Consensus Criteria Predict Futile Prehospital Trauma Resuscitation
None of 294 patients had meaningful survival, and EMS resuscitation triggered hospital costs approaching $4 million.
In 2003, the National Association of Emergency Medical Services (EMS) Physicians and the American College of Surgeons Committee on Trauma published guidelines on when to withhold or terminate prehospital resuscitation in traumatic cardiopulmonary arrest (TCPA). Using data from a level I trauma registry from 2003 through 2010, researchers studied prehospital TCPA patients aged 18 years for whom these guidelines were violated.
Criteria to withhold or terminate care were
- (1) blunt trauma with apnea, pulselessness, and no organized electrocardiogram activity;
- (2) penetrating trauma with the preceding clinical presentation and no other signs of life;
- (3) 15 minutes of cardiopulmonary resuscitation without return of spontaneous circulation; or
- (4) EMS-witnessed TCPA followed by 15 minutes of unsuccessful resuscitation en route to the emergency department (ED).
Among 294 patients, mechanism of injury was blunt in 90 (31%) and penetrating in 204 (69%). Overall, 274 patients (93%) died in the ED, and 12 (4%) died during surgery. Of the 8 patients who reached the intensive care unit, 7 died in the ICU, and 1 (0.3%) survived but had a Glasgow Coma Scale score of 6 and was discharged to a long-term care facility.
Comment: The charges for hospital care for these 294 patients totaled nearly US$4 million, and the one surviving patient had a horrible outcome. These data strongly support the existing guidelines and the need to ensure that EMS personnel understand and adhere to them.
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine December 9, 2011
CITATION(S): Mollberg NM et al. The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients. J Trauma 2011 Oct; 71:997.