Elsevier

Resuscitation

Volume 83, Issue 4, April 2012, Pages 465-470
Resuscitation

Clinical paper
Traumatic out-of-hospital cardiac arrests in Melbourne, Australia

https://doi.org/10.1016/j.resuscitation.2011.09.025Get rights and content

Abstract

Introduction

Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of adult traumatic OHCA.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged ≥16 years.

Results

Between 2000 and 2009, EMS attended 33,178 OHCAs of which 2187 (6.6%) had a traumatic aetiology. The median age (IQR) of traumatic OHCA cases was 36 (25–55) years and 1612 were male (77.5%). Bystander CPR was performed in 201 cases (10.2%) with median (IQR) EMS response time 8 (6–11) min. The first recorded rhythm by EMS was asystole seen in 1650 (75.4%), PEA in 294 (13.4%) cases and VF in 35 cases (1.6%). Cardiac output was present in 208 (9.5%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 545 (24.9%) patients of whom 84 (15.4%) achieved ROSC and were transported, and 27 (5.1%) survived to hospital discharge; 107 were transported with CPR of whom 8 (7.4%) survived to hospital discharge. Where EMS attempted resuscitation in traumatic OHCAs, survival for VF was 11.8% (n = 4), PEA 5.1% (n = 10) and asystole 2.4% (n = 3). In EMS witnessed traumatic OHCA, resuscitation was attempted in 175 cases (84.1%), 35 (16.8%) patients achieved sustained ROSC before transport of whom 5 (14%) survived to leave hospital and 60 (28.8%) were transported with CPR of whom 6 (10%) survived to leave hospital. Compared to OHCA cases with ‘presumed cardiac’ aetiology traumatic OHCAs were younger [median years (IQR): 36 (25–55) vs 74 (61–82)], had resuscitation attempted less (25% vs 48%), were less likely to have a shockable rhythm (1.6% vs 17.1%), were more likely to be witnessed (62.8% vs 38.1%) and were less likely to receive bystander CPR (10.2% vs 25.5%) (p < 0.001, respectively). Multivariate logistic regression identified factors associated with EMS decision to attempt resuscitation. The odds ratio [OR (95% CI)] for ‘presence of bystander CPR’ was 5.94 (4.11–8.58) and for ‘witnessed arrest’ was 2.60 (1.86–3.63).

Conclusion

In this paramedic delivered EMS attempted resuscitation was not always futile in traumatic OHCA with a survival of 5.1%. The quality of survival needs further study.

Introduction

Resuscitation of traumatic out-of-hospital cardiac arrest (OHCA) is considered by many to be futile and an inappropriate use of resources due to the associated low survival and poor neurological outcomes.1, 2, 3 Attempts to revive unsalvageable patients can result in the consumption of large amounts of prehospital, emergency department (ED), surgical and intensive care unit (ICU) resources, as well as medical products including blood, medications and equipment. Previous authors have suggested that the survival of a select few needs to be weighed against the burden of resuscitation.4 The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma produced guidelines in 2003 regarding the withholding or termination of resuscitation in out-of-hospital traumatic cardiopulmonary arrest.4 Controversy exists around these guidelines with some authors suggesting that attempted resuscitation is not always futile.5, 6 Much of the literature is based on doctor provided prehospital trauma services7, 8 which may not be representative of a paramedic provided Emergency Medical System (EMS). The published work in the area tends to be based on data from trauma registries as opposed to cardiac arrest registries and does not contextualize traumatic cardiac arrest against other aetiologies of cardiac arrest. Therefore mortality comparisons, and initiatives associated with improved survival in non traumatic cardiac arrest such as increases in bystander CPR, may not be appreciated. This study aims to describe the characteristics and profile of adult traumatic OHCA in Melbourne.

Section snippets

Methods

The state of Victoria has a population of 5.3 million with approximately 4 million residing in metropolitan Melbourne. Victoria is served by a state-wide trauma system with triage of major trauma patients to designated major trauma services comprising two adult and one paediatric level 1 centres.9 The emergency medical service comprises ambulance paramedics who have some advanced life support skills (laryngeal mask airway, intravenous epinephrine) and mobile intensive care ambulance (MICA)

Results

Between 2000 and 2009, EMS attended 33,178 adult OHCAs of which 2187 (6.6%) had a traumatic aetiology. This was second to presumed cardiac aetiology [n = 24,284 (73.2%)] as a cause of OHCA attended by EMS (Fig. 1).

Compared to OHCA cases with ‘presumed cardiac’ aetiology, traumatic OHCAs were younger, more likely to be male and less likely to have a shockable rhythm of VF/VT (Table 1). Traumatic OHCAs were more likely to occur in the street and more likely to be witnessed by both lay people and

Discussion

This is the largest case series describing traumatic OHCA from a paramedic provided EMS. Traumatic aetiology of OHCA was relatively frequent when compared to other causes of OHCA and paramedics were more likely to attempt resuscitation in recent years. The rates of bystander CPR are low and the presence of bystander CPR influenced the paramedic decision to attempt resuscitation. Traumatic and presumed cardiac aetiology OHCA differed significantly in terms of the profile of patients, the profile

Conclusions

Traumatic aetiology of OHCA is relatively frequent when compared to other causes of OHCA and the odds of paramedic attempted resuscitation have increased in recent years. Rates of bystander CPR were low and the presence of bystander CPR influenced the paramedic decision to attempt resuscitation. Traumatic and presumed cardiac aetiology OHCA differ significantly in terms of the profile of patients, the profile of the cardiac arrests and the outcome. In this paramedic delivered EMS, attempted

Conflict of interest statement

There are no conflicts of interest to declare.

Acknowledgements

Ambulance Victoria paramedics.

Vanessa Barnes and Marian Lodder and staff at VACAR, Ambulance Victoria.

A/Prof Belinda Gabbe, Dept of Epidemiology and Preventive Medicine for statistical advice.

References (31)

  • F.D. Battistella et al.

    Field triage of the pulseless trauma patient

    Arch Surg

    (1999)
  • A.S. Rosemurgy et al.

    Prehospital traumatic cardiac arrest: the cost of futility

    J Trauma

    (1993)
  • L.R. Hopson et al.

    Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest: a joint position paper from the National Association of EMS Physicians Standards and Clinical Practice Committee and the American College of Surgeons Committee on Trauma

    Prehosp Emerg Care

    (2003)
  • J.J. Pickens et al.

    Trauma patients receiving CPR: predictors of survival

    J Trauma

    (2005)
  • P.A. Cameron et al.

    A statewide system of trauma care in Victoria: effect on patient survival

    Med J Aust

    (2008)
  • Cited by (50)

    • Out-of-hospital cardiac arrests and bystander response by socioeconomic disadvantage in communities of New South Wales, Australia

      2022, Resuscitation Plus
      Citation Excerpt :

      In the current study, LGAs were assigned to quintiles of relative socioeconomic disadvantage created by merging two adjacent decile rankings.28 OHCAs that occurred across all age groups and those due to a medical cause were included in this study, excluding causes such as trauma, hanging, overdose, drowning, and other non-medical causes, given the differences in bystander response rates in such situations.29 In addition, arrests that were witnessed by EMS and those that occurred in a medical facility, hospital, nursing home, or police station were excluded given the likelihood that resuscitation would be provided by medical staff or other trained personnel on-site.

    View all citing articles on Scopus

    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.09.025.

    d

    On behalf of the VACAR Steering Committee.

    View full text