Clinical Pearl 75: Prehospital Traumatic Arrests

Traumatic cardiopulmonary arrests are rare compared to nontraumatic arrests but are still the fifth leading cause of the death in the United States.

In 2007, Gonzalez et al evaluated MVC traumatic arrests looking at response, scene, and transport times.  On average, rural trauma mortalities increased when EMS spent more than 10 minutes getting to a scene, 18 minutes on scene, and 12 minutes getting to a hospital.  Similar effects were found in urban areas when EMS spent more than 6 minutes getting to a call, spent more than 10 minutes on scene, and when transport took more than 7 minutes.

In McCoy et al. 2013 study performed in Orange County California, blunt and penetrating trauma were evaluated to determine whether on scene time vs. transport time mattered more.  On scene time was more significant in traumatic deaths than transport time to hospitals.  Additionally, when on scene times were 20 minutes or more, risk of death increased.  If providers spent less than 10 minutes on scene in urban penetrating traumas, patients had a better survival rate.  They acknowledged limitations, such as being unable to account for paramedic experience in evaluating injuries, excluding patients needing extrication, and not looking at long term survival rates.

Brown et al. evaluated blunt and penetrating traumas from 2000-2013 and found the only time interval that was associated with mortality in blunt or penetrating traumas was prolonged scene time.  Extrication and intubation were the two most important contributing factors for mortality. Hypotension, penetrating trauma, and flail chests were associated with mortality but not to the extent of extrication and intubation.  Contrary to other studies, longer transport times to trauma centers vs the closest hospital were actually not predictive of mortality.  They proposed it was because the longer transport time was balanced by the wider availability of services at trauma centers. 

           

In 2013, NAEMSP and ACSCOT put out new guidelines on prehospital care of blunt and penetrating trauma. 

• Narrow complex PEA with a normal or tachycardic rhythm - Initiatiate resuscitation; if code lasts more than 10 minutes - termination of resuscitation (TOR)

• Asystole or wide complex bradycardic PEA of less than 40 – TOR

Support is still given for treating easily reversible causes of traumatic arrest with needle decompression and hemorrhage control, despite a study showing an increase in mortality for every EMS procedure performed, as the potential benefits of emergent intervention are high for the relative time spent.
In the case of direct medical oversight, suggestions are to establish a standardized protocol instead of reporting to medic control because reporting may take time away from the patient and delay prompt transport of the patient to a trauma center.

There appears to be a time and place for CPR for traumatic arrests, but it should not last longer than 10 minutes and not be initiated in those in asystole or bradycardic PEA.   One must weigh the amount of time spent on scene performing procedures, such as intubation, against the benefits of surgical intervention available at hospitals.  If a provider can stabilize the patient with a fast, easily performed procedure such as placement of a tourniquet and needle decompression, the benefits are real; but if the patient can be oxygenated and ventilated without risking a prolonged intubation, consider transporting the patient instead. 

Sources:

Brown JB1, Rosengart MR, Forsythe RM, Reynolds BR, Gestring ML, Hallinan WM, Peitzman AB, Billiar TR, Sperry JL. Not all prehospital time is equal: Influence of scene time on mortality.  J Trauma Acute Care Surg. 2016 Jul;81(1):93-100.

Gonzalez RP, Cummings GR, Phelan HA, Mulekar MS, Rodning CB. Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis. Am J Surg. 2009 Jan;197(1):30-4.

McCoy CE, Menchine M, Sampson S, Anderson C, Kahn C. Emergency medical services out-of-hospital scene and transport times and their association with mortality in trauma patients presenting to an urban Level I trauma center.  Ann Emerg Med. 2013 Feb;61(2):167-74.

Merlin, M.  Destination procedures for traumatic cardiac arrest. MONOC clinical standard of practice.  2008, May.  Reviewed 2016, April.

Millin MG, Galvagno SM, Khandker SR, Malki A, Bulger EM; Standards and Clinical Practice Committee of the National Association of EMS Physicians (NAEMSP); Subcommittee on Emergency Services–Prehospital of the American College of Surgeons’ Committee on Trauma (ACSCOT).  Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the joint NAEMSP-ACSCOT position statements.  J Trauma Acute Care Surg. 2013 Sep;75(3):459-67.