Clinical update

Traumatic cardiac arrest

New guidelines clarify why a cardiac arrest due to a traumatic injury needs to be treated differently to a medical cardiac arrest

New guidelines clarify why a cardiac arrest due to a traumatic injury needs to be treated differently to a medical cardiac arrest

Traumatic cardiac arrest should be treated differently to a medical cardiac arrest
Picture: Alamy

Essential information

Traumatic cardiac arrest (TCA) can occur in emergency departments (EDs) that are not trauma centres. The evidence base for the best management approach is still evolving and there remain areas of controversy, according to the Royal College of Emergency Medicine (RCEM).

Survival from TCA is improving and is now similar to survival from medical cardiac arrest. Haemorrhage is the most common cause of death in a TCA.

Most studies report survival rates between 5.1% and 7.7% for TCA, according to the Royal College of Surgeons of Edinburgh.

Despite the high mortality, patients who survive appear to have a better neurological outcome than those with a non-traumatic cause of cardiac arrest. 

What’s new?

The RCEM has published best practice guidance for managing TCA in the ED.

In an ED which is not a trauma centre, a TCA can require a modification to the standard cardiac arrest protocol and a different mental model for the whole team.

All trauma team members should have an understanding of the priorities when managing a TCA, and how they differ from the management of medical cardiac arrests.

ED consultants should be present during TCA and they should ensure the team has a shared understanding and expectation.

Implications for nurses

The RCEM's TCA guidelines are designed to help ED teams' understanding.

Initial management priorities – include stopping catastrophic external haemorrhage (tourniquet, haemostatic dressings), ensuring adequate oxygenation and ventilation, performing bilateral thoracostomies, minimising internal haemorrhage (for example, pelvic binder) and rapid blood transfusion as per major haemorrhage protocols.

Some interventions which are standard procedure in a medical cardiac arrest could be omitted or delayed during the initial phases of a TCA by a senior clinical decision maker. These are external chest compressions, which can make low output state even lower and cause further chest trauma, vasopressors such as adrenaline, and defibrillation.

Favourable signs – include a penetrating mechanism of injury, particularly thoracic, vital signs at any time, signs of life such as any spontaneous movement, respiratory efforts, organised electrical activity on electrocardiogram, reactive pupils, a cardiac arrest under ten minutes and cardiac contractility on point of care ultrasonography.

Indications for withholding resuscitation on likelihood of futility – include massive trauma incompatible with survival (for example, decapitation, hemicorporectomy, exposed brain matter), no signs of life in the preceding 15 minutes (reactive pupils, spontaneous movement, agonal respiratory efforts, organised electrocardiographic activity), or signs of prolonged cardiac arrest (dependent lividity, rigor mortis).

Indications to stop resuscitation – include cardiac standstill on ultrasound, lack of response to life-saving interventions, persistently low end-tidal carbon dioxide (ETCO2), and long duration of cardiac arrest.

Expert comment

Janet Youd is an emergency nurse consultantJanet Youd, emergency nurse consultant at the Calderdale and Huddersfield NHS Foundation Trust and chair of the RCN emergency care association, says: ‘ED nurses may not see TCAs often, particularly if they don’t work in a major trauma centre. It is important to understand the rationale for, and the differences between, this and a medical cardiac arrest, for which they are likely to have more experience. In reality TCA can occur in any ED.

‘Patients who are too unstable to transfer to major trauma centres, or victims of knife crime brought by car or taxi, are often brought to the nearest ED. Nurses need to be aware that interventions such as extra chest compression may need to be omitted or delayed as this may reduce the chances of survival when thoracotomy or bilateral thoracostomies may be more appropriately employed. They also need to be aware of strategies for treating massive haemorrhage.

‘Identifying and understanding equipment that may be necessary in TCA is a vital competency, including the use of massive haemorrhage protocols. Being aware of local guidance in relation to invasive procedures, such as thoracotomy, is essential. As is being aware of the appropriateness of withholding or stopping resuscitation attempts in a timely manner.’

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