Trauma month – management of traumatic cardiac arrest

Advanced trauma team

Although rare, patients who have a traumatic cardiac arrest (TCA) are on the whole previously fit and well, until the point of injury that has caused the arrest. It is therefore important to target our management to reverse, where possible, the cause of the TCA.

The Clinical Practice Guidelines supports the European Resuscitation Council guidance by identifying the main underlying causes as:

  • hypoxia – caused by manageable issues such as obstruction of the airway
  • breathing problems – e.g. pneumothorax/haemothorx
  • hypoperfusion – e.g. hypovolaemia or cardiac tamponade.

Whilst resuscitation is attempted, it is important that clinicians work to apply treatment strategies to address the above underlying causes. 


Control catastrophic haemorrhage


Manage an airway with either a SGA or ETT, capnography must be used and the clinician should select the most appropriate advanced airway.


Search for and manage any open sucking chest wounds, decompress   the chest with needle thoracocentesis or thoracostomy (if trained)   bilaterally and support ventilation.


Apply external haemorrhage control as appropriate, fluid resuscitate with up to 2l of 0.9%NaCl.


Special Circumstances:

Penetrating TCA – in the absence of an enhanced care team, the patient must be resuscitated with a plan for rapid transport to hospital. The patient may be indicated for a resuscitative thoracotomy. If after 20 minutes of resuscitation consider ROLE (recognition of life extinct) – not forgetting the clinical advice line (CAL) is there to support you in your decision making.

Paediatrics – all paediatric TCA should be resuscitated unless an unsurvivable injury in line with JRCALC. In the unlikely event of ROLE, the patient must be conveyed to the emergency department for assessment by a paediatrician.

Pregnancy – in the absence of an enhanced care team, patients must be resuscitated with a plan for rapid transport to hospital. The patient is indicated for a resuscitative hysterotomy.

When not to resuscitate and ROLE:

Resuscitation should not be commenced for TCA patients in line with Clinical Practice guidelines and include for the purpose of TCA:

  • massive cranial and cerebral destruction
  • hemicorporectomy or similar massive injury.

Too frequently the term ‘incompatible with life’ is used, but clinicians should stop and think ‘does this injury pattern fit in line with the above two points’? Patients may indeed have catastrophic internal injuries, although identification of these is impossible for us in the pre-hospital setting. Resuscitation should therefore be commenced.

It is possible to ROLE with TCA patients, but this must be once more than 20 minutes of ALS has been provided and with the reversible causes excluded (as identified above). The CAL is available to staff to discuss complex cases and provide decision support. 

When deciding to undertake ROLE, clinicians should utilise all of the information that is available to them to support this decision making process. This includes the use of EtCO2 (a EtCO2 of <1.0 is indicative of a poor prognosis).

The role of critical care:

Within the region, 24/7 critical care support is potentially available to assist you with this group of patients. They may already be dispatched, but it is important to contact CCD on channel 202 to advise/request or give a sit-rep.

Enhanced care teams are able to perform interventions such as resuscitative thoracotomy and or hysterotomy – these interventions are time-sensitive so ensure help is requested early, and if not available the patient should be conveyed under emergency conditions to the nearest receiving trauma unit.

The future:

There are a lot of discussions surrounding the role of, and importance of chest compressions in a patient in TCA. Whilst discussion and challenges to what is currently undertaken are ongoing, staff are asked to continue to practice clinical care in-line with the Clinical Practice Guidelines.

As evidence and consensus statements emerge the Trust may decide to modify the advice or standard of care offered within EEAST.

Published 20th May 2015 

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