Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?

On May 2019 was published an article we review today, cause the authors conclusions are pretty astonishing and worth a deeper look.

Israr, S & Cook, AD & Chapple, KM & Jacobs, JV & McGeever, KP & Tiffany, BR & Schultz, SP & Petersen, SR & Weinberg, JA. (2019). Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?. Injury. 10.1016/j.injury.2019.05.025.

Authors Conclusions: Following pre-hospital traumatic cardiac arrest, PEA on arrival portends death. Although Cardiac Wall Motion (CWM) is associated with survival to admission, it is not associated with meaningful survival. Heroic resuscitative measures may be unwarranted for PEA following pre-hospital traumatic arrest, regardless of CWM.

What kind of study is this?

A retrospective, cohort study consisting of adult trauma patients (n. 277 patients ≥18 years of age) admitted to one of two American College of Surgeons verified level 1 trauma centers in Maricopa County, Arizona within the same hospital system between February 2013 to September 2017 and January 2015 to December 2017.

Pre-hospital management by emergency medical transport services was guided by advanced life support protocols. 

Both hospitals for management of Traumatic Cardiac Arrest (TCA) followed the Western Trauma Association Guidelines

The following variables were collected from each patient:

• Age
• Gender
• Duration of pre-hospital CPR
• Survival to admission vs. pronouncement of death in ED
• Disposition at hospital discharge

Results

• 277 trauma patients that underwent pre-hospital CPR for TCA
• Mean patient age was 43.1
• Mechanism of injury was penetrating in 99 patients (35.7%), the most common of which was due to ballistic injuries, the rest where blunt trauma.
• 52.0% of the patients were intubated prior to hospital arrival
• 235 patients received epinephrine in route (84.8%)
• Pre-hospital resuscitation duration, 20.0 (15.0 – 25.0) minutes

Outcomes

20 patients were identified on arrival to have had ROSC. 18 of these patients survived to hospital admission and 4 of them were discharged alive from hospital

147 patients were identified on arrival in asystole. Among these patients none were discharged alive from hospital.

The remaining 110 patients presented with PEA. 10 patients survived to admission, 9.1%, but only one, 0.9% was discharged from alive from hospital.

P-FAST was performed in 79 of the 110 patients with PEA (71.8%)

Presence of CWM was significantly associated with survival to hospital admission (2 but not to hospital discharge (zero with or without CWM).

Authors conclusions

• Resuscitative efforts are unlikely to reverse the course of this pathophysiology, warranting sound clinical judgement from the treating physician concerning the decision to continue or desist, relative to mechanism of injury and clinical presentation.
• CWM (signifying a beating heart and thereby pseudo PEA) was not associated with meaningful survival.
• Nonetheless, we conclude that P-FAST is a useful tool for distinguishing PEA with cardiac standstill, which is in all likelihood terminal (and continued resuscitation would become an attempt at reanimation), versus pseudo PEA, whereby the heart is actually still beating, representative of a veritable sign of life, and ongoing resuscitative attempts may be considered appropriate despite the unfavorable prognosis.

My considerations on methodology and results

1. Conventional ACLS protocol, as performed in the study, IS NOT the standard of care in TCA.
2. No clinical intervention to address reversible causes where performed (or mentioned) in the field.
3. The only clinically oriented manoeuvre performed in the field was tracheal intubation in just half of the patients (52.0% of the patients were intubated).
4. Prehospital resuscitation time (20 minutes mean time) was spent performing non useful and potentially  dangerous interventions (closed chest compressions, epinephrine administration) for TCA.
5. Patients with PEA and documented CWM (but not only them) at their arrival in ED has been hypo perfused during the entire pre-hospital resuscitation time and lost most of their chances for good clinical outcome.

So in my opinion this study and it’s conclusions are biased by a wrong approach to Traumatica Cardiac Arrest in the prehospital phase.

Emergency providers, when treating patients in traumatic cardiac arrest, need to perform interventions addressing the possible REVERSIBLE causes:

1. Exanguination/Massive Hemorrage (Pelvic Binding, TXA administration, Tourniquet or direct compression)
2. Hypoxia (Tracheal Intubation)
3. Tension Pneumo (Double Thoracostomy)
4. Hypovolemia (Blood or fluid resuscitation)

Emergency providers need to rely on direct (central pulse palpation, Ultrasuond) or indirect (EtCO2, Plethysmography) signs of perfusion to guide their clinical interventions.

Resuscitation of Traumatic Cardiac Arrest patients in not futile just need to be performed in the right way.

References

Israr, S & Cook, AD & Chapple, KM & Jacobs, JV & McGeever, KP & Tiffany, BR & Schultz, SP & Petersen, SR & Weinberg, JA. (2019). Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?. Injury. 10.1016/j.injury.2019.05.025.