Clinical paperResuscitation attempts and duration in traumatic out-of-hospital cardiac arrest☆
Introduction
Survival from traumatic out-of-hospital cardiac arrest (OHCA) is low with a recent systematic review reporting overall survival of 3.3%.1 Given this, the resuscitation of patients with traumatic OHCA has been considered by some to be futile and an inappropriate use of resources.2, 3 This perceived futility has resulted in limited research into this sub-group of OHCA and, in contrast to OHCA with a presumed cardiac aetiology, there is little known about the characteristics and outcomes of traumatic OHCA patients. Of those studies conducted in traumatic OHCA, the predominant focus has been on survival rates and predictors of survival.4, 5, 6, 7 There is a paucity of data on paramedic decisions to withhold or terminate resuscitation attempts in traumatic OHCA.
Given that the Utstein template recommends reporting survival in patients who receive any attempted resuscitation,8 understanding trends in selection of cases for attempted resuscitation over time may have important implications on reporting. Additionally, resuscitation attempts of presumed cardiac OHCA lasting less than or equal to 10 min have increased over time in our region,9 and this has implications for both treatment practices and the reporting of survival rates. However, these trends have not previously been studied in traumatic OHCA.
In a cohort of traumatic OHCA patients, we aimed to (1) understand factors associated with withholding or commencing resuscitation, and (2) characterise the duration of resuscitation attempts in those who die at the scene.
Section snippets
Study design
A retrospective analysis of OHCA data extracted from the Victorian Ambulance Cardiac Arrest Registry (VACAR) was conducted for cases of traumatic aetiology occurring between 1st July 2008 and 30th June 2014. Cases were excluded if the patient was aged less than 16 years or had a mechanism of hanging or drowning.
Setting
The study was conducted in the state of Victoria, Australia, which has a population of approximately 5.6 million people,10 75% of whom reside in the metropolitan region of Melbourne.
Baseline characteristics
From July 2008 to June 2014, paramedics attended 2334 cases of traumatic OHCA in Victoria, Australia, representing 7.4% of all OHCA cases (Fig. 1). The median age of patients was 44 years (IQR: 28–60) and 68% were male (Table 1). The majority of traumatic OHCA cases occurred in a public place (73%), resulted from blunt trauma (76%) and were a result of a motor vehicle collision (37%). There were no trends in the mechanism of injury over time (p > 0.05 for all) (Fig. 2). While 53% of cases were
Discussion
The purpose of this study was to investigate factors associated with paramedics’ decision to attempt resuscitation and to characterise resuscitation attempts ≤10 min in a cohort of traumatic OHCA patients. Our results demonstrate that paramedics were more likely to commence resuscitation in urban locations and when the mechanism of injury was a motorcycle collision, fall or shooting/stabbing relative to a motor vehicle collision. Paramedics were less likely to commence resuscitation in patients
Conclusion
In this study we identified that paramedics’ decisions to attempt resuscitation were influenced by the arresting rhythm, witnessed status, bystander CPR, region of the arrest, mechanism of injury and the presence of prolonged downtime. Resuscitation attempts ≤10 min represented over one third of cases where resuscitation was attempted but the patient subsequently died at the scene. The inclusion of these cases in reporting outcomes from traumatic OHCA may under-represent survival rates in those
Funding
B.B., J.B. and L.S. receive salary support by the National Health and Medical Research Council (NHRMC) Australian Resuscitation Outcomes Consortium (Aus-ROC) Centre of Research Excellence#1029983 (https://www.ausroc.org.au/). J.B. is supported by a co-funded NHMRC/National Heart Foundation (NHF) Fellowship (#1069985). P.C. was supported by a NHMRC Practitioner Fellowship (#545926).
Conflict of interest statement
We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.
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Cited by (19)
The prehospital management of ambulance-attended adults who fell: A scoping review
2023, Australasian Emergency CareCitation Excerpt :A total of 115 studies were included from 16 countries, spanning from 1988 to 2021 [6–14,17,18,26–129], and most commonly using a cohort study design (Table 1). Fifty-two sources contained a study population of exclusively adults who fell [6–10,12,13,18,27,28,31–33,35,37,40,41,43,44,51–53,55,56,60,62–64,67,71,74,79,82,84,86–88,91,95,97,100,105,107,112,114–116,118,123,124,126,127], and 63 contained a study population with a subset of adults who fell [11,14,17,26,29,30,32,34,36,38,39,42,45–50,54,57–59,61,65,66,68–70,72,73,75–78,81,83,85,89,90,92–94,96,98,99,101–104,106,108–111,113,117,119–122,125,128,129]. All sources were unique apart from five sources where we accepted non-overlapping data.
A novel scoring system using easily assessible predictors of return of spontaneous circulation and mortality in traumatic out-of-hospital cardiac arrest patients: A retrospective cohort study
2022, International Journal of SurgeryCitation Excerpt :The length of time for which CPR should be carried out in those without ROSC has not been established. Beck et al. reported that paramedics attempted resuscitation less often in TCA patients with asystole due to motor vehicle collisions and in rural regions; those receiving resuscitation for less than 10 min frequently died at the scene [27]. Chien et al. concluded that 15 min is insufficient for in-hospital resuscitation and that longer CPR duration increases ROSC and survival [15].
Survival outcomes in emergency medical services witnessed traumatic out-of-hospital cardiac arrest after the introduction of a trauma-based resuscitation protocol
2021, ResuscitationCitation Excerpt :The study compares a control period of nine consecutive years (January 2008 to December 2016) against an intervention period (January 2017 to December 2019) which followed the introduction of a revised EMS resuscitation protocol for traumatic OHCA. In the control period, there was no differentiation between traumatic and medical causes of OHCA in prehospital treatment guidelines.9 The guidelines recommended immediate chest compressions and defibrillation, insertion of a laryngeal mask airway, adrenaline administration, and then correction of reversible causes of arrest (e.g. haemorrhage, tension pneumothorax, etc.).
Impact of a trauma-focused resuscitation protocol on survival outcomes after traumatic out-of-hospital cardiac arrest: An interrupted time series analysis
2021, ResuscitationCitation Excerpt :The observed delays in intensive care paramedic arrival may also contribute to delays in the administration of optimal treatments. We reported a low proportion of attempted resuscitation by paramedics (25.2%) in our study that was related to patient’s prolonged downtime, initial arrest rhythm of asystole, or injuries being incompatible with life.2,24 Our guidelines for withholding resuscitation are conservative and require initial asystolic patients to have an estimated downtime longer than 10 min before resuscitation can be withheld.
Potentially preventable trauma deaths: A retrospective review
2019, InjuryCitation Excerpt :In Victoria, Australia, the work of the Consultative Committee of Road Traffic Fatalities, led by McDermott et al. [8] was instrumental in the introduction of the Victorian State Trauma System; a regionalised trauma system that has been demonstrated to significantly improve outcomes for major trauma patients [1,2]. The majority of trauma deaths occur in the prehospital setting [9,10]. Yet, these deaths have not been subject to the same scrutiny as in-hospital deaths.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi: http://dx.doi.org/10.1016/j.resuscitation.2016.11.011.