Photo courtesy Dave Rynders
"Medic 1, please respond to 123 Maple Tree Drive for a gunshot wound."
After a short drive, you arrive at a scene that has been secured by police to see a young male lying supine in the middle of the road with several gunshot wounds to his chest. He yells "help me" several times before going unresponsive. You check for a pulse and find none.
What interventions should be considered? Are advanced cardiac life support (ACLS) medications and guidelines appropriate to follow? Should you transport the patient in cardiac arrest if the nearest trauma center is five minutes away? What about 20 minutes away?
Unintentional injuries are the fourth most common cause of death among all, and the most common among children and young adults.1 Although many systems have established trauma care guidelines, the management of traumatic cardiac arrest often is inconsistent and variable. The issue of futility in the resuscitation of a traumatic cardiac arrest is one that is often brought up when discussing the merits of resuscitation.
The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma (NAEMSP/ASCOT) stated in their consensus guidelines in 2012 that "termination of resuscitation may be considered when there are no signs of life and there is no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation (CPR)."2
Airway management and fluid administration are generally considered standard of care; however, the NAEMSP/ASCOT recommendations are limited by the fact that "further research is appropriate to determine the optimal duration of CPR prior to terminating resuscitative efforts" and that "appropriate field EMS treatment" isn't uniformly defined. This often leaves field providers with a conundrum of what to do on scene when patients undergo traumatic cardiac arrest.2
The NAEMSP/ASCOT guidelines do offer some objective guidance on withholding resuscitation in patients with "... blunt trauma who, on the arrival of EMS personnel, are found to be apneic, pulseless, and without organized electrocardiographic activity," and in penetrating trauma when "… on the arrival of EMS personnel, are found to be pulseless and apneic and there are no other signs of life, including spontaneous movement, electrocardiographic activity, and pupillary response."3 However, providers will often encounter a patient who doesn't meet these stringent withholding guidelines upon arrival, as they're in pulseless electrical activity (PEA) or have other signs of life, or they may begin treatment on a patient who will then undergo a witnessed cardiac arrest and thus fall into the termination guidelines which are far less well defined.
The lack of adherence to guidelines and provider uncertainty with resuscitation is best highlighted with a study from 2010, which showed that seven (21%) of 33 of the nation's largest cities EMS systems would transport an "asystolic blunt trauma patient emergently" or "leave the transport decision to paramedic judgment" and 15 (46%) would transport an "asystolic penetrating trauma patient." The study also found that 27 (82%) would transport penetrating trauma patients and 20 (61%) would transport blunt trauma patients with persistent ECG activity but no palpable pulses.4
The vagueness in the guidelines combined with competing evidence discussed in this article drives field provider and medical director uncertainty regarding the appropriate field management of traumatic cardiac arrest.
Airway management and fluid administration are generally considered
standard of care for traumatic arrest patients. Photo courtesy Dave Rynders
Much of the early prehospital research would seem to show that outcomes of patients in traumatic cardiac arrest were dismal. A study from 1982 found no survivors from blunt or penetrating truncal trauma who underwent CPR for more than three minutes in the prehospital setting.5 In 1993, another study found no survivors from traumatic cardiac arrest who had CPR performed at the scene or during transport. The authors argued that "the wisdom of transporting trauma victims suffering cardiopulmonary arrest at the scene or during transport must be questioned."6 Another study, published in 2003, concluded that patients who had a "combination of no respiratory rate, no systolic blood pressure, and a Glasgow Coma Score of 3 should be declared dead on scene."7
With the published literature arguing against the transport of traumatic cardiac arrest patients, many EMS services took a less aggressive approach to resuscitating patients in traumatic cardiac arrest.
Other studies, however, supported better outcomes for traumatic cardiac arrest patients. A 2007 study reported a survival rate of 19.5% of patients who underwent CPR on scene from traumatic arrest with ROSC and 17.2% in all traumatic cardiac arrest patients. Impressively, the authors also found a survival rate of 7.7% on patients with circulatory and respiratory arrest and a Glasgow coma score of 3 on scene. It's important to note that the German EMS system from which the data were abstracted from utilizes physicians on scene. Also worth considering is that the large proportion of these traumatic arrests (94.3%) were from blunt trauma-interesting given the perceived better outcomes of penetrating trauma that will be discussed later.8
A 2006 study from London Air Ambulance found that 7.5% of patients who underwent traumatic cardiac arrest on scene survived to hospital discharge. The authors argued that under the 2003 NAESMP/ASCOT guidelines, several of their survivors would have met termination criteria, concluding that "outcome [for patients in traumatic cardiac arrest] is still poor but, for reasons that are unclear, better than previously described." It's worth noting that this service also utilizes physicians on scene and several patients underwent scene thoracotomies.9
A 2004 study reviewing patients who underwent traumatic cardiac arrest and were subsequently transported to the ED found that 7.6% of the patients survived to discharge. They also found that "three of our survivors (21.4%) had EMS CPR times greater than 15 minutes, and 93% of survivors exceeded the recommended 15-minute total transportation time." The authors concluded that "the survival of traumatic cardiopulmonary arrest patients cannot be predicted in the urban prehospital setting," and "guidelines may not be applicable to urban systems with rapid transport to a Level 1 trauma center."10
What's important to recognize regarding traumatic arrest is that "survival rates are highly variable depending on the etiology, and traumatic pathologies associated with an improved chance of successful resuscitation include hypoxia, tension pneumothorax and cardiac tamponade."11
Finally, a study from Madrid, Spain, found that return of spontaneous circulation was obtained in 49.1% of traumatic cardiac arrest patients, of which 6.6% obtained a complete neurological recovery. As with other European studies, physicians were integrated into the prehospital response in this study.12
These studies reflect significantly improved survival rates that approach or eclipse the national average for medical cardiac arrests, for which there's little argument about aggressive initial resuscitation. They make the strong argument that more aggressive resuscitation may be supported for traumatic cardiac arrest.
The management futility of traumatic cardiac arrest seems to be more complex than early published guidelines would suggest, and the literature is inconclusive in establishing perfectly sensitive markers for withholding or terminating resuscitation. This competing literature likely leads to the current state of management of traumatic cardiac arrest.
Penetrating vs. blunt traumatic cardiac arrest: Historically, one of the most important factors that should be considered in the management of traumatic cardiac arrest is the etiology of the traumatic cardiac arrest. Penetrating trauma-gunshot wounds and stab wounds in particular-have much better outcomes than blunt traumatic arrest. In fact, the trauma surgical societies' thoracotomy guidelines are notably more aggressive with penetrating trauma than they are with blunt trauma. The Eastern Association for the Surgery of Trauma's guidelines has their strongest recommendation for thoracotomy for penetrating trauma to the thoracic area. The Western Trauma Association's guidelines extend the downtime for consideration of thoracotomy from 10 minutes with blunt trauma to 15 minutes with penetrating trauma. As such, more consideration should be given to load and go transport to a trauma center if penetrating trauma is the etiology, in particular if isolated to the thoracic area and in close proximity to a trauma center.13,14 It should be noted however that there are studies which don't show significant differences or demonstrate similar survival rates in blunt trauma, and that both U.S. trauma surgery guidelines still even suggest thoracotomy as a possible intervention for blunt traumatic arrest patients.8,10,12-14
Rhythm analysis: Traditionally, a patient in asystole has had an extremely poor outcome from traumatic cardiac arrest. The 2013 NAEMSP/ASCOT paper states that "... analysis of the existing literature demonstrates that patients in an asystolic rhythm have extremely low odds of survival (<1%)."15 However, one recent study showed a survival rate of 2.7% in patients with an initial rhythm of asystole, much less than other rhythms, but higher than suggested previously. Other studies show isolated cases of survival as well.10 Certainly these rates are much lower than other rhythms and a few isolated cases do not necessarily refute the general consensus, but they should be noted for completion sake.12
Additionally, several studies show poor outcome in patients with PEA at initial rates< 40 beats per minute with a rate > 40 beats per minute shown to be an independent predictor of survival.10 Patients in wide complex rhythms should be treated with defibrillation as per the American Heart Assocation (AHA) guidelines.16 Significant consideration should be given to medical causes of arrest as well when considering termination in these patients. Outcomes for patients in these wide complex rhythms have been shown to be significantly better than those in asystole or slow PEA.12
Witnessed vs. unwitnessed: Given the above information, unwitnessed traumatic cardiac arrest patients who present in asystole after either blunt or penetrating trauma are unlikely to survive and the current guidelines support withholding resuscitation. Witnessed traumatic cardiac arrest patients will benefit from aggressive attempts at resuscitation on scene including fluids, CPR, and procedural interventions as discussed below, and potentially rapid transport to a trauma center for a select subset of patients. Distance and time to a trauma center for witnessed arrest patients is vital to the decision to transport, as those patients who have extended transport times (i.e., > 10-15 minutes) will likely not fit into the guidelines for thoracotomy. It may be reasonable to manage all unwitnessed traumatic arrest patients on scene due to the inability to establish a downtime and thus the likelihood that they won't not be a candidate for thoracotomy based on U.S. guidelines.
Role of epinephrine: The 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care makes no mention of the use of ACLS drugs in the section on cardiac arrest associated with trauma. Even within the realm of all causes of cardiac arrest, there's much dispute on the efficacy of epinephrine.16
A single randomized controlled trial conducted on the use of epinephrine for all-cause out of hospital cardiac arrest found that patients receiving epinephrine had higher rates of ROSC with no statistically significant improvement in survival to hospital discharge, despite overall higher rates of survival to discharge (1.9% vs. 4.0%). There were several limitations to the study and its authors were unable to recruit their full sample size potentially leading to the lack of statistical significance in their survival to discharge rates. Additionally, this was an all-cause out-of-hospital study of cardiac arrest, with the majority of patients with a cardiac cause cited.17
In a meta-analysis on prehospital use of epinephrine in cardiac arrest, the authors noted increased prehospital ROSC with the use of epinephrine, but no improvement in overall ROSC, hospital admission or survival to discharge.18
A retrospective review on epinephrine administration in children with traumatic cardiac arrest-an isolated study looking at traumatic causes only-found increased rates of ROSC, but no improvement in survival or good neurological outcome.19
Some literature would even suggest a negative effect on tissue perfusion in hemorrhagic shock with the use of epinephrine, and that given the natural rise in catecholamines in hemorrhagic shock, additional vasopressors would be unjustified.20
The evidence on epinephrine use in medical cardiac arrest is equivocal at best, and with the characteristics of traumatic cardiac arrest being very different, it's likely that there's limited to no role for epinephrine in the management of traumatic cardiac arrest.
Role of external compressions: Since the 1960s, external compressions have been the hallmark of management of cardiac arrest. However, much of the early data have been obtained on medical cardiac arrests. Little to no literature currently exists looking at patients in traumatic cardiac arrest.
A study in baboons found that external cardiac compressions increased the systolic blood pressure (BP) in the setting of hemorrhagic shock and in cardiac tamponade. However, these increases in BP were significantly less than the response to their subjects with non-traumatic, normovolemic cardiac arrest. Since the cause of traumatic arrests involve more commonly hemorrhagic shock for which there was less effect, it's thought that more emphasis should be placed on procedural interventions and resuscitation than external cardiac compressions. Additionally, the use of external cardiac compressions on a patient with cardiac tamponade may worsen the cardiac output by increasing the intrapericardial pressure.21,22
A recent best evidence report on the efficacy of chest compressions in children in traumatic cardiac arrest found no direct evidence to answer the question.23 However, the NAEMSP/ASCOT guidelines clearly state that CPR is an integral part of in the management of traumatic arrest.2 At this time, while external cardiac compression has become standard of care and recommended by the national guidelines, there's no direct evidence to support its use and they shouldn't impede procedural interventions in patients with traumatic cardiac arrest which may be of more help.
Transport guidelines: Transportation of patients in cardiac arrest comes with many risks to providers, the patient and the public. The management of medical cardiac arrest patients is relatively uniform and there are minimal differences in the resuscitation of patients in the field vs. in an ED; therefore, it often doesn't make sense to transport medical cardiac arrest patients given the risks of expedient transport and the difficulty of managing a resuscitation in the back of an ambulance.
However, there may be some special circumstances for traumatic arrest patients that suggest transport is beneficial. A 1982 study, for example, found that the prompt transport of patients with penetrating heart injuries resulted in higher rates of survival than those who received resuscitation on scene.24
The argument of transportation revolves around the surgical interventions that may be available in a hospital that aren't available to prehospital providers in the field, such as ED thoracotomy and chest tube insertion. This may be reflected in the improved survival of traumatic arrest patients from the recent European studies which utilize physician providers in the field performing some of these procedures within a short time of cardiac arrest.8,9,12
In the U.S., ED thoracotomy is the surgical procedure of choice for traumatic arrest and something that's rarely an option in the prehospital setting. Although local resources and policy, in particular closeness of a trauma center, should dictate the protocols surrounding the transportation of patients in cardiac arrest, it should be recognized that there may be a role for very selective emergent transportation of patients in traumatic cardiac arrest to hospitals to potentially undergo this procedure. It's reasonable to consider rapid transportation in a subset of patients whose etiology and characteristics include: witnessed arrest, penetrating trauma of thoracic location, and close (10-15 minute) proximity to a trauma center.13,14
Needle thoracostomy: It seems reasonable to strongly consider needle thoracostomy in traumatic cardiac arrest. The incidence of tension pneumothorax in one study of traumatic arrest patients was 5.7%, and the placement of a chest tube was detected as statistically significant in increasing the probability of survival. The authors recommend on-scene chest decompression for patients in traumatic cardiac arrest.8 This was supported by another study that also recommended chest decompression in traumatic cardiac arrest as part of the resuscitation effort.25
The length and size of the catheter is an area of debate regarding this procedure. The traditional use of 14-gauge IV catheters at the standard midclavicular line has come under scrutiny. One study showed that a 5.0 cm catheter would be unlikely to access the pleural cavity in half of adult patients in the standard position. They also found that the 5th intercostal space, midaxillary line was a better option for placement.26 This is supported by a study that showed that a 4.4 cm catheter would be unsuccessful in 50% of trauma patients determined by CT in the standard location.27 Another study showed that the fifth intercostal space was statistically thinner than the traditional second intercostal space in adult cadavers. If using a standard 5.0 cm angiocath, the study's authors found that only 58% of placement at the traditional site would have been successful vs. 100% success at the alternate site.28
Therefore, it should be recommended that providers ensure that they have longer needles than the standard 14-gauge angiocath and access to alternate sites, such as the mid- or anterior axillary line, of decompression to ensure penetration into the pleural cavity. There's also literature to support the more aggressive use of needle decompression in traumatic cardiac arrest as part of the standard resuscitation effort.
Resuscitative thoracotomy: In a review of the current literature in the U.S. regarding resuscitative thoracotomies, the current guidelines suggest that a patient may be a candidate for this procedure if presented within 10-15 minutes of the time of traumatic cardiac arrest and based on mechanism and signs of life.
The Western Trauma Association's data suggests that there were no survivors of blunt trauma with > 10 minutes of prehospital CPR and penetrating trauma with > 15 minutes of prehospital CPR. They support consideration of thoracotomy within that timeframe. They also recognize that case reports exist outside of their data of patient survival beyond their studies time end points and go so far as to criticize the 2003 NAEMSP/ASCOT guidelines as "excessively restrictive."13
The Eastern Association for the Surgery of Trauma published guidelines that remove any time durations of CPR and instead rely on signs of life. They suggest that a thoracotomy is either strongly or conditionally recommended for patients with penetrating injuries both with and without signs of life and blunt trauma with signs of life only.14
These guidelines would seem to support the transport of patients in traumatic cardiac arrest who reside in a short geographical distance from trauma centers with prompt surgical intervention available. For those services with access to physicians in the prehospital setting, as in many of the European literature, prehospital thoracotomy may be supported.8,9,12
Load and go transport to a trauma center should be considered if penetrating
trauma is the etiology and providers are in close proximity to a trauma center.
Photo courtesy Dave Rynders
Pericardiocentesis: Pericardiocentesis is within the scope of practice of many paramedics. In the setting of pericardial tamponade, it may be used as a temporizing procedure until definitive surgical intervention is made. The available literature is limited in applicability as most literature is hospital based. One study concluded that there remains a limited role for pericardiocentesis in non-trauma centers. This study isn't directly applicable to prehospital providers. For many EDs, the broad application of ultrasound to evaluate the pericardium has led to a decrease in empiric pericardiocentesis. Additionally, it isn't without iatrogenic injury risk, including injury to the myocardium, diaphragm and lung among others.29 The routine application of pericardiocentesis in traumatic cardiac arrest isn't supported in the literature, but should be considered for isolated chest wounds, in particular from stabbing mechanisms.
Ultrasound: The application of ultrasound in the treatment of prehospital traumatic arrest lies in its abilities to diagnose cardiac tamponade, evaluate cardiac activity and evaluate for other chest or abdominal injury. The enhanced focused assessment with sonography in trauma (eFAST) exam includes cardiac, thoracic and abdominal views which may show tamponade, intra-abdominal hemorrhage and even pneumothorax. Additionally, ultrasound may be able to quantify fluid status that may suggest a hypovolemic state and the need for further crystalloid or colloid resuscitation.22 It may also be used to evaluate for cardiac standstill and confirm the decision to terminate resuscitation.
In the U.S., paramedic providers aren't traditionally trained in the use of ultrasound in the field. Recent advances in technology, however, have made ultrasound more accessible to prehospital providers, and several EMS systems around the country have adopted the technology and trained providers. In many countries where physicians are a standard part of the prehospital response, ultrasound has demonstrated clinical advantages that may aid in treatment and assessment of patients in traumatic cardiac arrest.12 It has been shown to be feasible and more reliable in the detection of intra-abdominal hemorrhage and cardiac tamponade compared with standard physical exam and vital sign assessment. Despite this, it should be noted that there's currently no literature that correlates the use of ultrasound to improvement in treatment of
Point of care (POC) testing: POC testing is available to limited EMS services in the U.S. Various devices can assess hemoglobin, blood gases, lactic acid, coagulation measures, including thromboelastography, and other lab values. The utility of these devices is limited in traumatic cardiac arrest. They may, however, be useful in monitoring the resuscitation of trauma patients prior to arrest and during resuscitation. TEG and coagulation testing, lactate and other measures have been used as markers of resuscitation for many years to guide a more thoughtful approach to resuscitation of the traumatically injured, however, in the setting of traumatic arrest, there's no current literature to support the use of these tests in the acute prehospital management of the patient.
POC testing may also distract providers from focusing on other tangible interventions. Very few studies can be found looking at the prehospital application of POC devices as a monitor of resuscitation in the prehospital setting with most exploring the feasibility and not patient outcomes.31 Additionally, end-tidal carbon dioxide (EtCO2) has been used to try to predict survival with values < 10 mmHg indicating poor outcomes, albeit with most literature being in medical cardiac arrest. This may be a useful measure as a monitor of resuscitation, with down trending or low levels (< 10mmHg) indicating worsening patient outcomes.
Conclusion & Sample Pathway
Recent literature would suggest that certain patients may benefit from aggressive resuscitation and rapid transport while in traumatic cardiac arrest. There exists some data that offer similar survival rates to those with medical causes of cardiac arrest, albeit many studies done in a different prehospital environment.
Penetrating trauma patients in particular may benefit from load-and-go treatment in some circumstances. Asytolic and slow PEA are indicators of worse outcome; wide complex rhythms should be managed with defibrillation and strong consideration of a medical cause. These rhythms have the highest rates of survival. There's no evidence to support the routine use of epinephrine in traumatic cardiac arrest. External cardiac compressions are standard of care, however, they shouldn't impede the performance of procedural interventions and fluid resuscitation.
The transport of patients in traumatic cardiac arrest is not always contraindicated, and in the right circumstances may offer potential benefit to the patient. At this time, the more aggressive use of needle thoracostomy is supported by evidence. The use of larger angiocaths and alternate sites of approach should be strongly considered to ensure penetration.
Within the areas of ultrasound and point of care testing, there may be future implications, but currently there's a sparse amount of literature to support its regular use in the prehospital setting outside of evaluation for cardiac standstill. There's still a lack of a completely sensitive time frame for which to terminate resuscitation.
We propose a sample pathway based on the evidence, with the understanding that it may not account for isolated cases of survival discussed in the article:
1. Patients meeting the NAEMSP/ASCOT withholding resuscitation guidelines may have no resuscitation started and be declared immediately on scene.
2. If patient develops traumatic arrest from penetrating trauma to thorax, transport immediately to trauma center if within 10 minutes.
3. If patient presents with penetrating traumatic arrest or develops penetrating traumatic arrest not meeting this strict guideline above for transport, initiate resuscitation on scene and transport only with ROSC.
4. If patient presents with blunt traumatic arrest or develops blunt traumatic arrest, initiate resuscitation on scene and transport only with ROSC.
5. Standard resuscitation should include: fluid bolus, procedural interventions (e.g., needle thoracostomy, pericardiocentesis, thoractomy, etc.) as indicated, external cardiac compressions, airway management, and medical direction consultation as per protocol for further management and/or termination order.
6. Consider consultation for termination if all indicated procedural interventions are completed, airway is managed, fluid bolus is administered, the rhythm changes to or is asystole or slow (< 40 beats per minute) PEA, EtCO2 is < 10 mmHg, and/or downtime is > 15 minutes.
What interventions should be considered? Needle decompression, airway management, and rapid fluid administration should be considered.
Are ACLS medications and guidelines appropriate to follow? No, there's no established role for epinephrine in the treatment of this patient and the cause of cardiac arrest is different than a medical arrest.
Should you transport the patient in cardiac arrest if the nearest trauma center is 5 minutes away? Yes. Transport in this case may provide benefit to the patient as they may be a candidate for thoracotomy or other advanced surgical procedures.
What about 20 minutes away? Likely no. The patient is unlikely to be a candidate for thoractomy and aggressive resuscitation should be done on scene with transport only with ROSC due to the risk to providers and predicted worse outcome.
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