs arrived. An integer point value system was built using multivariable logistic regression. The area under the receiver operating characteristic (AUROC) curve and Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration in the derivation and validation cohorts.

RESULTS

In total, 74,844 patients were eligible for database review. The model comprised five prehospital predictors: age <40 years, systolic blood pressure <100 mmHg, respiration rate >20/minute, pulse oximetry <94%, and levels of consciousness to pain or unresponsiveness. The AUROC in the derivation and validation cohorts was 0.767 and 0.782, respectively. The HL test revealed good calibration of the model (p = 0.906).

CONCLUSION

We established a prediction model using variables from the PATOS database and measured them immediately after EMS personnel arrived to predict EMS-witnessed TCA. The model allows prehospital medical personnel to focus on high-risk patients and promptly administer optimal treatment.

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) arrest definition. Outcomes included the incidence of EX arrest, survival to discharge, and hospital costs. Descriptive statistics were used. Significance was set at p < 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.

Outcomes of prehospital traumatic cardiac arrest managed by helicopter emergency medical service personnel in Japan: a registry data analysis

BACKGROUND

Traumatic cardiac arrest (TCA) is associated with poor outcomes. Helicopter emergency medical services (HEMSs) are often used to transport critically ill patients to hospitals. However, the role of HEMS in the treatment of TCA remains unclear. Therefore, in this study, we aimed to determine the current status of patients with prehospital TCA managed by HEMS personnel in Japan and compare the outcomes of patients who experienced TCA before and after the arrival of HEMS.

METHODS

The Japanese Society for Aeromedical Services registry data of patients managed by HEMS personnel from April 2015 to March 2020 were analyzed in this retrospective cohort study. HEMS arrival and physicians' interventions at the scene were the variables of interest. The survival rate and neurological outcomes at 28 days after injury were analyzed.

RESULTS

Of the 55 299 registered patients, 722 who experienced prehospital TCA were included in the analysis. The distribution of first-witnessed TCA was as follows: pre-emergency medical service (EMS) arrival (n = 426/722, 60.3%), after EMS arrival (n = 113/722, 16.0%), and after HEMS arrival (n = 168/722, 23.8%). The 28-day survival rate was 6.2% (n = 44/706), with a cerebral performance category of 1 or 2 in 18 patients. However, patients who experienced TCA after receiving interventions provided by physicians before HEMS arrival had the worst outcomes, with only 0.6% of them surviving with favorable neurological outcomes. Multivariable analysis revealed that securing the intravenous route by the EMS team (adjusted odds ratio: 2.43, 95% confidence interval [CI]: 1.11-5.30) and tranexamic acid infusion by the HEMS team (adjusted odds ratio: 2.78, 95% CI: 1.16-6.64) may have increased the return of spontaneous circulation (ROSC) rate.

CONCLUSIONS

The results of our study were similar to those reported in previous studies with regards to the use of HEMS in Japan for transporting patients with TCA. Our findings suggest that in patients with severe trauma, cardiac arrest after initiation of HEMS, the highest level of prehospital medical intervention, may be associated with an inferior prognosis. Tracheal intubation and administration of tranexamic acid by the EMS team may increase the rate of ROSC in TCA.

Traumatic cardiac arrest - a nationwide Danish study

BACKGROUND

Cardiac 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).

METHODS

This 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.

RESULTS

A 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].

CONCLUSION

Survival 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.

Outcomes in traumatic cardiac arrest patients who underwent advanced life support

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

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

AIM

To 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.

METHODS

Data 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.

RESULTS

4,980 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.

CONCLUSIONS

Despite 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.

Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden

BACKGROUND

Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy.

METHODS

Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors.

RESULTS

Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min.

CONCLUSION

Survival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines.

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.

Predictive Factors of Outcome in Cases of Out-of-hospital Cardiac Arrest Due to Traffic Accident Injuries in Thailand; a National Database Study

INTRODUCTION

Traffic accident injury is one of the global leading causes of death and an important public health problem. This study aimed to evaluate the predictive factors of return of spontaneous circulation (ROSC) at the scene in out-of-hospital cardiac arrest (OHCA) due to traffic accidents.

METHODS

This retrospective cross-sectional study was conducted on cases of OHCA due to traffic accident, who were resuscitated at the scene by emergency medical services (EMS) in Bankok, Thiland, from January 1, 2020, to December 31, 2020 (1 year). Patients were divided into two groups of with and without ROSC and independent predictive factors of outcome were evaluated.

RESULTS

2400 OHCA cases met the inclusion criteria, among them, 1728 (72.0%) achieved ROSC at the scene. Facial injury (adjusted OR = 2.17, 95%CI: 1.37-3.44, p = 0.001); prehospital airway management using bag valve mask (adjusted OR = 1.69, 95%CI: 1.21-2.34, p = 0.002), and endotracheal tube (adjusted OR = 3.88, 95%CI: 1.84-8.18, p <0.001); and prehospital fluid therapy using normal saline (adjusted OR = 4.24, 95%CI: 3.12-5.77, p <0.001), ringer lactate (adjusted OR = 5.13, 95%CI: 3.47-7.61, p <0.001), and other solutions (adjusted OR = 5.25, 95%CI: 2.16-12.8, p <0.001) were independent predictive factors of ROSC at the scene in OHCA due to traffic accidents.

CONCLUSION

Based on the findings, the rate of ROSC at the scene for cases with OHCA due to traffic accidents, serviced by EMS was high, i.e., 72%, and three independent predictive factors of ROSC at the scene were facial injury, prehospital airway management, and prehospital fluid management.

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.

Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest

BACKGROUND

Traumatic cardiac arrests (TCAs) are associated with high mortality and the majority of deaths occur at the prehospital scene. The aim of the present study was to assess, in a prehospital physician-led emergency medical system, the factors associated with sustained return of spontaneous circulation (ROSC) in TCA, including advanced life procedures. The secondary objectives were to assess factors associated with 30-day survival in TCA, evaluate neurological recovery in survivors, and describe the frequency of organ donation among patients experiencing a TCA.

METHODS

We conducted a retrospective study of all TCA patients included in the French nationwide cardiac arrest registry from July 2011 to November 2020. Multivariable logistic regression analysis was used to identify factors independently associated with ROSC.

RESULTS

A total of 120,045 out-of-hospital cardiac arrests were included in the registry, among which 4,922 TCA were eligible for analysis. Return of spontaneous circulation was sustained on-scene in 21.1% (n = 1,037) patients. Factors significantly associated with sustained ROSC were not-asystolic initial rhythms (pulseless electric activity (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.40-2.35; p < 0.001), shockable rhythm (OR, 1.83; 95% CI, 1.12-2.98; p = 0.016), spontaneous activity (OR, 3.66; 95% CI, 2.70-4.96; p < 0.001), and gasping at the mobile medical team (MMT) arrival (OR, 1.40; 95% CI, 1.02-1.94; p = 0.042). The MMT interventions significantly associated with ROSC were as follows: intravenous fluid resuscitation (OR, 3.19; 95% CI, 2.69-3.78; p < 0.001), packed red cells transfusion (OR, 2.54; 95% CI, 1.84-3.51; p < 0.001), and external hemorrhage control (OR, 1.74; 95% CI, 1.31-2.30; p < 0.001). Among patients who survived (n = 67), neurological outcome at Day 30 was favorable (cerebral performance categories 1-2) in 72.2% cases (n = 39/54) and 1.4% (n = 67/4,855) of deceased patients donated one or more organ.

CONCLUSION

Sustained ROSC was frequently achieved in patients not in asystole at MMT arrival, and higher ROSC rates were achieved in patients benefiting from specific advanced life support interventions. Organ donation was somewhat possible in TCA patients undergoing on-scene resuscitation.

LEVEL OF EVIDENCE

Prognostic and epidemiologic, Level III.

Evaluation of outcomes after EMS-witnessed traumatic out-of-hospital cardiac arrest caused by traffic collisions

AIM

The survival rate of patients with traumatic cardiac arrest is 3 % or lower. Cardiac arrest witnessed by emergency medical services (EMS) accounts for approximately 16% of prehospital traumatic cardiac arrests, but the prognosis is unknown. We aimed to compare the 1-month survival rate of cardiac arrest witnessed by EMS with that of cardiac arrest witnessed by bystanders and unwitnessed cardiac arrest in traffic trauma victims; further, the time from injury to cardiac arrest was assessed.

METHODS

This analysis used the Utstein Registry in Japan and included data of 3883 patients with traumatic cardiac arrest caused by traffic collisions registered between 2014 and 2019 in Japan.

RESULTS

The 1-month survival rate was 10.9 % in the EMS-witnessed cardiac arrest group; this was significantly higher than that in the bystander-witnessed (7.2 %) and unwitnessed (5.6 %) cardiac arrest groups (P<0.01). The median time from injury to cardiac arrest was 18 min (25% quartile: 12, 75% quartile: 26).

CONCLUSION

The 1-month survival rate was significantly higher in the EMS-witnessed cardiac arrest group than in the bystander-witnessed and unwitnessed cardiac arrest groups. It is important to prevent progression to cardiac arrest in trauma patients with intact respiratory function and pulse rate at the time of contact with EMS. A system for early recognition of severe trauma is needed, and a doctor's car or helicopter can be requested as needed. We believe that early recognition and prompt intervention will improve the prognosis of prehospital traumatic cardiac arrest.

Neurological outcomes after traumatic cardiopulmonary arrest: a systematic review

Background

Despite appropriate care, most patients do not survive traumatic cardiac arrest, and many survivors suffer from permanent neurological disability. The prevalence of non-dismal neurological outcomes remains unclear.

Objectives

The aim of the current review is to summarize and assess the quality of reporting of the neurological outcomes in traumatic cardiac arrest survivors.

Data sources

A systematic review of Embase, Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ProQuest databases was performed from inception of the database to July 2020.

Study eligibility criteria

Observational cohort studies that reported neurological outcomes of patients surviving traumatic cardiac arrest were included.

Participants and interventions

Patients who were resuscitated following traumatic cardiac arrest.

Study appraisal and synthesis methods

The quality of the included studies was assessed using ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) for observational studies.

Results

From 4295 retrieved studies, 40 were included (n=23 644 patients). The survival rate was 9.2% (n=2168 patients). Neurological status was primarily assessed at discharge. Overall, 45.8% of the survivors had good or moderate neurological recovery, 29.0% had severe neurological disability or suffered a vegetative state, and 25.2% had missing neurological outcomes. Seventeen studies qualitatively described neurological outcomes based on patient disposition and 23 studies used standardized outcome scales. 28 studies had a serious risk of bias and 12 had moderate risk of bias.

Limitations

The existing literature is characterized by inadequate outcome reporting and a high risk of bias, which limit our ability to prognosticate in this patient population.

Conclusions or implications of key findings

Good and moderate neurological recoveries are frequently reported in patients who survive traumatic cardiac arrest. Prospective studies focused on quality of survivorship in traumatic arrest are urgently needed.

Level of evidence

Systematic review, level IV.

PROSPERO registration number

CRD42020198482.

Refractory Ventricular Fibrillation in Traumatic Cardiac Arrest: A Case Report and Review of the Literature

Ventricular fibrillation (VF) is a lethal cardiac arrhythmia that leads to cardiac arrest and death. It is especially deadly when it fails to respond to conventional treatment with electrical defibrillation. This arrhythmia is often triggered by acute myocardial ischemia, but in rare cases, it can be precipitated by direct myocardial trauma. Most patients with traumatic cardiac arrest do not survive, but in a minority of patients, an emergency thoracotomy may improve survival by addressing reversible causes such as haemorrhage control, relief of cardiac tamponade, and direct wound closure. We present an unusual case of a traumatic cardiac arrest, presenting with refractory ventricular fibrillation due to a cardiac laceration in a young trauma patient with an isolated chest injury.

A Case Report of External Cardiac Pads Used for Internal Cardiac Defibrillation During Resuscitative Thoracotomy

This is a case report regarding the use of non-conventional methods to perform internal cardiac defibrillation on a trauma patient in an austere environment. The patient was a polytrauma causality of an improvised explosive device who arrived to a far forward resuscitative surgical team during a recent armed conflict. After arrival, the patient lost pulses. An emergency resuscitative thoracotomy was performed, and the patient was noted to have ventricular fibrillation on direct cardiac visualization. In the absence of standard surgical defibrillation paddles, the team applied external defibrillator stickers directly to the patient's myocardium to deliver an electrical shock. The procedure successfully led to the return of spontaneous circulation. This report highlights a novel approach to resuscitation in resource-limited environments by a military surgical team.

Impact of puberty as threshold to differentiate outcome of out-of-hospital cardiac arrest care groups: a nationwide observational study in France

BACKGROUND

Since 2005, the international guidelines for out-of-hospital cardiac arrest (OHCA) use puberty to differentiate paediatric and adult care. This threshold is mainly relied on the more frequent respiratory aetiologies in children. Hitherto, to the best of our knowledge, no study has compared the characteristics and outcomes of non-pubescent children, adolescents and adult patients with OHCA. In this study, we intended to describe the characteristics, outcome and factors associated with survival of patients who experienced OHCA in the three groups: children, adolescents (pubescent<18 years) and adults (<65 years), to assess the pertinence of the guidelines.

METHODS

Data from the French national cardiac arrest registry (2012-2017) were used in this nationwide observational study. Victims of OHCA who were <65 years old were included. The characteristics and outcomes of children and adolescents, and adolescents and adults were compared. Logistic regression was performed in each group to identify factors associated with survival at day 30.

RESULTS

We included 934 children, 433 adolescents and 26 952 adults. Respiratory aetiology was more frequent and shockable rhythm less frequent in children compared with adolescents (25.5% vs 17.2%, p=0.025 and 2.4% vs 6.8%, p<0.001, respectively). However, these differences were not observed between adolescents and adults (17.2% vs 14.1%, p=0.266 and 6.8% vs 10%, p=0.055, respectively). Between children and adolescents, and adolescents and adults, there was no significant difference in survival at day 30 (8.6%vs 9.8% and 9.8% vs 8.5%, respectively). For all groups, shockable initial rhythm was a factor of survival.

CONCLUSION

Frequency of respiratory aetiologies and shockable rhythm were common in adolescents and adults and different between children and adolescents. These results indicate that puberty as a threshold in international guidelines seems to be relevant.

Factors associated with survival in adult patients with traumatic arrest: a retrospective cohort study from US trauma centers

Background

Traumatic arrests increasingly affect young adults worldwide with low reported survival rates. This study examines factors associated with survival (to hospital discharge) in traumatic arrests transported to US trauma centers.

Methods

This retrospective cohort study used the US National Trauma Databank 2015 dataset and included patients who presented to trauma centers with “no signs of life”. Univariate and bivariate analyses were done. Factors associated with survival were identified using multivariate regression analyses.

Results

The study included 5980 patients with traumatic arrests. Only 664 patients (11.1%) survived to hospital discharge. Patients were predominantly in age group 16–64 (84.6%), were mostly males (77.8%) and white (55.1%). Most were admitted to Level I (55.5%) or Level II trauma centers (31.6%). Injuries were mostly blunt (56.7%) or penetrating (39.3%). The median of the injury severity score (ISS) was 19 (interquartile range [IQR]: 9–30). Factors associated with decreased survival included: Age group ≥ 65 (Ref: 16–24), male gender, self-inflicted and other or undetermined types of injuries (Ref: assault), injuries to head and neck, injuries to torso and ISS ≥ 16 (Ref: < 16) and ED thoracotomy. While factors associated with increased survival included: All injury mechanisms (with the exception of motor vehicle transportation) (Ref: firearm), injuries to extremities or spine and back and all methods of coverage (Ref: self-pay).

Conclusion

Patients with traumatic arrests have poor outcomes with only 11.1% surviving to hospital discharge. Factors associated with survival in traumatic arrests were identified. These findings are important for devising injury prevention strategies and help guide trauma management protocols to improve outcomes in traumatic arrests.

Level of evidence

Level III.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

Acting on the potentially reversible causes of traumatic cardiac arrest: Possible but not sufficient

INTRODUCTION

Traumatic cardiac arrest (TCA) guidelines emphasize specific actions that aim to treat the potential reversible causes of the arrest. The aim of this study was to measure the impact of these recommendations on specific rescue measures carried out in the field, and their influence on short-term outcomes in the resuscitation of TCA patients.

METHODS

We conducted a retrospective study of all TCA patients treated in two emergency medical units, which are part of the Northern Alps Emergency Network, from January 2004 to December 2017. We categorised cases into three periods: pre-guidelines (from January 2004 to December 2007), during guidelines (from January 2008 to December 2011), and post-guidelines (from January 2012 to December 2017). Local guidelines, a physician education programme, and specific training were set up during the post-guidelines period to increase adherence to recommendations. Utstein variables, and specific rescue measures were collected: advanced airway management, fluid administration, pelvic stabilisation or tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at day 30 with good neurological status (cerebral performance category scores 1 & 2) in each period, considering the pre-guidelines period as the reference.

RESULTS

There were 287 resuscitation attempts in the TCA cases included, and 279 specific interventions were identified with a significant increase in the number of fluid expansions (+16%), bilateral thoracostomies (+75%), and pelvic stabilisations (+25%) from the pre- to post-guidelines periods. However, no improvement in survival over time was found.

CONCLUSION

Reversible measures were applied but to a varying degree, and may not adequately capture pre-hospital performance on overall TCA survival.

Establishment of a swine model of traumatic cardiac arrest induced by haemorrhage and ventricular fibrillation

OBJECTIVE

To establish and evaluate a swine model of traumatic cardiac arrest (TCA) induced by haemorrhage and ventricular fibrillation.

METHODS

Thirteen male pigs were divided into a sham group (n = 5) and TCA group (n = 8). Animals in the sham-operated group underwent intubation and monitoring but not haemorrhage and resuscitation, while animals in the TCA group underwent 40% blood volume haemorrhage over 20 min followed by 5 min of ventricular fibrillation and 5 min of cardiopulmonary resuscitation with fluid resuscitation.

RESULTS

Restoration of spontaneous circulation was achieved in seven of eight animals in the TCA group. After resuscitation, the heart rate was significantly increased while the mean arterial pressure and ejection fraction were significantly decreased in the TCA group. The TCA group had significant cardiac and neurological injuries post-resuscitation and had higher serum creatinine and blood lactic acid levels and lower PaO₂ than the sham group. Animals in the TCA group also exhibited significantly higher apoptotic indices and caspase-3 protein levels in the heart, brain and kidney than the sham group.

CONCLUSION

Animals in this swine model of TCA exhibited high rates of successful resuscitation, significant vital organ injury and prolonged survival. The model is suitable for use in further TCA research.

Outcomes after Prehospital Traumatic Cardiac Arrest in the Netherlands: a Retrospective Cohort Study

BACKGROUND

Traumatic cardiac arrest (TCA) is a severe and life-threatening situation that mandates urgent action. Outcomes after on-scene treatment of TCA in the Netherlands are currently unknown. The aim of the current study was to investigate the rate of survival to discharge in patients who suffered from traumatic cardiac arrest and who were subsequently treated on-scene by the Dutch Helicopter Emergency Medical Services (HEMS).

METHODS

A retrospective cohort study was performed including patients ≥ 18 years with TCA for which the Dutch HEMS were dispatched between January 1^st 2014 and December 31^st 2018. Patients with TCA after hanging, submersion, conflagration or electrocution were excluded. The primary outcome measure was survival to discharge after prehospital TCA. Secondary outcome measures were return of spontaneous circulation (ROSC) on-scene and neurological status at hospital discharge.

RESULTS

Nine-hundred-fifteen patients with confirmed TCA were included. ROSC was achieved on-scene in 261 patients (28.5%). Thirty-six (3.9%) patients survived to hospital discharge of which 17 (47.2%) had a good neurological outcome. Age < 70 years (0.7% vs. 5.2%; p=0.041) and a shockable rhythm on first ECG (OR 0.65 95%CI 0.02-0.28; p<0.001) were associated with increased odds of survival.

CONCLUSION

Neurologic intact survival is possible after prehospital traumatic cardiac arrest. Younger patients and patients with a shockable ECG rhythm have higher survival rates after TCA.

LEVEL OF EVIDENCE

prognostic study, level III.

Depiction of Resuscitation on Medical Dramas: Proposed Effect on Patient Expectations

The public has unrealistic views regarding the success of cardiopulmonary resuscitation, and one potential source of misinformation is medical dramas. Prior research has shown that depictions of resuscitation on television are skewed towards younger patients with acute injuries, while most cardiac arrests occur in older patients as a result of medical comorbidities. Additionally, the success rate of televised resuscitations on older shows has vastly exceeded good outcomes in the real world. We sought to understand resuscitation outcomes on current medical dramas and to review the literature for evidence that media affects patient decision-making. We reviewed medical dramas to evaluate the demographics of cardiac arrest victims and the success rate of resuscitations and compared the results to outcomes for real-world patients. Medical dramas continue to focus on trauma as the main cause of cardiac arrest and portray favorable outcomes more frequently than should be expected. Patients who believe the overly optimistic prognoses portrayed on television may be more likely to desire aggressive medical care in the face of serious illness. Healthcare workers should anticipate the need to counter misinformation when discussing patient goals of care and end-of-life planning.

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Survival Following Lay Resuscitation

BACKGROUND

Resuscitation by laypersons is important in bridging the time between the occurrence of an out-of-hospital cardiac arrest (OHCA) and the arrival of emergency rescue service personnel. Depending on the reason for the cardiac arrest, however, the effectiveness of chest compressions is uncertain. The aim of this study was to explore the impact of lay resuscitation on survival following OHCA of different causes.

METHODS

The data set for analysis comprised all cases of cardiac arrest before the arrival of emergency rescue service personnel that were fully documented in the German Resuscitation Registry in the period 2007-2019. The following endpoints related to resuscitation by bystanders were evaluated-separately for each cause-descriptively and by means of multivariate logistic regression analysis: return of spontaneous circulation (ROSC), 30 days' survival/discharged alive from the hospital, and good neurological function at discharge.

RESULTS

Altogether, 40 604 cases of cardiac arrest were included. Resuscitation by laypersons was carried out in 35.1% of these cases. The rate of ROSC was statistically significantly higher after lay resuscitation for OHCA caused by cardiac events, drowning, intoxication, or central nervous system disorders (overall 48.1% versus 41.0%). For all causes-with the exception of trauma/bleeding to death and sepsis- the endpoint 30 days' survival/discharged alive was better with lay resuscitation (overall 17.0% versus 9.5%). In multivariate regression analysis, lay resuscitation was associated with improvement of the endpoint 30 days' survival/discharged alive only for OHCA caused by cardiac events (odds ratio [OR] 1.16) or intoxication (OR 1.81). For all other causes-except hypoxia-lay resuscitation tended to yield better results. Neurological function at discharge was also significantly better (overall 11.5% versus 6.1%) after lay resuscitation for OHCA of all causes except trauma/ bleeding to death, hypoxia, and sepsis.

CONCLUSION

Resuscitation by laypersons is associated with an improved result regarding the endpoint 30 days' survival/discharged alive in cases of OHCA caused by cardiac events and intoxication. These two groups account for 81% of the resuscitation patients in the study. Because there was also a tendency towards higher survival rates following OHCA of other causes (except hypoxia), laypersons should continue to be encouraged to attempt resuscitation in all cases of OHCA, whatever the cause.

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.

Dispatcher-assisted cardiopulmonary resuscitation for traumatic patients with out-of-hospital cardiac arrest

Background

Resuscitation efforts for traumatic patients with out-of-hospital cardiac arrest (OHCA) are not always futile. Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) during emergency calls could increase the rate of bystander cardiopulmonary resuscitation (CPR) and thus may enhance survival and neurologic outcomes of non-traumatic OHCA. This study aimed to examine the effectiveness of DA-CPR for traumatic OHCA.

Methods

A retrospective cohort study was conducted using an Utstein-style population database with data from January 1, 2014, to December 31, 2016, in Tainan City, Taiwan. Voice recordings of emergency calls were retrospectively retrieved and reviewed. The primary outcome was an achievement of sustained (≥2 h) return of spontaneous circulation (ROSC); the secondary outcomes were prehospital ROSC, ever ROSC, survival at discharge and favourable neurologic status at discharge. Statistical significance was set at a p-value of less than 0.05.

Results

A total of 4526 OHCA cases were enrolled. Traumatic OHCA cases (n = 560, 12.4%), compared to medical OHCA cases (n = 3966, 87.6%), were less likely to have bystander CPR (10.7% vs. 31.7%, p < 0.001) and initially shockable rhythms (7.1% vs. 12.5%, p < 0.001). Regarding DA-CPR performance, traumatic OHCA cases were less likely to have dispatcher recognition of cardiac arrest (6.3% vs. 42.0%, p < 0.001), dispatcher initiation of bystander CPR (5.4% vs. 37.6%, p < 0.001), or any dispatcher delivery of CPR instructions (2.7% vs. 20.3%, p < 0.001). Stepwise logistic regression analysis showed that witnessed cardiac arrests (aOR 1.70, 95% CI 1.10–2.62; p = 0.017) and transportation to level 1 centers (aOR 1.99, 95% CI 1.27–3.13; p = 0.003) were significantly associated with achievement of sustained ROSC in traumatic OHCA cases, while DA-CPR-related variables were not (All p > 0.05).

Conclusions

DA-CPR was not associated with better outcomes for traumatic OHCA in achieving a sustained ROSC. The DA-CPR program for traumatic OHCAs needs further studies to validate its effectiveness and practicability, especially in the communities where rules for the termination of resuscitation in prehospital settings do not exist.

Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest

Background

Out-of-hospital cardiac arrest (OHCA) is prevalent in the UK. Reported survival is lower than in countries with comparable healthcare systems; a better understanding of outcome determinants may identify areas for improvement.

Methods

An analysis of 9109 OHCA attended in East of England between 1 January 2015 and 31 July 2017. Univariate descriptives and multivariable analysis were used to understand the determinants of survival for non-traumatic cardiac arrest (NTCA) and traumatic cardiac arrest (TCA). Two Utstein outcome variables were used: survival to hospital admission and hospital discharge.

Results

The incidence of OHCA was 55.1 per 100 000 population/year. The overall survival to hospital admission was 27.6% (95% CI 26.7% to 28.6%) and the overall survival to discharge was 7.9% (95% CI 7.3% to 8.5%). Survival to hospital admission and survival to hospital discharge were both greater in the NTCA group compared with the TCA group: 27.9% vs 19.3% p=0.001, and 8.0% vs 3.8% p=0.012 respectively.

Determinants of NTCA and TCA survival were different, and varied according to the outcome examined. In NTCA, bystander cardiopulmonary resuscitation (CPR) was associated with survival at discharge but not at admission, and the likelihood of bystander CPR was dependent on geographical socioeconomic status. An air ambulance was associated with increased survival to both hospital admission and discharge in NTCA, but only with survival to admission in TCA.

Conclusion

NTCA and TCA are clinically distinct entities with different predictors for outcome—future OHCA reports should aim to separate arrest aetiologies. Determinants of survival to hospital admission and discharge differ in a way that likely reflects the determinants of neurological injury. Bystander CPR public engagement may be best focused in more deprived areas.

Outcome after pre-hospital cardiac arrest in accordance with underlying cause

AIM

In terms of treatment options, the underlying cause of out-of-hospital cardiac arrest (OHCA) has an impact on survival. This study aimed to examine the frequencies of different causes of OHCA and their outcomes using data from a national resuscitation registry.

METHODS

All pre-hospital cardiopulmonary resuscitations (CPR) documented in the German Resuscitation Registry between 2007 and 2017 were retrospectively investigated with regard to cause of cardiac arrest, return of spontaneous circulation (ROSC), and hospital discharge rate with good neurological outcome. To avoid selection bias, only rescue services with a return rate in the form 'further clinical treatment' of >30% were included, this resulted in a total return rate of 84% of the included data.

RESULTS

In total, 33,772 patients were included. The most common causes of OHCA were cardiac events (62.2%), hypoxia (11.1%) and trauma (3.2%), in 17.2% no or unknown cause were documented. Overall, 44.8% of patients achieved ROSC, 13.1% of patients were discharged alive from hospital and 68.3% of these were in good neurological condition (9.0% of all patients). ROSC rates differed between 8.9% (sudden infant death syndrome) and 64.4% (intracranial bleeding), while discharge rates with good neurological outcome ranged between 0.9% (sepsis) and 14.0% (intoxication).

CONCLUSION

The most common causes of OHCA are cardiac events and hypoxia. Depending on the underlying cause, outcome after pre-hospital CPR varies widely with a survival rate with good neurological outcome ranging from 0.9 to 14%.

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

INTRODUCTION

Helicopter 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.

METHODS

We 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.

RESULTS

During 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%).

CONCLUSION

HEMS 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.