Year : 2021 | Volume
: 14 | Issue : 4 | Page : 193--194
What's new in emergencies, trauma, and shock – Prehospital cardiac arrest in trauma victims
Department of Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
Dr. Vivek Chauhan
Department of Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh
|How to cite this article:|
Chauhan V. What's new in emergencies, trauma, and shock – Prehospital cardiac arrest in trauma victims.J Emerg Trauma Shock 2021;14:193-194
|How to cite this URL:|
Chauhan V. What's new in emergencies, trauma, and shock – Prehospital cardiac arrest in trauma victims. J Emerg Trauma Shock [serial online] 2021 [cited 2022 Jan 20 ];14:193-194
Available from: https://www.onlinejets.org/text.asp?2021/14/4/193/333688
The American Heart Association resuscitation guidelines for traumatic cardiac arrest (TCA) recommend giving epinephrine during cardiopulmonary resuscitation (CPR) with a caution that it may not be helpful in hypovolemic patients.
The current issue of the Journal of Emergencies, Trauma, and Shock includes a meta-analysis presenting the outcomes of the patients who received epinephrine during resuscitation of prehospital TCA. In this study, epinephrine showed no significant improvement in the return of spontaneous circulation (ROSC), in-hospital survival, or short-term survival in the patients with prehospital TCA.
Although one recent study showed significantly higher 30-day survival with epinephrine, there was no significant difference in favorable neurological outcome at discharge compared to the placebo group. The patients who survived with epinephrine had more chances of poor neurological outcomes, thus negating the overall benefit of epinephrine in prehospital TCA.
Other than the use of epinephrine in prehospital TCA, important issues regarding resuscitation of prehospital TCA include the decision of onsite resuscitation versus transport to a trauma center, when to stop resuscitation, blunt versus penetrating trauma, and witnessed versus unwitnessed arrest. Overall, the outcome of prehospital TCA is poor compared to nontraumatic out-of-hospital cardiac arrest.
In a patient with TCA, correction of underlying cause of arrest becomes more important than CPR alone. Pulseless electrical activity (PEA) and bradysystolic rhythms are more common terminal rhythms than ventricular tachycardia or ventricular fibrillation in patients with TCA.
The important interventions include hemorrhage control, intravenous or intraosseous fluid administration, treatment of tension pneumothorax, establishing a definitive airway, pericardiocentesis, and resuscitative thoracotomy. These interventions need to be undertaken simultaneously with the CPR in TCA, and this needs to be done in the first 10 to 15 min of arrest. Cardiac compressions and epinephrine alone may not be able to achieve sufficient blood pressure in patients who have bled significantly and may even be counterproductive.
The chances of survival in TCA with PEA depend on the rapidity of transport of these victims to a trauma center. After TCA, the recommended time window for transportation to a trauma center is 10–15 min, 10 min for blunt trauma and 15 min for penetrative trauma. A systematic review of 42 studies of resuscitative thoracotomies in 6675 patients showed survival of 11% (500 of 4482) for victims of penetrating trauma and 1.6% (35 of 2193) for victims of blunt trauma. If the TCA patient having blunt injury is more than 10 min from the trauma center, the resuscitation must be initiated onsite and only those patients who achieve ROSC should be transported to the trauma centers. The time to transport may be extended to 15 min for penetrating trauma patients as they have been found to have better outcomes in resuscitative thoracotomy.
The level and quality of prehospital trauma care are not the same worldwide. Some countries employ physicians as the first responders for trauma service, resulting in superior outcomes compared to those with paramedic first responders. The National Association of emergency medical service physicians and the American College of Surgeons Committee on Trauma have released guidelines in 2012 stating the conditions where resuscitation efforts can be stopped after proper documentation.
The guidelines also include the circumstances where patients should be declared dead on the spot rather than transported them to the hospital. Since 2012, there is enough evidence that guidelines may not cover all aspects of prehospital TCA care in all settings, especially for those countries where physicians are the first responders for the trauma victims.
Physician-based onsite assessment and care in TCA have better outcomes in trauma because of the resuscitative procedures and decisions made by competent physicians. Use of ultrasound can help quickly diagnose pneumothorax, pericardial tamponade, hypovolemia, and intra-abdominal hemorrhage in patients of TCA. However, the availability of physician first responders and point-of-care ultrasound is a distant reality for most of the world that depends on paramedics for prehospital trauma care. Therefore, it becomes important to train the paramedics in life-saving interventions such as needle thoracostomy, definitive airway procedures, intraosseous devices, fluid management, and hemorrhage control. Trauma ambulances need to be connected to the trauma centers via telemedicine support, which also becomes important in a shared decision to stop resuscitation. Many questions regarding pre-hospital resuscitation of TCA patients remain unanswered at the moment and patient outcomes remain poor except for some settings where Physicians are the first responders.
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Conflicts of interest
There are no conflicts of interest.
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