The mortality from traumatic cardiac arrest (TCA) is high with survival rates ranging between 5.1% – 7.5% (with good neurological outcomes ranging between 2-6%-6.6%).1 Patient with TCA are a heterogeneous group however. Those suffering a TCA as a result of penetrating trauma have been shown to have better survival to discharge (10.6 vs 2.3%) and neurologically intact outcomes (90% vs 59.4%) than those with blunt aetiology.2
The aim of resuscitation is to identify immediately reversible pathology.
Some patients may have suffered trauma due to a medical event. If the patient is suspected to have had cardiac arrest due a medical cause, then standard ACLS protocols should be followed.
A special cause of cardiac arrest in trauma is “commotio cordis”. This occurs when a patient suffers a direct blow to the chest at a critical time in the cardiac cycle causing VF arrest. Immediate effective CPR and rapid defibrillation is lifesaving.
An increasingly recognised phenomenon is “impact brain apnoea” which can occur in patients with head injury (often occurs without serious underlying structural damage) due to a sudden surge in catecholamines. A prolonged period of apnoea can then cause hypoxic cardiac arrest. These patients should be managed as per standard ACLS, with an emphasis on assisting respiration.
Patients that have had part of their body crushed for a period of time (a rule of thumb is that one limb crushed for one hour can cause crush syndrome) can suffer cardiac arrest when the crushed area is freed due to a sudden release of potassium and other mediators into the circulation.
These patients should be treated as per standard ACLS with the addition of medication to treat hyperkalaemia
This is an area of controversy, but there is little physiological utility of CPR in patients who have suffered a traumatic cardiac arrest due to hypovolaemia or obstructive shock.1 The emphasis should be managing the cause of the cardiac arrest and as CPR makes performing procedures on a patient very difficult, it should be ceased in preference of addressing reversible causes of traumatic cardiac arrest (see ANZCOR guidelines).1
Similarly, ACLS drugs such as IV adrenaline are also controversial in the setting of traumatic cardiac arrest – there is not much evidence for or against administration. ANZCOR does not recommend the administration of adrenaline until the reversible causes of traumatic cardiac arrest have been addressed.1
Patients with no cardiac activity seen on bedside ultrasound following traumatic cardiac arrest have been found to have extremely low chances of survival (approaching 100%). 3,4
Patients with injuries that are not compatible with life (eg: hemicorpectomy, unsurvivable head injury) should not be resuscitated.
There is no consensus as to when to stop resuscitation in potentially salvageable patients – ANZCOR recommends ceasing resuscitative efforts 10 minutes after all reversible causes have been addressed (with continuation of full BLS/ACLS with external cardiac compressions).1