Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile
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.
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