Traumatic arrest in the field – except in the narrowest of circumstances – has universally dismal outcomes. Yet, As the authors of this study observe, a great number of these patients continue to be transported to hospitals.
This is a retrospective review of a prospective trauma registry at Sinai in Chicago in which all traumatic patients with pre-hospital arrest were considered. Patients were excluded for pediatrics, medical causes, drowning/electrocution injuries, and if the prehospital time was less than 15 minutes. Essentially, they were looking at guidelines from the ACS Committee on Trauma for termination of resuscitation in the out of hospital setting – pulseless, apneic, no organized ECG activity, or unresponsive to 15 minutes of resuscitation.
They identified 428 patients in their cohort – and found that 294 of them were transported in violation of guidelines. Of the inappropriately transported patients, 93% were declared dead in the ED and the remaining 6.8% (20 patients) survived the ED. Of those 20, 12 died in surgery, 8 made it to the ICU, and 7 died. A single, neurologically devastated, patient survived to discharge to a long-term care facility with a GCS of 6.
The total hospital charges incurred for the futile resuscitation of these patients totaled $3.8 million – a figure that excludes the EMS charges as well as the long-term care facility charges for the patient with GCS 6.
And this is just a single hospital.
“The Consequences of Noncompliance With Guidelines for Withholding or Terminating Resuscitation in Traumatic Cardiac Arrest Patients”
http://www.ncbi.nlm.nih.gov/pubmed/21986740
Patients were excluded if the prehospital time was less than 15 minutes? Why is anyone taking 15 minutes or more on a traumatic arrest, that cannot be fixed on scene? If you're going to transport these people, you have to do it immediately. Given the ineffectiveness of closed chest compressions in traumatic arrests, obviously this group was destined to have dismal outcomes. I don't think this study adds anything to the literature.
Field termination of trauma arrest can be difficult for field medics for several reasons: 1)trauma centers/surgeons that encourage medics to bring these pts; 2)lack of skills/training in managing the crowd/family/loved ones when the field decision to terminate is made. My medics find this scene management even more difficult for field termination of cardiac arrests: how to manage the family expectation that transport will occur (and the pt will be saved, etc). I am trying to develop more training for these situations to help my medics.
It is most definitely difficult to no-transport a traumatic victim – particularly because in many cases, the patient is young and/or previously healthy leading just up to the event. It is undoubtedly difficult for EMS and bystanders to accept that nothing can be done.
Jordan,
Only witnessed traumatic arrests with less than 15 minutes of total prehospital time were excluded. This was only 11% of the total number of patients before exclusions.
How many calls have a total time of less than 15 minutes?
I have worked in places where this would not be uncommon, but I have also worked in places where this would be rare.
TCPA guidelines have been implemented as policy in the region of this study. 17 Given that, why were so many patients meeting criteria for the withholding or termination of resuscitation treated and transported?
While we might be more aggressive in pronouncing patients according to these guidelines, others have less confidence in field termination protocols. This research may help convince them that termination is appropriate.
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