Elsevier

Injury

Volume 37, Issue 5, May 2006, Pages 448-454
Injury

Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile

https://doi.org/10.1016/j.injury.2005.11.011Get rights and content

Summary

Introduction

The use of guidelines regarding the termination or withholding of cardiopulmonary resuscitation (CPR) in traumatic cardiac arrest patients remains controversial. This study aimed to describe the outcomes for victims of penetrating and blunt trauma who received prehospital CPR.

Methods

We conducted a retrospective review of a statewide major trauma registry using data from 2001 to 2004. Subjects suffered penetrating or blunt trauma, received CPR in the field by paramedics and were transported to hospital. Demographics, vital signs, injury severity, prehospital time, length of stay and mortality data were collected and analysed.

Results

Eighty-nine patients met inclusion criteria. Eighty percent of these were blunt trauma victims, with a mortality rate of 97%, while penetrating trauma patients had a mortality rate of 89%. The overall mortality rate was 95%. Sixty-six percent of patients had a length of stay of less than 1 day. Four patients survived to discharge, of which two were penetrating and two were blunt injuries. Hypoxia and electrical injury were probable associated causes of two cardiac arrests seen in survivors of blunt injury.

Conclusions

While only a small number of penetrating and blunt trauma patients receiving CPR survived to discharge, this therapy is not always futile. Prehospital emergency personnel need to be aware of possible hypoxic and electrical causes for cardiac arrest appearing in combination with traumatic injuries.

Introduction

In 2001, The National Association of Emergency Medical Services Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma established guidelines regarding the termination or withholding of out of hospital resuscitation in traumatic cardiopulmonary arrest cases (Table 1).8 This came in response to increasing evidence of low survival rates and exceedingly poor outcomes following cardiopulmonary resuscitation (CPR) in trauma victims.17 Blanket administration of CPR in the prehospital setting for cases widely predicted as having poor survival and neurological recovery, represents potential medical futility with both economic and personal risks.4

However, the adoption of these guidelines remains controversial. While trauma represents the greatest threat to life for all people between 1 and 44 years of age, the incidence of successful CPR in blunt and penetrating injuries remains largely unreported. A trauma registry (VSTR), developed in 2001, was ideally placed to investigate the outcomes for all major trauma, including those who receive CPR in the field. Results from this analysis contribute to a growing literature regarding the impact of prehospital CPR on trauma victims and examine the issue from an Australian perspective.

Section snippets

Setting

This study was conducted within the Victorian State Trauma System, which serves a population of approximately 5 million. Prehospital emergency care is administered by both road and air ambulance services supporting one paediatric and two major adult trauma services with another 126 metropolitan and rural health services. The EMS is two tiered, and paramedics with advanced trauma life support skills (intubation, intravenous (i.v.) cannulation and decompression of tension pneumothorax) are

Results

Between July 2001 and December 2004, there were 5349 major trauma cases transported to hospital and recorded by VSTR. Blunt injuries (n = 4787) accounted for the majority of major trauma (89%), while 6.6% were recorded as penetrating (n = 355). There were 1327 traumatic cardiac arrest cases (234 penetrating, 1032 blunt and 61 unknown) where an ambulance was called to scene. Of these, 89 patients received CPR in the field and were subsequently transferred to an ED (thus included in VSTR). These

Discussion

The high mortality rate (95%) for victims of penetrating and blunt injuries who require CPR in the field found in this study was consistent with the prognosis reported by other authors.8 The vast majority of patients included in this analysis (74%) died within the first day of admission to hospital. Penetrating injuries have previously been associated with an improved chance of survival.1 Current policies which allow for the termination of CPR in blunt trauma patients who are found with

Conclusion

Over a 3-year period, in a population of 5 million people, there were four survivors of penetrating and blunt trauma who received prehospital CPR. Of these, two were penetrating injuries, with one demonstrating signs of life. Two were exceptional blunt injury circumstances, probably experiencing cardiac arrest secondary to electrocution and hypoxia. The current NAEMSP guidelines for withholding or terminating resuscitation in prehospital traumatic cardiac arrest require careful consideration

Acknowledgements

The Victorian State Trauma Registry is funded by the Victorian Trauma Foundation and the Department of Human Services, Victoria. Thanks to Andrew Hannaford for preparation of the data set. Thanks also to Vanessa Barnes (the Victorian Ambulance Cardiac Arrest Registry VACAR) for non-VSTR data.

References (19)

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