Elsevier

Resuscitation

Volume 111, February 2017, Pages 14-21
Resuscitation

Clinical paper
Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2016.11.011Get rights and content

Abstract

Background

This study aimed to understand factors associated with paramedics’ decision to attempt resuscitation in traumatic out-of-hospital cardiac arrest (OHCA) and to characterise resuscitation attempts ≤10 min in patients who die at the scene.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all cases of traumatic OHCA between July 2008 and June 2014. We excluded cases <16 years of age or with a mechanism of hanging or drowning.

Results

Of the 2334 cases of traumatic OHCA, resuscitation was attempted in 28% of cases and this rate remained steady over time (p = 0.10). Multivariable logistic regression revealed that the arresting rhythm [shockable (adjusted odds ratio (AOR) = 18.52, 95% confidence interval (CI):6.68–51.36) or pulseless electrical activity (AOR = 12.58, 95%CI:9.06–17.45) relative to asystole] and mechanism of injury [motorcycle collision (AOR = 2.49, 95%CI:1.60–3.86), fall (AOR = 1.91, 95%CI:1.17–3.11) and shooting/stabbing (AOR = 2.25, 95%CI:1.17–4.31) relative to a motor vehicle collision] were positively associated with attempted resuscitation. Arrests occurring in rural regions had a significantly lower odds of attempted resuscitation relative to those in urban regions (AOR = 0.64, 95%CI:0.46–0.90). Resuscitation attempts ≤10 min represented 34% of cases in which resuscitation was attempted but the patient died at the scene. When these resuscitation attempts were selectively excluded from the overall EMS treated population, survival to hospital discharge non-significantly increased from 3.8% to 5.0% (p = 0.314).

Conclusion

Survival in our study was consistent with existing literature, however the large proportion of cases with resuscitation attempts ≤10 min may under-represent survival in those patients that receive full resuscitation attempts.

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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    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.

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