Elsevier

Resuscitation

Volume 82, Issue 9, September 2011, Pages 1194-1197
Resuscitation

Clinical paper
Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study

https://doi.org/10.1016/j.resuscitation.2011.04.018Get rights and content

Abstract

Aim

To determine the characteristics of military traumatic cardiorespiratory arrest (TCRA), and to identify factors associated with successful resuscitation.

Methods

Data was collected prospectively for adult casualties suffering TCRA presenting to a military field hospital in Helmand Province, Afghanistan between 29 November 2009 and 13 June 2010.

Results

Data was available for 52 patients meeting the inclusion criteria. The mean age (range) was 25 (18–36) years. The principal mechanism of injury was improvised explosive device (IED) explosion, the lower limbs were the most common sites of injury and exsanguination was the most common cause of arrest. Fourteen (27%) patients exhibited ROSC and four (8%) survived to discharge. All survivors achieved a good neurological recovery by Glasgow Outcome Scale. Three survivors had arrested due to exsanguination and one had arrested due to pericardial tamponade. All survivors had arrested after commencing transport to hospital and the longest duration of arrest associated with survival was 24 min. All survivors demonstrated PEA rhythms on ECG during arrest. When performed, 6/24 patients had ultrasound evidence of cardiac activity during arrest; all six with cardiac activity subsequently exhibited ROSC and two survived to hospital discharge.

Conclusion

Overall rates of survival from military TCRA were similar to published civilian data, despite military TCRA victims presenting with high Injury Severity Scores and exsanguination due to blast and fragmentation injuries. Factors associated with successful resuscitation included arrest beginning after transport to hospital, the presence of electrical activity on ECG, and the presence of cardiac movement on ultrasound examination.

Introduction

Trauma causes more than 5 million deaths per year worldwide and is a major cause of death during military conflicts.1 Cardiorespiratory arrest following trauma occurs in 1–4% of patients transported to civilian trauma centres, where it is associated with a very poor overall prognosis.2, 3, 4, 5 Although outcomes following traumatic cardiorespiratory arrest (TCRA) have been studied extensively in civilian settings, there is limited data on outcomes following military TCRA.

The loss of central pulses and respiratory effort precede death due to blunt or penetrating trauma through a number of mechanisms, including exsanguination, cardiac injury, pneumothorax, brain injury and asphyxia. Attempted resuscitation will ultimately prove unsuccessful in the majority of these patients, but for a small proportion of TCRA victims, timely and appropriate interventions may be life-saving.6, 7

Attempted resuscitation from TCRA consumes a large amount of medical resources, and is not without risk to healthcare providers.8, 9 This is especially true in the military setting where casualty numbers may be high, evacuation may be dangerous and resources are finite. Guidelines aimed at reducing the provision of futile care5 have been limited in their acceptance following reports of a number of survivors who would have met the proposed criteria for withdrawal of care.7, 10, 11 Current European Resuscitation Council guidelines recognise the lack of reliable predictors of survival following TCRA.12

We conducted a prospective, observational study of military TCRA casualties treated at the multinational Role 3 hospital in Helmand Province, Afghanistan, in order to determine the characteristics of military TCRA, and to identify factors associated with successful resuscitation.

Section snippets

Methods

Camp Bastion UK Multinational Role 3 Hospital is the major military trauma centre for Helmand Province, Afghanistan. The hospital receives military and civilian casualties, who are usually transported to hospital from the point of wounding by helicopter-based medical retrieval teams.

Data was collected prospectively between 29 November 2009 and 13 June 2010 for adult casualties (>18 yrs) suffering TCRA, defined as the loss of palpable central pulses and respiratory effort following trauma.

Results

During the study period, a total of 55 cases of TCRA were identified meeting the inclusion criteria for the study. Notes were unavailable in three cases, and the remaining 52 cases were included for analysis. All patients were male and the mean age (range) was 25 (18–36) years. The principal mechanism of injury was improvised explosive device (IED) explosion and the lower limbs were the most common sites of injury (Table 1). The median Injury Severity Score (ISS) was 33. Exsanguination was the

Discussion

Previously published evidence for outcomes following TCRA in civilian patients is limited to retrospective studies2, 3, 4, 6, 7, 8, 10, 11, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 with only a small number of survivors in each study. Reported rates of survival to hospital discharge have ranged from 0 to 17%, with most studies reporting rates of considerably less than 10%.2, 3, 4, 6, 7, 8, 10, 11, 15, 16, 17, 18, 19, 20, 21, 22, 23 Rates of neurological disability, where reported, have ranged from

Conclusions

Rates of survival from military TCRA were similar to published civilian data, with 8% of patients surviving to discharge. This was despite military TCRA victims typically presenting with high Injury Severity Scores and exsanguination due to blast and fragmentation injuries. Factors associated with successful resuscitation from military TCRA included arrest beginning after transport to hospital, the presence of electrical activity on ECG, and the presence of cardiac movement on ultrasound.

Conflicts of interest statement

The authors declare no conflicts of interest. The views expressed in this paper are those of the authors and may not reflect the views of the Ministry of Defence.

Acknowledgements

The deployed Trauma Nurse Coordinators are thanked for their assistance with the collection of this data. The Academic Department of Military Emergency Medicine (ADMEM) is thanked for collecting, collating and identifying the appropriate data for this paper. Lt Col R Russell is thanked for his assistance with interpretation of the Injury Severity Score data.

References (35)

  • A.S. Rosemurgy et al.

    Prehospital traumatic cardiac arrest: the cost of futility

    J Trauma

    (1993)
  • F.D. Battistella et al.

    Field triage of the pulseless trauma patient

    Arch Surg

    (1999)
  • R.L. Fulton et al.

    Confusion surrounding the treatment of traumatic cardiac arrest

    J Am Coll Surg

    (1995)
  • L.R. Hopson et al.

    Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest

    J Am Coll Surg

    (2003)
  • S.M. Cera et al.

    Physiologic predictors of survival in post-traumatic arrest

    Am Surg

    (2003)
  • J.J. Pickens et al.

    Trauma patients receiving CPR: predictors of survival

    J Trauma

    (2005)
  • S.K. Martin et al.

    Blunt trauma patients with prehospital pulseless electrical activity (PEA): poor ending assured

    J Trauma

    (2002)
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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.02.040.

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