Is there a role for closed chest compressions and Cardiopulmonary Resuscitation (CPR) after a traumatic cardiac arrest due to blunt trauma?

From the Guidelines

Yes, there is a role for closed chest compressions and CPR after traumatic cardiac arrest from blunt trauma, though with important considerations. According to the most recent guidelines from the American Heart Association, CPR should be initiated promptly while simultaneously addressing the likely causes of arrest, particularly tension pneumothorax, cardiac tamponade, hypovolemia, and hypoxia 1. Standard high-quality CPR with a rate of 100-120 compressions per minute and a depth of 2-2.4 inches should be performed. However, chest compressions alone may be less effective in traumatic arrest compared to medical cardiac arrest because the primary issues are often mechanical obstructions or severe blood loss rather than primary cardiac problems.

Some key considerations in the management of traumatic cardiac arrest include:

• Prompt initiation of CPR
• Addressing reversible causes of cardiac arrest, such as hypoxia, hypovolemia, pneumothorax, and pericardial tamponade 1
• Rapid interventions to address underlying causes, including needle decompression for suspected tension pneumothorax, pericardiocentesis for cardiac tamponade, aggressive fluid resuscitation with blood products, and securing the airway with endotracheal intubation. The survival rates for traumatic cardiac arrest are generally lower than for medical cardiac arrest, but outcomes have improved with this balanced approach of providing CPR while simultaneously treating the specific traumatic pathologies. CPR must be accompanied by rapid interventions to address these underlying causes, and the routine transfer of patients to a specialized facility should be carefully considered, weighing the risk of transport against the possible improvement in neurologically intact survival 1.

From the Research

Role of Closed Chest Compressions and CPR in Traumatic Cardiac Arrest

• The effectiveness of closed chest compressions and CPR in traumatic cardiac arrest (TCA) from blunt trauma is a topic of ongoing debate 2, 3, 4, 5, 6.
• Studies have shown that survival rates for TCA are generally low, ranging from 2-5% 3, and have not improved significantly over the past two decades in high-income countries.
• However, some research suggests that CPR can be beneficial in certain cases, particularly when initiated promptly and in conjunction with other treatments such as bleeding control and oxygen supplementation 4, 5.

Factors Influencing Outcomes in TCA

• The presence of bystander CPR, shockable initial rhythms, and rapid identification and treatment of reversible causes are associated with favorable outcomes in TCA patients 3.
• Advanced interventions, such as resuscitative thoracotomy and resuscitative endovascular balloon occlusion of the aorta (REBOA), may also improve outcomes in selected cases 2, 3.
• The injury severity score (ISS) and time interval to hospital transport are significant predictors of failure of CPR in TCA patients 4.

Open-Chest vs. Closed-Chest CPR

• Open-chest CPR has been recommended as a treatment option for patients with penetrating injuries, but its role in blunt trauma is less clear 5.
• One study found that open-chest CPR may be beneficial in patients with blunt chest or abdominal trauma, particularly when initiated promptly after cardiac arrest 5.
• However, the evidence is limited, and further research is needed to determine the optimal approach to CPR in TCA patients with blunt trauma.

Decision-Making in TCA Resuscitation

• The decision to undertake aggressive resuscitation efforts in TCA patients should be made on a case-by-case basis, taking into account factors such as the patient's age, injury severity, and initial rhythm 6.
• A 20-min resuscitation effort and termination of the effort are thought to be relevant in BT-CPA patients, but the initial rhythm is not a prognostic indicator 6.