Clinical paperTraumatic out-of-hospital cardiac arrests in Melbourne, Australia☆
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.
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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.
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On behalf of the VACAR Steering Committee.