Prehospital care for traumatic cardiac arrest in the US: A cross-sectional analysis and call for a national guideline

Abstract

Aim

We describe emergency medical services (EMS) protocols and prehospital practice patterns related to traumatic cardiac arrest (TCA) management in the U.S.

Methods

We examined EMS management of TCA by 1) assessing variability in recommended treatments in state EMS protocols for TCA and 2) analyzing EMS care using a nationwide sample of EMS activations. We included EMS activations involving TCA in adult (≥18 years) patients where resuscitation was attempted by EMS. Descriptive statistics for recommended and actual treatments were calculated and compared between blunt and penetrating trauma using χ² and independent 2-group Mann-Whitney U tests.

Results

There were 35 state EMS protocols publicly available for review, of which 16 (45.7%) had a specific TCA protocol and 17 (48.5%) had a specific termination of resuscitation protocol for TCA. Recommended treatments varied. We then analyzed 9,565 EMS activations involving TCA (79.1% blunt, 20.9% penetrating). Most activations (93%) were managed by advanced life support. Return of spontaneous circulation was achieved in 25.5% of activations, and resuscitation was terminated by EMS in 26.4% of activations. Median prehospital scene time was 16.4 minutes; scene time was shorter for penetrating mechanisms than blunt (12.0 vs 17.0 min, p < 0.001). Endotracheal intubation was performed in 32.0% of activations, vascular access obtained in 66.6%, crystalloid fluids administered in 28.8%, and adrenaline administered in 60.1%.

Conclusion

Actual and recommended approaches to EMS treatment of TCA vary nationally. These variations in protocols and treatments highlight the need for a standardized approach to prehospital management of TCA in the U.S.

Introduction

Out-of-hospital traumatic cardiac arrest (TCA) has a poor survival rate, and optimal prehospital management of TCA is difficult to achieve. Survival for out-of-hospital TCA has historically been estimated at 2%,¹ although more recent studies demonstrate survival rates of 6–7%.2., 3. Given that TCA is typically the result of either a limited set of potentially reversible physiologic insults (e.g., profound blood loss, tension pneumothorax, cardiac tamponade, airway obstruction, or respiratory failure from spinal cord injury) or a devastating and irreversible neurological or multisystem injury, management of TCA is directed toward treating reversible processes and terminating resuscitative efforts when resuscitation appears futile.

There is no standardized set of guidelines for the prehospital management of TCA in the United States (U.S.). Although national trauma societies offer guidelines for in-hospital resuscitation of TCA with emergency department thoracotomy, neither the Eastern Association for the Surgery of Trauma nor the Western Trauma Association offer guidelines for the prehospital management of TCA.4., 5. Similarly, the American Heart Association does not include TCA within Advanced Cardiac Life Support guidelines.⁶ Although the National Association of EMS Physicians and American College of Surgeons’ Committee on Trauma have co-developed guidelines for prehospital termination of resuscitation (TOR) of TCA,¹ they do not provide specific treatment guidelines. Unfortunately, this guideline gap is likely to result in large geographic variations in prehospital care for TCA, similar to those observed with severe traumatic injuries.⁷

To provide a current assessment of prehospital TCA care in the U.S., we sought to identify the current approaches used by EMS clinicians to manage TCA. We reviewed state EMS protocols and performed a descriptive analysis of EMS practice patterns for TCA, comparing management of cases associated with blunt versus penetrating trauma. By studying the current approaches to managing out-of-hospital TCA in the U.S., we hope to evaluate the need for a unified approach to the prehospital management of TCA.