Traumatology

Surviving traumatic cardiac arrest: Identification of factors associated with survival

a b s t r a c t

Introduction: The endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary ar- rest varies across institutions and even among providers. The purpose of this study was to examine survival char- acteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED).

Methods: The National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hos- pitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed.

Results: A total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mech- anism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99).

Conclusion: Over a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physi- cians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.

(C) 2021 Published by Elsevier Inc.

  1. Introduction

Trauma is the leading cause of mortality in adults under 44 years of age [1]. Annually in the United States (US), more than 350,000 patients suffer from out-of-hospital cardiac arrest, with resuscitation attempted in 60% of these cases. While 84-99% of out-of-hospital cardiac arrests are of a medical etiology, survival from Traumatic cardiac arrest (TCA) and medical cardiac arrest are similarly very poor [2]. Survival rates

* Corresponding author.

E-mail addresses: [email protected] (A. Khalifa), [email protected] (J.B. Avraham), [email protected] (K.Z. Kramer), [email protected] (F. Bajani), [email protected] (C.Y. Fu), [email protected] (A. Pires-Menard), [email protected] (M. Kaminsky), [email protected] (F. Bokhari).

range from 3 to 20%, with differing neurologic functional outcomes in blunt and penetrating trauma [2,3]. One study demonstrated the sur- vival rate for TCA was 2.6%, with a 1.5% functional outcome [4]. But, as traumatic injury is more prevalent among younger populations, a dis- proportionate number of potential productive life years are lost to trau- matic cardiac arrest [2]. TCA is defined as the abrupt cessation of Cardiac activity resulting from blunt or penetrating trauma. The most common causes of TCA are severe head injury, hypovolemia, upper airway ob- struction, hypoxia, air embolus, Tension pneumothorax, Pericardial tamponade, myocardial contusion, Commotio cordis, and disruption of the heart and great vessels [2].

In addition to cardiopulmonary resuscitation (CPR), emergency de- partment (ED) thoracotomy is used as a resuscitative adjunct among patients presenting after TCA. Despite its invasiveness, it remains an im- portant tool in the armamentarium of physicians treating penetrating

https://doi.org/10.1016/j.ajem.2021.01.020 0735-6757/(C) 2021 Published by Elsevier Inc.

trauma, especially among those with significant hemodynamic abnor- malities [10]. Its efficacy has been widely studied; according to one re-

Table 1

Comparisons between survivors and non-survivors in all patients (N = 24,191)

port, only 20% of patients with isolated Penetrating cardiac injury who

underwent ED thoracotomy survived, as did fewer than 2% after blunt

Survivors (N = 246)

Non-survivors (N = 23,945)

p-value

injury [11]. In addition, ED thoracotomy was futile among patients with- out vital signs (VS) who were pronounced dead upon arrival [12].

We examined the survivor characteristics of TCA among those with- out VS presenting to the ED who had resuscitative measures performed. These interventions included ED thoracotomy, open chest cardiac mas- sage (OCM), and definitive surgery of the chest or abdomen. The objec- tive of this study was to better understand patient factors associated with survival and more favorable discharge. Identification of those with higher likelihood of survival may aid in decreasing futile resuscita- tive efforts, which may unnecessarily increase risk for Healthcare workers.

  1. Materials and methods

This was a retrospective cohort study in torso trauma patients with no recorded VS who underwent resuscitation following traumatic car- diac arrest in United States (US) EDs between 2007 and 2015. The data obtained from the National Trauma Data Bank included pa- tients without VS who sustained blunt or penetrating trauma to the torso and were sent directly to a trauma center without transfer.

Survival characteristics of the overall study cohort were analyzed, followed by various analysis with patients who were pronounced DOA excluded. Logistic regression analysis was performed to identify factors associated with survival after patients with DOA were excluded. Analy- sis was conducted comparing patients based on mechanism of action. Sub analysis comparing survivors with non survivors excluding patients who were DOA based on mechanism of injury was conducted followed by logistic regression analysis for independent factors and associated OR for survival when appropriate. Finally, analysis was conducted compar- ing between survivors who were routinely discharged home (or into police custody) vs survivors who were discharged to long-term care.

Blunt injury and penetrating injury codes (ECODE as NTDB defini- tion, RDS_ECODEDES) were used. ICD-9 codes for intra-thoracic injury (860.0 to 862.9), intra-Abdominal injury to both solid and hollow organs (836.0 to 869), pelvic fracture (808), and injury to blood vessels of the thorax, abdomen and pelvis (901.0 to 902.9) were included. Without VS defined as pulse = 0, SBP = 0, respiratory rate = 0, Glasgow Coma Scale (GCS) = 3. Patients with isolated head injuries, those transferred from other hospitals, or those with missing values, were excluded.

Basic demographic features included age, gender, mechanism of trauma (blunt vs. penetrating), transportation time, ED time and Injury Severity Score (ISS).

Whether or not patients received interventions such as exploratory thoracotomy (ICD-9 PCODE: 34.04), open cardiac massage (37.91) and

Age 34.9 35.5 0.687$

Male (N, %) 184 (74.8%) 18,882 (78.9%) 0.141#

Mechanism (N, %) 0.082#

Blunt trauma 113 (45.9%) 12,900 (53.3%)

Penetrating trauma 133 (54.1%) 11,045 (46.7%)

Transportation time (minutes) 63.2 90.0 0.237$

ED time (minutes) 73.8 56.6 0.666$

ISS 29.0 34.1 <0.001$

$ Student t-test.

# Chi-square test.

significant on initial analysis. p values <0.05 were considered signifi- cant. Summary statistics with a normal distribution were reported as mean [standard deviation] and median [interquartile range (IQR)], if non-normally distributed.

  1. Results

A total of 24,191 torso trauma patients who presented to the ED without VS were included in this study. Population demographics of survivors (n = 246) vs non-survivors (n = 23,945) are summarized in Table 1.

Survivor (n = 246) characteristics (Table 2) demonstrate survivors sustained a higher proportion of penetrating trauma (54.1% vs. 31.3%, p < 0.001), shorter transport times (63.2 vs. 105 min, p = 0.042 [mean]) (22 vs. 23 min, p = 0.042 [median]), less time spent in the ED (31 vs. 66 min, p < 0.427 [median]), and higher rates of exploratory thoracotomy (30.9% vs. 18%, p < 0.001) and definitive surgery (69.5% vs. 47.3%, p < 0.001). Average ISS was also significantly lower in patients who survived (29 vs. 34.6, p = 0.017) [median ISS, 26 vs. 34.0

p < 0.001].

Logistic regression analysis (Table 3) identified that lower ISS (p = 0.001), shorter ED time (p < 0.001), penetrating mechanism of injury (p < 0.001), and performance of a definitive chest or abdominal surgery (p = 0.006) were independent factors for survival. Each unit increase in ISS was associated with a 1.4% decrease in survival rate, every additional minute in the ED was associated with a 0.2% decreased in survival rate, penetrating trauma was associated with a 2.12 times increase in

Table 2

Comparisons between survivors and non-survivors after patients with death on arrival were excluded (N = 812)

definitive surgery (origin file: RDS_PCODE and RDS_PCODEDES) were also included in analysis between survivors and non-survivors. Addi-

Survivors (N = 246)

Non-survivors (N = 566)

p-value

tional characteristics of survivors analyzed included mean hospital length of stay , intensive care unit (ICU) LOS, ventilator days, com- plications, and discharge destination. Those who were either dead upon arrival or never responded to resuscitation in the ED (which we defined as “early death“) were excluded in subsequent sub-analysis.

A “complication” included severe sepsis, unplanned return to ICU,

Age (mean) 34.9 35.4 0.732$

Age (median) 30.0 33.0 0.732$

Male (N, %) 184 (74.8%) 403 (71.2%) 0.617#

Mechanism (N, %) <0.001#

Blunt trauma 113 (45.9%) 389 (68.7%)

Penetrating trauma 133 (54.1%) 177 (31.3%) Transportation time (minutes) (mean) 63.2 105.0 0.042$

unplanned return to the operating room , osteomyelitis, catheter

related blood-stream infection, unplanned intubation, superficial surgi-

Transportation time (minutes) (median)

22.0 23.0 0.042$

cal site infection, deep surgical site infection, stroke or cerebrovascular accident (CVA), pulmonary embolism, pneumonia, organ/space surgical site infection, myocardial infarction, deep vein thrombosis, subsequent cardiac arrest with Resuscitative efforts by healthcare provider, acute lung injury, and acute kidney injury.

The study cohort was dichotomized according to survivors and non- survivors and statistically analyzed with SPSS. Logistic regression was used to calculate odds ratios (OR) to control for variables identified as

ED time (minutes) (mean) 73.8 430.3 0.027$ ED time (minutes) (median) 31.0 65.5 0.027$ Exploratory thoracotomy (N, %) 76 (30.9%) 102 (18.0%) <0.001#

Open cardiac massage (N, %) 37 (15.0%) 75 (13.3%) 0.554#

Definitive surgery (N, %) 171 (69.5%) 268 (47.3%) <0.001

ISS (mean) 29.0 34.6 <0.001$

ISS (median) 26.0 34.0 <0.001$

$ Student t-test.

# Chi-square test.

Table 3

Logistic regression analysis for the independent factor for survival (excluding patients with DOA)

Table 6

Logistic regression for survival after blunt trauma patients with death on arrival were excluded

p-value

Odds Ratio

p-value

Odds Ratio

ISS

0.001

0.986

Definitive surgery

0.062

0.639

ED time (minutes)

0.000

0.998

Exploratory thoracotomy

0.060

0.496

Transportation time (minutes)

0.114

1.000

Transportation time (minutes)

0.165

0.999

Exploratory thoracotomy

0.927

1.020

ED time (minutes)

0.014

0.997

Penetrating trauma

0.000

2.123

ISSAIS

0.054

0.988

Definitive surgery (chest/abdomen)

0.006

1.692

Constant

0.291

1.497

Constant

0.022

1.624

Table 4

Comparisons between the blunt trauma and penetrating trauma patients (DOA patients were excluded) (N = 812)

Blunt trauma

Penetrating trauma

p-value

(N = 502)

(N = 310)

Age

38.9

29.4

0.693$

Male (N, %)

310 (61.8%)

277 (89.4%)

<0.001#

Transportation time (minutes)

96.6

85.5

0.071$

ED time (minutes)

192.1

158.1

<0.001$

Open cardiac massage (N, %)

15 (3.0%)

97 (31.3%)

<0.001#

Exploratory thoracotomy (N, %)

41 (8.2%)

137 (44.2%)

<0.001#

Definitive surgery (N, %)

203 (40.4%)

236 (76.1%)

<0.001#

Mortality (N, %)

389 (77.5%)

42 (48.3%)

<0.001#

Complication (N, %)

357 (71.1%)

199 (64.2)

0.039#

Hospital LOS (day)

10.1

17.6

<0.001$

ICU LOS (days)

7.3

10.7

<0.001$

Ventilator day (days)

6.0

7.8

<0.001$

ISS

33.6

31.9

<0.001$

$ Student t-test.

# Chi-square test.

survival compared to blunt injury among this patient cohort, and under- going definitive surgery was associated with a 1.69 times Survival benefit.

Table 4 compares mechanism of trauma, excluding early deaths. Data demonstrate that there were more males injured by penetrating than blunt trauma (89.4% vs. 61.8%, p < 0.001) and patients with pene- trating trauma spent fewer minutes in the ED (158.1 vs. 192.1, p < 0.001). Also, patients with penetrating trauma more frequently re- ceived OCM (31.3% vs. 3.0%, p < 0.001), exploratory thoracotomy (44.2% vs. 8.2%, p < 0.001), and definitive surgery (76.1% vs. 40.4%, p < 0.001). ISS (31.9 vs. 33.6, p < 0.001) and mortality (48.3% vs. 77.5%, p < 0.001) were significantly lower in patients who sustained penetrating trauma. Those who sustained penetrating trauma had longer Hospital length of stay (17.6 vs. 10.1, p < 0.001), longer ICU LOS (10.7 vs. 7.3,

p < 0.001), and more days on a ventilator (7.8 vs. 6, p < 0.001).

Table 5 demonstrates that, after excluding early deaths, survivors of blunt trauma had lower ISS, shorter transport time, spent less time in the ED, and had higher rates of exploratory thoracotomy and definitive surgery. However, logistic regression analysis (Table 6) showed only time in ED to be an independent predictor of mortality (p < 0.013, OR 0.99).

The same analysis with penetrating trauma (Table 7) demonstrates that only ISS differed between survivors and non-survivors (28.3 vs. 34.5, p = 0.006).

Table 8 demonstrates that survivors who were discharged home (or into police custody, n = 73) versus those who needed long term care (n = 173) were: younger (29.1 vs. 37.4, p < 0.001), more often male (87.7% vs. 69.4%, p = 0.003), and had lower ISS (25.5 vs. 30.1, p = 0.01); a greater number also underwent exploratory thoracotomy (40.1% vs. 26.6%, p = 0.024).

  1. Discussion

In this retrospective analysis of survival after traumatic cardiac ar- rest resulting from torso trauma, we considered age, gender, injury se- verity, mechanism of injury, transport time, ED time and management to identify factors associated with survival. Among 24,191 patients who fit our criteria for TCA, there were only 241 survivors (1%), consis- tent with previous reports [6,[7,8],9]. Our analysis also confirms previ- ously described survival differences between patients suffering blunt versus penetrating injury [2,6,13]. We report overall survival in blunt TCA of 0.87%, and 1.2% following penetrating mechanism. After exclud- ing early deaths, identifying only those responsive to initial resuscitative efforts, we demonstrate a survival increase to 30% (246/812), with 22.5% survival in blunt trauma and 43% in penetrating trauma. We also report that penetrating trauma, shorter ED time, lower ISS, or un- dergoing definitive torso surgery were each independently associated with increased survival. After further examination of outcomes, distinguishing between patients who did not require long term care (a potential surrogate for better neurological outcome) from those who did, we found that those discharged home (or into police custody)

Table 5

Comparisons between survivors and non-survivors after blunt trauma patients with death on arrival were excluded (N = 502)

Table 7

Comparisons between survivors and non-survivors after penetrating trauma patients with death on arrival were excluded (N = 310)

Survivors

Non-survivors

p-value

Survivors

Non-survivors

p-value

(N = 113)

(N = 389)

(N = 133)

(N = 177)

Age

41.4

38.2

0.158$

Age

29.4

29.4

0.996$

Male (N, %)

65 (57.5%)

245 (63.0%)

0.292#

Male (N, %)

119 (89.4%)

158 (89.3%)

0.887#

Transportation time (minutes)

56.0

108.4

0.033$

Transportation time (minutes)

69.3

97.7

0.421$

ED time (minutes)

83.5

223.7

<0.001$

ED time (minutes)

65.5

884.3

0.164$

Exploratory thoracotomy (N, %)

18 (15.9%)

23 (5.9%)

<0.001#

Exploratory thoracotomy (N, %)

58 (43.6%)

79 (44.6%)

0.069#

Open cardiac massage (N, %)

2 (1.8%)

13 (3.3%)

0.388#

Open cardiac massage (N, %)

35 (26.3%)

62 (35.0%)

0.102#

Definitive surgery (N, %)

63 (55.8%)

140 (36.0%)

<0.001#

Definitive surgery (N, %)

108 (81.2%)

128 (72.3%)

0.857#

ISS

29.8

34.7

0.003$

ISS

28.3

34.5

0.006$

$ Student t-test.

# Chi-square test.

$ Student t-test.

# Chi-square test.

Table 8

Comparisons between survivors with routine discharge and long-term care (N = 246)

Routine discharge (N = 73)

Long-term care (N = 173)

p-value

Age

29.1

37.3

<0.001$

Male (N, %)

64 (87.7%)

120 (69.4%)

0.003#

Transportation time (minutes)

80.2

56.0

0.466$

ED time (minutes) (mean)

54.6

81.9

0.237$

Exploratory thoracotomy (N, %)

30 (40.1%)

46 (26.6%)

0.024#

Open cardiac massage (N, %)

13 (17.8%)

24 (13.9%)

0.430#

Definitive surgery (N, %)

56 (76.7%)

115 (66.5%)

0.111#

ISS

25.5

30.1

0.010$

$ Student t-test.

# Chi-square test.

were more likely to be: younger, male, victims of penetrating trauma, have a lower ISS, or have undergone exploratory thoracotomy.

Survival rates after TCA are dismal, typically reported to range from 0 to 7.5% [13,15,16, 17]. Improvements in pre-hospital care and treat- ment have led to modest survival improvements over time [11], with at least one military study reporting 18 of 78 (24%) patients who underwent resuscitation for TCA survived [18]. Identifying unique char- acteristics among survivors may help identify those most likely to ben- efit from aggressive resuscitation.

Extent of injury is known to be a reasonable indicator for progno-

sis [2,14], and we observed a significantly lower ISS among survivors. Javali et al. also reported significant differences in ISS between TCA survivors and non-survivors among the elderly [20]. Variations in organ damage and case complexity can impact survival in ways that a database cannot capture precisely with ISS. TCA patients can present with hypotension secondary to shock or cardiac tamponade, and the latter are not necessarily hypovolemic and thus have a higher chance of survival, all other factors being equal and assuming rapid diagnosis and treatment [9]. In a large series that similarly analyzed survivor characteristics [8], patients with TCA resulting from hypo- volemia outside the hospital rarely survived. As expected, most TCA survivors in that group had an injury pattern that was easily identi- fied and corrected at initial hospital triage.

While age and male gender were also associated with Discharge home,

only ED time and ISS remained independent factors for home discharge on multivariate analysis. Logically, one would expect patients with less severe injuries to be discharged home more often. These patients who were even- tually discharged home also spent nearly 30 fewer minutes in the ED. It is possible that patients with penetrating trauma spend less time in the ED prior to definitive treatment due to more recognizable injuries, while blunt trauma patients–more commonly polytrauma–spend more time in the ED until the full scope of injuries are accurately determined. Survi- vors spent half the time in the ED compared to non-survivors, and every five additional minutes spent in the ED was associated with a 1% decrease in survival. In an animal study [5], mortality increased with hypovolemia time from 38% at 5 min to 100% at 10 min. Previous research has demon- strated that patients who have less time since the loss of VS or cardiac ac- tivity have higher rates of survival after resuscitation [9]. Durham et al. reported a difference in survival related to length of time CPR was admin- istered, with survivors receiving an average of 5 min of CPR compared with 9 min among non-survivors.

We found survival and more favorable outcomes were associated with definitive treatment and exploratory thoracotomy, respectively. A 26-year review of TCA patients showed that survivors of EDT received less than 15 min of prehospital CPR [13]; a similar six-year observational study by the Western Trauma group [23] reported no survivors who required more than 15 min of prehospital CPR. Rapid treatment after arrest is essen- tial for Neurologic recovery as the maximum time that the brain can toler- ate ischemic insult is 18-20 min [11]. While survival after 15 min without signs of life is unlikely [19], those with Penetrating injuries that can be

rapidly addressed do best. This is reflected in the current Eastern trauma guidelines regarding the performance of ED thoracotomy [21]. Collectively, these highlight the importance of the timing to exploratory thoracotomy and definitive treatment [22].

Interestingly, transport time was not significantly associated with survival in our study, although it was in others [6,13,19]. We know from previous reports that patients who do not undergo CPR prior to EDT have better outcomes, and those who do undergo CPR, a shorter du- ration of CPR before EDT is associated with improved outcomes [9]. Thus, since most transport times were greater than the 15-min optimal window for performing EDT, and since most TCA patients die regardless of intervention, it is not surprising that transport time alone would not prove significant. There is growing interest in taking invasive interven- tions used in the in-hospital setting to the prehospital setting such as thoracotomy and Resuscitative Endovascular balloon occlusion of the aorta (REBOA) although there are limited data [22]. This may improve outcomes among those TCA patients unable to reach hospitals quickly, but more data are needed.

There are several limitations of our study. In addition to its retro- spective design, we were unable to determine critical metrics of recov- ery, such as neurologic and long-term functional status among TCA survivors. Also, the use of the NTDB introduces a number of limitations including the possible misclassification of injuries or missing data, as well as the lack of laboratory data. In addition, it was not possible to ex- clude patients dead upon arrival and, therefore, the subcategory of “early death” was created to compensate for this limitation. Further- more, the survivor cohort is a relatively small sample, perhaps limiting its generalizability. Finally, there may be regional (or urban versus rural) variability with regard to aggressive ED interventions, a reality we could not capture in this national dataset.

In conclusion, we report a 1% survival rate in patients with TCA pre- senting to EDs. Only 0.3% of patients are eventually discharged directly to home. However, among those who demonstrate a response to resus- citation, the survival rate increased to 30.3%; among those survivors, 29.7% were discharged home. Higher survival rates were associated with penetrating injuries, lower ISS, and receiving definitive chest or ab- dominal surgery. Among survivors, only lower ISS was associated with a greater likelihood of home discharge. A trauma center must attempt over one hundred TCA resuscitations to save one patient, suggesting that aggressive efforts – particularly among those with prehospital trau- matic arrest – is likely not indicated. However, despite the high mortal- ity rate associated with TCA, aggressive ED intervention is the only chance for survival [11], and may be particularly beneficial for those with isolated penetrating trauma.

Meetings

Presented at the 71st Annual Southwestern Surgical Congress: April 14-17, 2019. Huntington Beach, CA.

Grants

None.

Declaration of Competing Interest None.

Author contributions

Conception and design was conducted by Dr. Faran Bokhari and Dr. Francesco Bajani. Data collection by Dr. Fu and Dr. Kramer. Data analysis by Dr. Fu, Dr. Khalifa, Dr. Avraham, Dr. Bajani and Dr. Pires-Menard. Manuscript written by Dr. Khalifa, Dr. Avraham, Dr. Pires-Menard, with a final approval by Dr. Matthew Kaminsky and Dr. Faran Bokhari.

Appendix A. Appendix

Unlabelled image

Fig. 1. Study population and protocol of current study.

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