Cardiac Arrest in Trauma

Background

• TCA is associated with poor outcomes, with recent reports of ~4% of patients surviving discharge; 1/3 of patients die prior to hospital arrival.¹
• As in most cases of trauma, TCA most commonly occurs in young healthy males.
  • In the United States, the average victim is 40 years old, with 79% of victims being male; Northern Europe has a similar demographic breakdown.^2,3

• In the United States, 50% of TCA occur in the pre-hospital setting, and over 2/3 of TCA are secondary to blunt trauma.²
• The leading etiology for TCA in North America is hemorrhage, with the location and mechanism of injury strongly predicting outcomes, as illustrated by penetrating trauma having a survival rate nearly 5-fold that of blunt trauma (up to 21% in some series compared to 1-4% in blunt trauma).¹
• Although hemorrhage accounts for nearly half of TCAs, the differential is broad, requires rapid evaluation, and swift intervention.⁴

• Emergency medical services should alert the receiving hospital of an incoming trauma patient who may be periarrest or in active cardiac arrest. The receiving hospital will then:
  • Establish the trauma team (trauma surgeons, emergency physicians, anesthesiologists, nurses, lab staff, radiology staff, and the blood bank).
  • Assign resuscitation roles, set communication expectations, and discuss immediate first steps.
  • Prepare necessary resources, such as massive transfusion supplies, airway supplies, ultrasound equipment, and bedside thoracostomy or thoracotomy sets, and activate any available direct-to-operating-room protocols.

Periarrest Patient Management

• In a periarrest trauma patient, the identification and treatment of major external bleeding is the highest priority, and hence exsanguinating hemorrhage control is now placed above ABCDE management in Advanced Trauma Life Support.
  • Early volume resuscitation to a systolic goal > 90 mmHg before advanced airway techniques is associated with a 54% reduction in mortality, thought to be due to drug-mediated post-intubation hypotension.⁵
  • Mechanisms to control bleeding are discussed below.
• Assess for patent airway and secure airway if:
  • Adequate volume resuscitation has occurred.
  • Glasgow coma scale < 8
    OR
  • Signs of airway burns (Facial burns and/or soot at nares or lips), or airway injury exist (Expanding hematoma, crepitus, stridor) or aspiration concerns, which may inhibit adequate ventilation.
    OR
  • Apnea/respiratory failure
• Assess breathing and ventilation.
  • Evaluate for paradoxical chest movement, auscultate bilateral breath sounds, and palpate for crepitus, as all can be signs of impending respiratory failure.
  • Rule out physiology that could be an immediate threat to life, ideally with the assistance of POCUS to perform an extended Focused Assessment with Sonography for Trauma (eFAST), which has high sensitivity for pneumothorax, tamponade, and thoracoabdominal as well as pelvic free fluid.

TCA Management

Determine whether further care is justified/futility of resuscitation.

• The European Resuscitation Council (ERC) 2025 recommendations state that patients should only be resuscitated from a TCA if the following criteria are met:
  • Signs of life were present in the 15 minutes preceding TCA.
    AND
  • There is no major trauma incompatible with survival, such as decapitation, extensive cardiac destruction, or a massive head injury with loss of brain tissue.
  • ERC guidelines advocate for a more aggressive approach to TCA resuscitation, given reports that neurologically intact survivors have initially presented with apnea, pulselessness, and without organized ECG activity.
• The American College of Surgeons holds a more conservative perspective, advocating to withhold care if a trauma patient presents with apnea, pulselessness, and without organized ECG activity.⁴
• If the decision is made to proceed with resuscitation, procedures (hemorrhage control, airway management, chest tubes, needle decompression, etc.) take priority over chest compressions as the effectiveness of chest compressions (especially if the heart is empty or obstructed) are uncertain and may reduce cardiac output in periarrest trauma patients.⁴
• Hypovolemia is the most common etiology for TCA, and the highest priority is to restore intravascular volume to support cardiac output and tissue perfusion.
• Prioritize rapid volume replacement, ideally with blood products, such as whole blood or a balanced transfusion (i.e., 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets).
• Compressible external hemorrhage can be treated with elevation of a bleeding limb, direct pressure, pressure dressings, tourniquets, and topical hemostatic agents (see OpenAnesthesia Stop the Bleed summary Link).
• Noncompressible hemorrhage should be addressed with splints (e.g., pelvic binder) and traction devices (e.g., Thomas splint), blood products, intravenous fluids, and tranexamic acid (TXA) until surgical hemostasis is achieved.
• Aortic occlusion via resuscitative thoracotomy or resuscitative endovascular balloon occlusion of the aorta (REBOA) is recommended as a last resort for exsanguinating and uncontrollable infra-diaphragmatic torso hemorrhage, as it allows immediate hemorrhage control while diverting flow to the brain and heart.
• Resuscitative thoracotomy with cross-clamping/manual compression of the descending aorta has the advantage of relieving pneumothorax/tamponade, the ability to directly intervene on penetrating cardiac injury, directly fill the heart with blood products if empty, provide internal cardiac massage and internal defibrillation if required.
  • Outcomes are best if the intervention occurs within 5-10 minutes of penetrating trauma.
  • See the OA Summary on anesthesia for thoracic trauma for more details. Link
  • Table 3 is an example of a resuscitative thoracotomy decision-making algorithm when assessing an unstable trauma patient (Harborview Medical Center, Seattle).

• REBOA is a minimally invasive alternative to resuscitative thoracotomy to control non-compressible subdiaphragmatic hemorrhage.
  • Contraindicated in major thoracic hemorrhage or pericardial tamponade and provides no survival advantage compared to resuscitative thoracotomy in TCA.⁶
  • See OA summary on REBOA for more details. Link
• Neither resuscitative thoracotomy nor REBOA has been shown to be superior to standard trauma resuscitation techniques.⁷
• Hypoxia is a significant driver for cardiac arrests in trauma and the most likely etiology in cases of traumatic brain injury.
• Prioritize oxygenation by maintaining an open airway via jaw thrust and bag-mask ventilation with high-flow 100% oxygen whilst maintaining cervical spine immobilization over securing a definitive airway (endotracheal intubation).³
• Specific care should be taken to minimize intrathoracic pressures (e.g., by using low positive end-expiratory pressure and tidal volume) while ensuring adequate ventilation, as assessed by capnography.
  • High intrathoracic pressures may inhibit venous return, further compromising cardiac output, reduce diastolic filling, and potentially expand a concomitant pneumothorax.⁴
• Brain impact apnea is an easily reversible yet underappreciated cause for TCA, with data suggesting survival rates of 15% and favorable neurologic outcomes when hypoxia is expediently addressed.
• Tension pneumothorax is a diagnosis of exclusion in TCA, as impaired venous return and gas exchange will quickly worsen during the resuscitation because of positive pressure ventilation.
• Only 0.5% of trauma patients develop tension pneumothorax; however, 13% will go on to develop TCA.
• Diagnosis of tension pneumothorax is based on hypoxia, unilateral breath sounds, mediastinal shift, and/or absence of lung sliding on POCUS prior to TCA.
• Immediate bilateral chest decompression via finger thoracostomies in the 4th intercostal space midaxillary line is often performed in the periarrest patient to both rule out as well as manage potential tension pneumothorax.⁴
• Cardiac tamponade is most likely in cases of penetrating trauma to the “cardiac box” (region defined superiorly by the clavicles, costal margin inferiorly, and nipples bilaterally to which trauma has a high risk of damaging major cardiovascular structures), and clinical suspicion should be elevated based on the mechanism and presence of Beck’s Triad (hypotension, jugular venous distension, and muffled heart sounds) prior to cardiac arrest.
• Resuscitative thoracotomy via clamshell or left anterolateral incision allows for direct management of cardiac and great vessel injury and is indicated in settings with near immediate access to definitive surgical management.
• Pericardiocentesis can be used as a bridge to definitive treatment in nontrauma centers.⁴

When to Terminate TCA Resuscitation

• No return of spontaneous circulation (ROSC) after reversible TCA etiologies are addressed.
  OR
• No cardiac motion on point of care ultrasound despite organized ECG activity if reversible causes of TCA have been addressed.³

ROSC Management

• Post-ROSC management should be dictated by the underlying trauma pathology, although some homogeneity in care exists in all post-ROSC TCA patients:
  • Strive to use hemodynamically neutral sedation and analgesia medications such as midazolam, fentanyl, and ketamine.
  • Limit post-arrest hyperthermia with a core temperature goal < 37.5 degrees Celsius.
  • Targeted hypothermia is no longer recommended given a lack of mortality benefit and increased risk of adverse events associated with hypothermia, especially in trauma patients.⁸
• Traumatic coagulopathies can complicate post-ROSC care with patients developing relative fibrinogen deficiencies, thus consider the administration of cryoprecipitate and qualitatively monitor clotting capabilities with laboratory hemorrhage panels and viscoelastic tests.
• Advanced airway insertion is preferred post-ROSC with ventilation titrated to normal oxygenation and carbon dioxide levels via a low volume optimized positive end-expiratory pressure approach to maximize venous return and coronary perfusion.
• Finger thoracotomies should be converted to chest drains via a standard aseptic technique.
• The patient should rapidly progress to further management of poly-trauma care (following the Advanced Trauma Life Support protocol).

Special Considerations

• Cardiac contusion, asphyxiation (i.e., burial or drowning), and electrocution-induced arrests should follow the advanced cardiovascular life support (ACLS) algorithm and prioritize high-quality cardiopulmonary resuscitation.
• Mild or moderate traumatic mechanisms of injury are often not significant enough to induce a TCA and should alert clinicians to the possibility that a medical arrest preceded the trauma, and thus the patient should be treated according to the ACLS algorithm.³
• Whilst trauma may be part of the presentation of a hypothermic arrested patient (e.g., an avalanche victim), usually management of the hypothermia will take priority.

Resuscitative Hysterotomy in Trauma

• Chest compressions are less effective in pregnant patients due to aortocaval compression by the uterus after 20 weeks’ gestation, decreasing venous return to the heart by ~20%.⁹
• Left uterine displacement via a left lateral decubitus position with an angle of 15-30 degrees and resuscitative hysterotomy (resuscitative cesarian delivery) are mechanisms to decrease aortocaval compression in TCA.
• In TCA, a resuscitative hysterotomy via vertical midline incision improves survival for both mother and fetus if started within 4 minutes of maternal cardiac arrest in a mother who is suspected to be more than 20 weeks of gestation.⁹
  • POCUS and physical examination, including fundal height measured above the umbilicus, are used to estimate gestational age.

Vasopressors

• Fixed-dose interval administration of vasopressors such as epinephrine are generally not recommended in TCA as they are associated with a lower chance of the patient surviving neurologically intact.⁸

TXA

• The American College of Surgeons recommends administering 1 gram of TXA within the first 3 hours of trauma, followed by 1 gram infused over 8 hours if there are clinical signs of hemorrhagic shock, as it is associated with a mortality benefit in such cases.
• No randomized control trials exist studying the use of TXA in a TCA population, but some retrospective analysis has found a positive association between TXA and ROSC.
• See the Open Anesthesia Summary on TXA in trauma for more details. Link

Point of Care Ultrasound

• POCUS is a key tool for excluding pericardial tamponade, tension pneumothorax, and internal hemorrhage in TCA.
• POCUS is a highly sensitive (91%) and specific (98%) predictor of survival to discharge in TCA based on whether any cardiac motion can be appreciated (100% vs 93% mortality) at the time of arrest.
• POCUS may aid in the decision to discontinue resuscitation in TCA after addressing all reversible etiologies.10
• Please see the ultrasound in trauma OA summary for more details. Link