a b s t r a c t

Background: cardio pulmonary resuscitation (CPR) for traumatized patients in the field portends poor survival but the outcome of trauma patients who arrive in-extremis and undergo CPR shortly after arrival has not been well studied. The purpose of our review is to evaluate survival to discharge for trauma patients with CPR from 1 to 120 minutes (min) after arrival.

Methods: The NTDB Research Data Set (RDS) was reviewed. Patients with vitals in the field who underwent CPR from 1 to 120 min after arrival were divided according to injury type and Injury Severity Score (ISS). Survival to discharge outcomes were determined in patients that underwent CPR from 1-60 min and 61-120 min after arrival. Results: The RDS contained 968,665 patients and 9,365 (0.96%) had CPR from 1 to 120 min after arrival. For Blunt injuries with CPR from 1 to 60 min, survival was similar for all levels of ISS (8.5-10.2%, p N 0.05). Blunt injury pa- tients with CPR 61-120 min and ISS 1-15 had significantly higher survival rate compared to ISS N25 (36.1% vs 8.7%, p b 0.00003). For Penetrating injuries and CPR from 1 to 60 min, survival was similar for all levels of ISS (4.3-6.8%, p N 0.05); Blunt and penetrating patients with CPR from 61 to 120 min, and ISS 1-15 had the highest survivals at 36.1 and 36.4%.

Conclusion: Trauma patients who undergo CPR shortly after arrival have a survival rate of (4.3%-36.4%). Over one-third of blunt and penetrating injuries and low ISS who had CPR from 61 to 120 min after arrival survived. Trauma patients who arrest shortly after arrival warrant an aggressive approach.

(C) 2018

Introduction

Cardiac arrest following any cause and in any location is extremely deadly, killing approximately 475,000 Americans each year [1]. More than 350,000 cardiac arrests occur outside of the hospital each year and about 90% of people who experience an out-of-hospital cardiac arrest die [2]. The results of cardiac arrest in the field from traumatic injury are even more grave. The need for cardio pulmonary resuscitation (CPR) after traumatic injury has been consistently associated with even higher patient mortality [3]. These statistics demonstrate just how vital it is to minimize the effects of cardiac arrest after injury.

It has been determined that the first few hours are the most critical period following a serious injury. There are, however, very limited studies on the outcome of trauma patients who arrive in-extremis and

? Conflicts of interests: nothing to disclose.

* Corresponding author at: 11750 Bird Road, Miami, FL 33175, United States of America.

E-mail address: [email protected] (A. Elkbuli).

undergo CPR shortly after arrival. One of the only studies to date that ex- amined survival in injured patients with CPR within the first hour of ar- rival to a trauma center reviewed the National Trauma Data Bank from 2007 to 2010 [3]. The reported survival rate to hospital discharge was low, with approximately 13% survival of patients who had received CPR within the first hour of arrival [3].

While few studies have assessed the outcome of patients who arrive

in-extremis and undergo CPR shortly after arrival, many have examined the impact and survival rates of in-hospital cardiac arrest and out-of-hospital cardiac arrest (OHCA), most in a non-trauma or mixed population. Evidence suggests that IHCA results in an improved survival rate as compared to OHCA. One analysis of non-trauma patients, at an urban academic hospital reported 37.8% survival after IHCA compared to 2.9% survival for OHCA [4]. Additional studies comparing IHCA with OHCA found similar results [5]. In general, patients who require CPR have low survival rates and most agree that further measures are needed to improve the survival rate of all patients who require CPR [6-8]. Additionally, evidence suggests that survival following CPR in hospital does not appear to have changed markedly in 40 years [9].

https://doi.org/10.1016/j.ajem.2018.09.031

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The purpose of this study was to evaluate survival to discharge for trauma patients who received CPR from 1 to 120 min after arrival.

Study design and methods

The NTDB Research Data Set (RDS) was reviewed. Data was submit- ted by participating trauma centers. Patients with vital signs in the field but then underwent CPR from 1 to 120 min after arrival were extracted and divided according to injury type (blunt or penetrating) and Injury Severity Score (ISS). Outcomes were evaluated in patients that underwent CPR from 1-60 min and 61-120 min after arrival. Categori- cal variables were assessed with chi squared and significance was defined as p b 0.05.

Results

The RDS contained 968,665 trauma patients and 9365 (0.96%) underwent CPR from 1 to 120 min after arrival. For blunt injuries with CPR from 1 to 60 min, survival was similar for all levels of ISS (8.5-10.2%, p N 0.05). Blunt patients with CPR 61-120 min and ISS 1-15 had significantly higher survival rate compared to ISS N25 (36.1% vs 8.7%, p b 0.00003). For penetrating injuries and CPR from 1 to 60 min, survival was similar for all levels of ISS (4.3-6.8%, p N 0.05); Less injured patients (ISS b15) who had vital signs for the first hour but then underwent CPR from 61 to 120 min with either injury type (blunt or penetrating) had the highest survivals at 36.1% for blunt injuries and 36.4% for penetrating, as shown in Table 1.

Discussion

It has previously been determined that the first few hours are the most critical following a serious injury. The need for CPR after traumatic injury has been consistently associated with high patient mortality [3]. The timeframe of CPR from our results administration plays a key role in the survival of patients after traumatic injury.

This study is currently the only study which examined the impact of injury type (blunt vs. penetrating) on survival to discharge for patients with CPR from 1-60 and 61-120 min after arrival. The only other study that examined patients who arrived in-extremis and underwent CPR shortly after arrival determined a survival rate of 13% and was not

Table 1

Post-Traumatic resuscitation survival rate at 1-60 and 61-120 min using the NTDB 2016.

divided based on injury type [3]. While in our study, results for CPR after 1-60 min were in a slightly worse with 7.6% surviving. In the 61-120 minute group, the survival was slightly better at 16.2%. This demonstrates a significantly higher survival rate for patients with CPR 61-120 min after arrival as compared to patients with CPR 1-60 min (Table 1). Also, looking at subsets, the highest survival occurred in blunt or penetrating injuries and low ISS patients who had CPR from 61 to 120 min of arrival. This subgroup produced similar survival rates for both blunt and penetrating trauma, with 36.1% and 36.4% survival respectively (Table 1). This reason this subgroup has better outcomes is not clear from our study. Further focus on the path- ophysiology may be warranted.

Other studies have analyzed survival after OHCA in both the medical and trauma setting. Huang and colleagues looked at OHCA for any con- dition and found that about 12% of patients survived after OHCA [7]. Chokengarmwong and colleagues looked at non-trauma patients and found that 2.9% of patients survived after OHCA [4]. And finally, Perron and colleagues found that 25% of Pediatric trauma patients survived to discharge after OHCA [10]. With these results, it is clear that OHCA is extremely life threatening but there are survivors with both medical and trauma diagnoses. In comparison our study only looked at trauma patients that had vital signs in the field but then went on to cardiac arrest after arrival.

Our study has limitations; it is a study of data from the NTDB, the largest collection of trauma registry data. The use of this data incorpo- rates the same limitations as any large dataset, which include possible misclassification of injuries, lack of consistency, unrepresentativeness, and wide variability. In addition, many patients had multiple injuries and the exact injury that was most responsible for cardiac arrest was also not available. We also used survival to discharge as our end marker without out of hospital follow up.

Conclusion

Trauma patients who undergo CPR shortly after arrival have a survival rate of (4.3%-36.4%). Over one-third of blunt and penetrating injuries and low ISS patients who had CPR from 61 to 120 min of arrival survived. Survival for patients receiving CPR after 61-120 min of arrival was higher as compared to patients receiving CPR after 1-60 min of arrival. Trauma patients who arrest shortly after arrival warrant an aggressive approach. Further research needs to be done to evaluate the effects of patients who arrive in-extremis and undergo CPR shortly after arrival.

Competing interests

The authors declare that they have no competing interests.

Funding

None.

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