Elsevier

Resuscitation

Volume 186, May 2023, 109763
Resuscitation

Clinical paper
Impact of the 2015 European guidelines for resuscitation on traumatic cardiac arrest outcomes and prehospital management: A French nationwide interrupted time-series analysis

https://doi.org/10.1016/j.resuscitation.2023.109763Get rights and content

Abstract

Aim

To evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on patient outcomes following traumatic cardiac arrest (TCA) and on advanced life support interventions carried out by physician-staffed ambulances.

Methods

Data of TCA patients aged ≥18 years were extracted from the French nationwide cardiac arrest registry. A pre- (2011–2015) and a post-publication period (2016–2020) were defined. In the guidelines, a specific TCA management algorithm was introduced to prioritise the treatment of reversible causes. Its impact was evaluated using adjusted interrupted time series analysis.

Results

4,980 patients were treated (2,145 during the pre-publication period and 2,739 during the post-publication period). There was no significant change in the rates of prehospital ROSC (22.4% vs. 20.2%, p = 0.07 in the pre- and post- intervention respectively), survival (1.4% vs. 1.4%, p = 0.87) or good neurological outcome (71.4% vs. 66.7%, p = 0.93) or in the incidence of organ donation (1.6% vs. 1.3%, p = 0.50). There were nonsignificant changes in the adjusted temporal trend for ROSC (aOR 0.88; 95% CI [0.77; 1.00]), survival (aOR 1.34; 95% CI [0.83;2.17]), good neurological outcome (aOR 1.57; 95% CI [0.82;3.05]), and organ donation (aOR 1.06; 95% CI [0.71;1.60]). The use of intraosseous catheters (13.0% vs. 19.2%, p < 0.001), external haemorrhage control measures (23.9% vs. 64.8%, p < 0.001), bilateral chest decompression (13.7% vs. 16.5%, p = 0.009), and packed red cell transfusion (2.7% vs. 6.5%, p < 0.001) increased in the post-publication period.

Conclusions

Despite the increased frequency of trauma rescue interventions performed by on-scene physicians, no change in patient-centred outcomes was associated with the publication of the 2015 ERC guidelines in France.

Introduction

Over the past decade, some authors reported an increase in survival following out-of-hospital traumatic cardiac arrest (TCA)1, 2, 3 with most survivors having good neurological prognosis.2, 4, 5 while resuscitation efforts used to be considered futile.6, 7 However, mortality among TCA patients remains very high despite increases in rates of bystander CPR and paramedic resuscitation over the years.8 Based on research that has shown the value of specific interventions focused on treating the underlying pathology, it has been emphasised in recent international guidelines that immediate resuscitative management should prioritise the treatment of reversible causes (hypoxia, tension pneumothorax, tamponade, and hypovolemia) over chest compressions.9 More specifically, the updated 2015 European Resuscitation Council (ERC) guidelines introduced a specific TCA treatment algorithm that prioritises the sequence of life-saving measures (control of external haemorrhage, airway control, bilateral chest decompression, transfusion, and fluid resuscitation). Nevertheless, previous studies have only found marginally improved outcomes regardless of whether patients experience out-of-hospital medical10, 11 or traumatic cardiac arrest.12, 13 Hence, the impact of specific TCA guidelines publication on survival and prehospital management remains unclear.

The objective was to evaluate the impact of the 2015 ERC guidelines publication on outcomes following adult TCA and on advanced life support (ALS) interventions carried out in the field by physician-staffed ambulances. We also investigated its influence on organ donation.

Section snippets

Study design

An interrupted time series (ITS) analysis of data from consecutive adult patients (aged ≥18 years) prospectively enrolled in the French nationwide cardiac arrest registry (Registre électronique des Arrêts Cardiaques, RéAC) was performed. Given that the latest ERC guidelines were released in 202114 and that we aimed to assess the effect of the 2015 ERC guidelines, we limited the study period to 1 January 2011–31 December 2020. The results are reported per the STrengthening the Reporting of

Results

A total of 133,230 patients sustained cardiac arrest and were included in the RéAC registry; among those 4,980 were included: 2,145 (43.9%) were treated during the pre-publication period, and 2,739 (56.0%) were treated during the post-publication period (Fig. 1).

Discussion

The present study found an increased frequency of specific TCA rescue interventions performed by on-scene physicians between the pre- and post-publication periods, but no change in patient-centred outcomes was associated with the release of the 2015 ERC guidelines for TCA patient management.

Despite multiple supporting evidence to prioritise the treatment of potentially reversible causes before initiating chest compressions in patients suffering TCA,18, 19, 20 no study has translated such

Conclusions

Despite the increased frequency of trauma rescue interventions performed by on-scene physicians, no significant change in patient-centred outcomes was associated with the 2015 ERC guideline publication in France. Further research should focus on evaluating the potential benefit of these guidelines in the specific TCA population with identified reversible causes as well as the impact of delay to ALS procedure implementation on patient outcomes.

Role of the funding source

The funding sources had no role in the design of this study and played no role during analyses, interpretation of the data, or writing.

Ethical approval

The registry received approval from the French national data protection commission (Commission Nationale de l’Informatique et des Libertés, CNIL; # 910946) and approval from the French advisory committee on information processing in material research in the field of health (Comité Consultatif sur le Traitement de l’Information en Matière de Recherche dans le Domaine de la Santé, #10.326Ter). In line with the French legislation on retrospective studies of registry data, patient consent was

Data statement

Requests for access to data must be sent by email to the corresponding author. Data sharing can be granted after analysis of each request by the ReACanROC steering committee and relevant ethical boards.

CRediT authorship contribution statement

Axel Benhamed: Conceptualization, Methodology, Validation, Writing - original draft. Eric Mercier: Methodology, Validation, Writing - review & editing. Julie Freyssenge: Methodology, Writing - review & editing. Clement Claustre: Conceptualization, Methodology, Formal analysis. Karim Tazarourte: Conceptualization, Methodology, Supervision, Validation.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We acknowledge with gratitude the funding agencies that made the collection of the data possible. We would also like to thank Philip Robinson (DRS, Hospices Civils de Lyon) for help in manuscript preparation, and the research staff and clinicians of all participating sites as well as all investigators of the registry and those involved in data management. Finally, we also wish to express gratitude to the EMS agencies and the prehospital responders for their commitment to excellent care and

References (32)

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1

The members of the RéAC investigators are listed in Appendix 1 at the end of the article.

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