Literature Review: Post-Traumatic Circulatory Arrest Transport Practices

   Brywczynski J, McKinney J, Pepe PE, et al. Emergency medical services transport decisions in post-traumatic circulatory arrest: Are national practices congruent? J Trauma 69(5): 1,154-1,060, Nov 2010.

Abstract

   The objective was to catalog the 9-1-1 emergency medical services (EMS) transport practices for post-traumatic circulatory arrest patients (PTCAPs) in the majority of the nation's largest municipalities and to compare those practices to guidelines recommended by the National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACSCOT). Methods--A survey was conducted in 33 of the nation's largest cities primarily to determine whether individual EMS systems transport PTCAPs to hospitals and, if so, whether the initial electrocardiographic (ECG) rhythm or mechanism of injury affects those transport decisions.

   Results--All 33 cities (100%) responded. Seven (21%) indicated that EMS would transport an "asystolic blunt trauma patient" emergently or "leave the transport decision to paramedic judgment" despite NAEMSP-ACSCOT guidelines to terminate resuscitation in such cases. Likewise, 15 (46%) of the 33 EMS agencies would transport "asystolic penetrating trauma patients" emergently. Similarly, 27 (82%) would transport penetrating injury patients and 20 (61%) would transport blunt trauma patients with persistent ECG activity but no palpable pulses. However, only five systems had policies that included a minimum ECG heart rate criterion for transport, and all agencies that monitor ECG (n=32) would transport PTCAPs found with ventricular fibrillation.

   Conclusions--Many of the nation's highest-volume EMS systems transport certain PTCAPs emergently, contrary to NAEMSP-ACSCOT guidelines to terminate resuscitative efforts in such cases. Reasons for these discrepancies should be evaluated to help better delineate applicable consensus guidelines for large urban EMS agencies.

Comment

   In early 2003 the NAEMSP and American College of Surgeons jointly published their Guidelines for Withholding or Termination of Resuscitation in Prehospital Traumatic Cardiopulmonary Arrest. The mission statement of the project was: "In order to preserve dignity, conserve precious human and financial resources, and to minimize risks to the healthcare workers involved, patients who can be predicted to be unsalvageable should not be transported emergently to the ED or trauma center." The guidelines were prepared with an evidence-based review of the medical literature. Subsequent reports have supported this strategy.

   However, as with many advances in medical practice, there is often a long interval between scientific consensus on a treatment and its eventual implementation. In EMS systems, where multiple providers, conflicting interests, political struggles and administrative concerns can weigh in, the delays can often be longer. Also, although this report only looked at large metropolitan EMS systems, it is likely that other systems have similar challenges. EMS systems should evaluate their policies and procedures with these guidelines in mind.

   Angelo Salvucci, Jr., MD, FACEP, is medical director for the Santa Barbara County and Ventura County (CA) EMS agencies.