Clinical paperPrehospital care for traumatic cardiac arrest in the US: A cross-sectional analysis and call for a national guideline
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.
Section snippets
Study design & data sources
We performed a cross-sectional evaluation of (1) current state-based EMS protocols concerning TCA and (2) current nationwide prehospital clinical practice patterns for TCA. For the protocol review, we identified publicly available state EMS protocols by reviewing the website for each state office of EMS. For the clinical practice component, we used a nationwide sample of EMS activations for TCA extracted from the 2018 National EMS Information System (NEMSIS) Version 3.4 Public Release Research
Protocol analysis
We identified 35 state EMS protocols that were publicly available to analyze. Of the protocols analyzed, 16 had a protocol for TCA that outlined specific steps for management (Fig. 1). There was a termination of resuscitation (TOR) protocol specific for TCA in 17 states. For states with a TCA protocol, a variety of different treatments were indicated, including chest compressions (100%), vascular access (100%), crystalloid fluid administration (93.8%), needle decompression thoracostomy (93.8%),
Discussion
In this national evaluation, we found wide variations in both the EMS protocols governing the prehospital management of TCA and in the actual practices of EMS clinicians managing these events. Many states lacked a protocol for TCA, and states with TCA protocols varied widely and were sometimes contradictory in their recommended treatments. There also was limited uptake of TOR for TCA in both EMS protocols and actual practice. Finally, EMS clinicians performed a wide variety of interventions for
Conclusions
This national sample of EMS activations for TCA demonstrated substantial variation in EMS protocols and actual practice. Only half of states included a protocol for the management of TCA, and there was variation and occasionally conflicting treatment recommendations between states that did include a TCA protocol. We observed similar variation in the nationwide patterns of prehospital management of TCA. Improving the quality of care for patients with TCA—and thus improving outcomes for the
Meeting presentations
This work was presented at the Society for Academic Emergency Medicine 2021 Annual Meeting.
Conflicts of interest
None.
Disclosure of funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Alexander J. Ordoobadi: Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft. Gregory A. Peters: Conceptualization, Methodology, Data curation, Formal analysis, Writing – review & editing. Sean MacAllister: Investigation, Data curation, Writing – review & editing. Geoffrey A. Anderson: Formal analysis, Writing – review & editing. Ashish R. Panchal: Formal analysis, Writing – review & editing. Rebecca E. Cash: Conceptualization, Formal analysis, Writing –
Acknowledgements
Dr Peters receives funding from the Emergency Medicine Foundation and the Emergency Medicine Residents’ Association.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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These authors contributed equally to this work.