Article, Emergency Medicine

Is 15 minutes an appropriate resuscitation duration before termination of a traumatic cardiac arrest? A case-control study

a b s t r a c t

Background: Previous guidelines suggest up to 15 minutes of cardiopulmonary resuscitation (CPR) accompanied by other resuscitative interventions before terminating resuscitation of a traumatic cardiac arrest. The current study evaluated the duration of CPR according to outcome using the model of a county-based emergency medical services (EMS) system in Taiwan.

Methods: This study was performed as a prospectively defined retrospective review from EMS records and cardi- ac arrest registration between June 2011 and November 2012 in Taoyuan, Taiwan.

Results: A total of 396 patients were enrolled. Among the Blunt injuries, most incidents were traffic accidents (66.5%) followed by falls (31.5%). Bystander CPR was performed in 34 patients (8.6%). Of the patients, 18.4% were sent to intermediate to advanced level traumatic care hospitals. Although 4.8% of patients survived for 24 hours, only 2.3% survived to discharge, and 0.8% achieved cerebral performance category 1 or 2. Among all pa- tients who developed return of spontaneous circulation (ROSC), 14.3% of ROSC was achieved within 15 minutes since CPR. Except for 1, most patients who developed ROSC over 24 hours but did not survive to discharge re- ceived CPR more than 15 minutes. Four of 6 patients who survived to discharge achieved ROSC after CPR for more than 15 minutes (16, 18, 22, and 24 minutes). Three patients discharged with cerebral performance cate- gory 1 or 2 received CPR for 6, 16, and 18 minutes, respectively.

Conclusions: Fifteen minutes of CPR before terminating resuscitation is inappropriate for patients undergoing traumatic cardiac arrsests, as longer duration resuscitation increases ROSC and survival.

(C) 2015

Introduction

Although recent studies had revealed comparable survival rates and neurologic outcomes of patients undergoing traumatic cardiac arrest in different regions, the mortality rate remains high [1-4]. Death is inevita- ble in many major trauma events. The National Association of Emergen- cy Medical Service Physicians and the American College of Surgeons Committee on Trauma published their statement of withholding

? Prior presentations: No.

?? Funding sources/disclosures: Chang Gung Memorial Hospital, Keelung, Taiwan (CMRPG2D0131).

* Corresponding author at: Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Department of Emergency Med- icine, Chang Gung Memorial Hospital, No. 5 Fushing St, Gueishan Shiang, Taoyuan, Taiwan. Tel.: +886 3 3281 200×2505; fax: +886 3 3287 715.

E-mail addresses: [email protected] (C.-Y. Chien), [email protected] (Y.-C. Su), [email protected] (C.-C. Lin), [email protected] (C.-W. Kuo), [email protected] (S.-C. Lin), [email protected], [email protected] (Y.-M. Weng).

1 Cheng-Yu Chien and Yi-Chia Su are the first authors. The first 2 authors contributed equally to this article.

resuscitation in certain situations [5]. According to the statement, emer- gency medical services (EMS) treatment of trauma patients includes ef- ficient evacuation to definite treatment without delay. Termination of resuscitation should be considered if there are no signs of life or no re- sponse to field resuscitation efforts with minimal interrupted cardiopul- monary resuscitation (CPR).

Terminating resuscitation should be protocol driven and mandated by physician oversight. In addition, the protocols should be adjusted de- pending on the setting and population. Previous guidelines suggest up to 15 minutes of CPR accompanied by other resuscitative interventions before terminating resuscitation [5]. However, no research has indicat- ed the appropriate CPR duration before terminating Resuscitative efforts under such conditions. Millin et al [6] reviewed recent studies and sug- gested that 10 minutes of resuscitative effort captures most survivors.

Whether up to 15 minutes is an appropriate CPR duration before ter- minating resuscitation in patients undergoing cardiac arrest after trau- ma is of major concern. In this regard, a study of the duration of CPR and outcomes is warranted. The current study evaluated the duration of CPR according to outcome using the model of a county-based EMS system in Taoyuan, Taiwan.

http://dx.doi.org/10.1016/j.ajem.2015.12.004

0735-6757/(C) 2015

Materials and methods

Study design

This study was performed as a prospectively defined retrospective review of a database. The study was approved by the Ethics Committee of Chang Gung Memorial Hospital, Linkou, Taiwan. The study protocol was reviewed and was determined to be exempt from the requirement to obtain informed consent.

Setting

The study was conducted in Taoyuan County, northern Taiwan. Taoyuan County has a population of 1958686 residents and a territorial area of 1221 km [2,7]. The incidence of traumatic cardiac arrest in adults is estimated to be 500 cases per year. Thirty-five EMS system branches are present in the area. emergency medical technicians function as primary providers of prehospital emergency care. In 2010, 104 EMT-1 (EMT-basic in the United States), 666 EMT-2 (EMT-intermediate in the United States), and 36 EMT-P (EMT-P in the United States) personnel were employed at various EMS stations in Taoyuan County. According to Taiwan legislation, endotracheal tube intubation and intravenous epinephrine injections should be performed only by board-certified EMT-P personnel. A laryngeal mask airway (LMA) and setting an intra- venous line with fluids can be performed by both EMT-2 and EMT-P personnel at their clinical judgment and discretion. There are no definite recommendations for routine use of automated external defibrillators (AEDs) in patients undergoing traumatic cardiac arrest. All levels of EMTs can apply an AED according to their judgment based on periarrest conditions. Emergency medical technicians are not allowed to perform a thoracotomy or pericardiocentasis in the field.

There is 1 medical center and 10 local hospitals in Taoyuan County. The medical center was certified by the country health care bureau as advanced level of trauma care with a trauma team standing 24 hours per day, 7 days per week. Not only the operating room and intensive care unit (ICU) but also a trauma surgeon, anesthesiologist, and ortho- pedic and neurosurgical specialists are available around the clock. One of the local hospitals was certified as intermediate level of trauma care with a trauma team standing by 24 hours per day, 7 days per week. Ex- cept for an ICU, the operating room and subspecialists might not be available during Off hours. The remaining 9 hospitals provide a general level of trauma care, that is, a trauma team or subspecialists may not be standing by at all times. Emergency physicians were in charge most of the time, but further consultation and referral might be required.

A centralized dispatch center activates the nearest EMS branch to send an ambulance and 2 to 3 EMTs to the site of an incident after re- ceiving an emergency call. The EMTs are not permitted to declare death or terminate resuscitation unless the patient is decapitated, incin- erated, or decomposed or displays signs of Rigor mortis. The EMTs per- formed a 30:2 chest compression and breathing once a cardiac arrest was identified. At the same time, airway management with an endotra- cheal tube or LMA might be inserted. A neck collar and long backboard were also applied. External hemostasis via external compression with a bandage or tourniquet was performed if any external bleeding was en- countered. Patients who had limb or pelvic fractures might receive air- splint fixation or pelvis wrapping, respectively. A peripheral intrave- nous line might be attempted. Further epinephrine Bolus injection and fluid challenge were added with a successful intravenous line. The EMTs transported the patient to a nearby hospital regardless of whether patients had return of spontaneous circulation (ROSC) at the scene. Al- though CPR was continued, the primary and second surveys were per- formed after arrival at the emergency department (ED). In addition to 2 large peripheral intravenous lines setup for fluid, other lifesaving in- terventions were indicated at bedside, including inserting a chest tube for traumatic hemo or pneumothorax or pericardiocentesis for cardiac tamponade. Specialists were consulted for further treatment in patients

with sustained ROSC. These patients were admitted to the ICU as indi- cated after surgical management. Those who survived might be discharged home or transported to a long-term care center in accor- dance with their Cerebral Performance Category [8]. Patients were declared dead if no ROSC was achieved in the ED.

Participant selection

Patients who were at least 18 years of age and experienced traumat- ic cardiac arrest as identified by activation of EMS between June 2011 and November 2012 were enrolled. Patients who were younger than 18 years, presumed to have other nontraumatic etiologies, and patients lost to follow-up with incomplete records were excluded.

Outcome assessments

We reviewed the records and abstracted data using the Utstein style of reporting guidelines, which uses clear definitions and codes [9]. De- mographic data and prehospital covariates were collected from the EMS records, including the age and sex of the patient, time and place of the event, presence of a witness, CPR application by bystanders, appli- cation of a AED, shockable rhythm by AED, methods of airway manage- ment used, and the timeliness of prehospital care (ie, response interval, duration of care administered at the scene, and transport interval).

Patient outcomes were abstracted via the out-of-hospital cardiac arrest registration maintained at each of the hospitals. The primary outcome was survival to discharge. Other outcome measures included ROSC achieved before arrival at the ED, successful resuscitation with sustained ROSC for at least 2 hours, survival for 24 hours, and CPC scale at discharge.

Statistical analysis

Data were analyzed using SPSS 13.0 for Windows (SPSS, Inc, Chicago, IL). Categorical variables (sex, mechanism [blunt, penetration, and un- determined], location [street/road, education/school, public building, sport field/park, mass rapid transit/station/airport, factory/workplace, house, and others], witnessed events [EMT witnessed], bystander CPR, AED application, shockable rhythm by AED, airway management [oxy- gen mask, bag valve mask, LMA, and endotracheal tube intubation], in- travenous fluid supply, intravenous epinephrine injection, levels of receiving hospital [general, intermediate, and advanced], and all out- comes [ROSC achieved before arrival at ED, survival b 2 hours, survival N 2 to 24 hours, survival N 24 hours, survival to discharge, CPC scale]) are presented as numbers and percentages. Continuous variables (age and timeline of prehospital care) are presented as medians and inter- quartile ranges. The time from CPR initiated until ROSC was achieved was calculated for each individual. Patients who had achieved ROSC were plotted on a Kaplan-Meier curve using cumulative events of ROSC over time according to the outcome group.

Results

Participant characteristics

There were 504 traumatic cardiac arrests during the study period. Seventy patients, who were decapitated, incinerated, or decomposed or displayed signs of rigor mortis, were pronounced dead by EMTs. Emergency medical technicians terminated resuscitation without fur- ther transfer. Among 38 patients who were excluded, 13 were younger than 18 years, 7 were lost to follow-up, and 18 were presumed to be nontraumatic etiologies such as hanging (9 patients), fire (4 patients), or Electrical shock (5 patients). A total of 396 patients were enrolled (49.7% blunt injury, 2.2% penetration injury, and 47.5% undetermined; Fig. 1). Among the blunt injuries, most incidents were traffic accidents (66.5%) followed by falls (31.5%). Bystander CPR was performed in 34

Table 2

Outcomes

n = 396

ROSC before arrival at ED, n (%) 9 (2.3)

Survival less than 2 h, n (%) 15 (3.8)

Survival over 2 to 24 h, n (%) 16 (4.0)

Survival over 24 h, n (%) 19 (4.8)

Survival to discharge, n (%) 9 (2.3)

CPC scale, n (%)

1, 2 3 (0.8)

3, 4, 5 6 (1.5)

intermediate to advanced level traumatic care hospitals (Table 1). Table 2 reveals all outcomes of the enrolled patients. Although 4.8% of patients survived for 24 hours, only 2.3% survived to discharge, and 0.8% achieved CPC 1 or 2.

Outcomes and time of ROSC

Fig. 1. Patients enrolled in the study. Number of patient included and excluded from the study. Traumatic cardiac arrests transferred via EMS were included. Patients younger than 18 years, pronounced death, lost follow-up, and presumed to be nontraumatic etiol-

ogies were excluded from the study. ?Patients, who were decapitated, incinerated, or

decomposed or displayed signs of rigor mortis, were pronounced dead by EMTs. Emergen- cy medical technicians terminated the resuscitation without further transfer.

patients (8.6%). Among the 145 patients who received AED application, 9 had a shockable rhythm. Of the patients, 49.2% received advanced air- way management by EMTs, and 18.4% of the patients were sent to

Table 1

Baseline characteristics of patients

n = 396

Male, n (%) 302 (76.3)

Age in years, median (IQR) 50.0 (32.0-63.0) Mechanism, n (%)

Blunt injury 197 (49.7)

Penetration injury 11 (2.8)

Undetermined 188 (47.5)

Location, n (%)

Street/road 198 (50.0)

Education/school 2 (0.5)

Public building 3 (0.8)

Sport field/park 2 (0.5)

Mass rapid transit/station/airport 2 (0.5)

Factory/workplace 37 (9.3)

House 116 (29.3)

Others 36 (9.1)

Witnessed event, n (%) 163 (41.2)

EMT witnessed 19 (4.8)

Bystander CPR, n (%) 34 (8.6)

AED use, n (%) 145 (36.6)

Shockable rhythm by AED, n (%) 9 (6.2) Airway management, n (%)

Oxygen mask 50 (12.6)

Bag valve mask 151 (38.1)

LMA 189 (47.7)

Endotracheal tube intubation 6 (1.5)

Intravenous fluid supply, n (%) 11 (2.8)

Intravenous epinephrine injection, n (%) 8 (2.0) Timeliness of prehospital care in minutes, median (IQR)

Response interval 6.0 (4.0-8.0)

Duration at scene 10.0 (8.0-14.0)

Transport interval 6.0 (3.0-9.0)

Receiving hospital, n (%)

General level 323 (81.6)

Intermediate/advanced level 73 (18.4)

Abbreviation: IQR, interquartile range.

Fig. 2 demonstrates the cumulative ROSC events over time for the different outcome groups. Eight, 6, and 3 patients who survived greater than 2 hours, greater than 24 hours, and survived to discharge were not plotted on the figure due to no record of ROSC time. Among all patients who developed ROSC, 14.3% (6/27) of ROSC was achieved within 15 mi- nutes since CPR. Four of 6 patients who survived to discharge achieved ROSC after CPR for 15 minutes (16, 18, 22, and 24 minutes). Three pa- tients who were discharged with CPC 1 or 2 received CPR for 6, 16, and 18 minutes, respectively. All 3 were witnessed events, and 1 of them had received bystander CPR. Only 1 patient who developed ROSC over 24 hours but did not survive to discharge received CPR less than 15 minutes.

Discussion

Fifteen minutes of CPR before termination of resuscitation is inappropriate

According to our study results, 15 minutes of CPR accompanying other resuscitative interventions before termination of resuscitation is inappropriate. Among all patients who developed ROSC, it was achieved in approximately one-seventh of ROSC within 15 minutes after initia- tion of CPR in our study. Four (66.7%) of 6 patients who survived to dis- charge developed ROSC after CPR for greater than 15 minutes. Patients

Fig. 2. Patient proportions of different outcome groups over time of return of spontaneous circulation*. *Eight, 6, and 3 patients of survival greater than 2 hours, survival greater than 24 hours, and survival to discharge group did not plot on the figure due to no record of time of ROSC, respectively.

who survived greater than 24 hours might be able to receive further sur- gical intervention and benefit from intensive care. Among these pa- tients, only 1 developed ROSC within 15 minutes since CPR. Moriwaki et al [10] reported that the decision to terminate after a 20-minute re- suscitation effort is relevant in blunt traumatic cardiac arrest but should be made on a case-by-case basis. Duration longer than the current sug- gestion of 15 minutes of high-quality CPR yielded more ROSC and sur- vivals. Thus, the guidelines should be revised.

Termination of resuscitation should be based on specific conditions in addition to Resuscitation duration

A few patients might develop sustained ROSC from prolonged CPR (N 60 minutes). Two survivors even developed ROSC after CPR for great- er than 20 minutes. Therefore, instead of a definite duration before ter- minating resuscitation, the decision to terminate resuscitation in a patient undergoing traumatic cardiac arrest should be based on the mechanism of injury and the physiological response of the patient dur- ing resuscitation. Terminating resuscitation should be adjusted for the clinical signs and physiological measurements. These signs and mea- surements might include corneal/pupil reflex, coma scale, ROSC before arrival at the ED [11,12], end-tidal volume carbon dioxide [13,14], pulseless electrical activity, and cardiac contraction by bedside echo [15]. The duration should be defined before terminating resuscitation; a conditional duration based on these signs or measurements must be fulfilled. However, it is irrational and unethical to abandon resuscitation no matter the duration of resuscitation in patients who have demon- strated physiological signs such as corneal/pupil reflex or heart me- chanical activity by Bedside sonography. Huber-Wagner et al [16] reviewed 757 traumatic cardiac arrest patients and identified strong predictors in non-survivors, including thromboplastin time, massive blood transfusion, blood pressure of 0 at the scene, age, and base excess. Schuster et al [15] demonstrated that any pulseless electrical activity is a grave prognostic indicator. In contrast, bedside sonography identified heart contractions as potential for survival. Other studies have also indi- cated that a penetration injury and prehospital thoracotomy are associ- ated with a survival outcome [2,17,18].

A retrospective cohort study conducted by Pickens et al [11] failed to show that terminating resuscitation was in accordance with prehospital clinical assessments in a patient undergoing traumatic cardiac arrest and that patients should be transferred to the ED. As discussed above, many predictors and physiological measurements are available only in the ED setting. Therefore, specific conditions, predictors, physiological measurements, and resuscitation interventions that identify nonsurvivors are a major concern. In short, the decision to terminate re- suscitation should not be based solely on a time limit but on the condi- tions in each individual case. Further study is warranted to develop and validate the termination of resuscitation rule according to the presence of these conditions in patients undergoing traumatic cardiac arrest.

Our study showed a survival rate comparable to previous reports of 2.3% [1,3,10]. However, only 3 survivors were discharged with CPC 1 or 2 in our cohort. Several aspects of our results should be mentioned. First, less than 20% of the patients were sent directly to intermediate to ad- vanced level traumatic care hospitals. Although there are advantages to bypass transportation to traumatic centers for major trauma events [19,20], the benefit of bypass transportation in patients undergoing traumatic cardiac arrest remains uncertain. Second, no prehospital treatment algorithm was in place to correct potential Reversible causes in the field in our study. This included airway management, immediate needle decompression, chest tube insertion, and intravenous or intraosseous route setup for volume repletion. Despite the fact that 49.2% of the patients received advanced airway management, only 2.8% received intravenous fluids, and none received needle decompres- sion or chest tube insertion before arrival at the ED. Kleber et al [21] an- alyzed epidemiological and autopsy data of unsuccessful CPR cases due to traumatic cardiac arrest in Berlin. Management errors occurred in

73%, and some may have been preventable. Therefore, a requirement for a structured cardiac arrest algorithm after major trauma is needed [21]. Lockey at al [22] developed a simple treatment algorithm, which includes resuscitative thoracotomy in cases of penetrating chest trauma, airway management, optimizing oxygenation, correcting hypovolemia, and chest decompression. As the guidelines for a prehospital manage- ment and transportation strategy remain unclear, it is too early to con- clude a time limit to withhold resuscitative efforts in patients undergoing traumatic cardiac arrest.

Limitations

There were several limitations of our study. First, this was a retro- spective cohort study, and data were collected from EMS and cardiac registration records. Selection bias might have occurred as a result of the retrospective design and the excluded patients. Only 7 (1.7%) of the enrolled patients were lost to follow-up and were excluded from the analysis. Those who had electrical shock injury, fire, and hanging were also excluded. Therefore, the enrolled population was specific to traumatic etiologies, and so our results likely reflect the real situation.

Second, there were unmeasured confounding factors in our study. We made every effort to collect data on variables that could have poten- tially correlated with our results using the Utstein style reporting guide- lines [9]. However, the data were abstracted from EMT records. There might be incorrect information, such as the mechanism of injury accord- ing to the first impression of EMT, and the estimate of the CPR duration. Third, this study was conducted in Taoyuan County, Taiwan, within a limited period, which may restrict the general applicability of our find- ings. Further comparative studies in different settings and regions would be of interest.

Conclusions

Fifteen minutes of CPR before terminating resuscitation is inappro- priate for patients undergoing traumatic cardiac arrests, as longer dura- tion resuscitation increases ROSC and survival. Until a prehospital treatment algorithm and transportation strategy are defined, further study should focus on terminating resuscitation based on the specific condition, in addition to the resuscitation duration.

Conflict of interest

None to declare.

Acknowledgments

We are grateful for the support from the Chang Gung Memorial Hos- pital, Keelung, Taiwan (CMRPG2D0131). Special thanks to the Taoyuan County fire departments, Taiwan, especially Liang-Tien Chien, who helped us arrange the trials.

References

  1. David JS, Gueugniaud PY, Riou B, Pham E. Does the prognosis of cardiac arrest differ in trauma patients? Crit Care Med 2007;35(10):2251-5.
  2. Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med 2006;48(3):240-4.
  3. Willis CD, Cameron PA, Bernard SA, Fitzgerald M. Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile. Injury 2006;37(5):448-54.
  4. Deasy C, Bray J, Smith K. Traumatic out-of-hospital cardiac arrests in Melbourne, Australia. Resuscitation 2012;83(4):465-70.
  5. Hopson LR, Hirsh E, Delgado J, Domeier RM. Guidelines for withholding or termina- tion of resuscitation in prehospital traumatic cardiopulmonary arrest: joint position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg 2003;196(1):106-12.
  6. Millin MG, Galvagno SM, Khandker SR. Withholding and termination of resuscita- tion of adult cardiopulmonary arrest secondary to trauma: resource document to the joint NAEMSP-ACSCOT position statements. J Trauma Acute Care Surg 2013; 75(3):459-67.
  7. Budget Accounting and Statistics Department, Taoyuan country, Population Statis- tics Analysis [Chinese]. Available at: http://www.tycg.gov.tw/site/site_index.aspx? site_id=033&site_content_sn=5453.
  8. Safar P. Resuscitation after brain ischemia. In: Grenvik A, Safar P, editors. Brain fail- ure and resuscitation. New York: Churchill Livingstone; 1981. p. 155-84.
  9. Jacobs I, Nadkarni V, Bahr J. Cardiac arrest and cardiopulmonary resuscitation out- come reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the interna- tional liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation 2004;63(3):233-49.
  10. Moriwaki Y, Sugiyama M, Yamamoto T. Outcomes from prehospital cardiac arrest in blunt trauma patients. World J Surg 2011;35(1):34-42.
  11. Pickens JJ, Copass MK, Bulger EM. Trauma patients receiving CPR: predictors of sur- vival. J Trauma 2005;58(5):951-8.
  12. Cera SM, Mostafa G, Sing RF, Sarafin JL, Matthews BD, Heniford BT. Physiologic pre- dictors of survival in post-traumatic arrest. Am Surg 2003;69(2):140-4.
  13. Deakin CD, Sado DM, Coats TJ, Davies G. Prehospital end-tidal carbon dioxide con- centration and outcome in major trauma. J Trauma 2004;57(1):65-8.
  14. Hatlestad D. Capnography as a predictor of the return of spontaneous circulation. Emerg Med Serv 2004;33(8):75-80.
  15. Schuster KM, Lofthouse R, Moore C, Lui F, Kaplan LJ, Davis KA. Pulseless electrical ac- tivity, focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma. J Trauma 2009;67(6):1154-7.
  16. Huber-Wagner S, Lefering R, Qvick M. Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest. Resuscitation 2007;75(2):276-85.
  17. Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed Resuscitation procedure that can yield good results. J Trauma 2011;70:E75-8.
  18. Coats TJ, Keogh S, Clark H, Neal M. Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rational and case series. J Trauma 2001;50:670-3.
  19. Garwe T, Cowan LD, Neas BR, Sacra JC, Albrecht RM. Directness of transport of major trauma patients to a level I trauma center: a propensity-adjusted survival analysis of the impact on short-term mortality. J Trauma 2011;70(5):1118-27.
  20. Sampalis JS, Denis R, Frechette P, Brown R, Fleiszer D, Mulder D. Direct transport to Tertiary trauma centers versus transfer from lower level facilities: impact on mortal- ity and morbidity among patients with major trauma. J Trauma 1997;43(2):288-95.
  21. Kleber C, Giesecke MT, Lindner T, Haas NP, Buschmann CT. Requirement for a struc- tured algorithm in cardiac arrest following major trauma: epidemiology, manage- ment errors, and preventability of traumatic deaths in Berlin. Resuscitation 2014; 85(3):405-10.
  22. Lockey DJ, Lyon RM, Davies GE. Development of a simple algorithm to guide the ef- fective management of traumatic cardiac arrest. Resuscitation 2013;84:738-42.

Leave a Reply

Your email address will not be published. Required fields are marked *