The right thing to do with trauma patients that come in arrest, or near arrest can be difficult to figure out. The generally accepted, evidence based rule for this is that for victims of penetrating trauma, they must have had vital signs when EMS arrived (found dead, stays dead), and should not have been in full arrest for more than ~10 minutes (with CPR). For blunt, the patient must have had vital signs of some sort (a pulse at least) in the ED, or within a minute or two of the ED. Even with loss of vital signs at the entrance to the ED, the recovery to discharge rate is abysmally low.

But, EMS often breaks their backs with these patients, doing rapid extrication, ALS, CPR, and priority red transport, and it always feels wrong to just pronounce them on arrival when we stop CPR and find no pulse and fixed dilated pupils. I hate to admit it, but I have done resuscitative thoracotomies in these patients, when I know very well there is no chance of survival. Often, making sure the airway is in, putting in bilateral chest tubes, and a shot of Epi is enough to make everyone feel we’ve tried in the bay, but it’s really just going through the motions, since none of that will resuscitate a trauma patient that has bled out.

I think its important for all trauma surgery, ED, and EMS providers to know the real stats on trauma arrest. I believe the highest discharge from hospital alive rate in penetrating was 7% when arriving in full arrest (some studies are higher, but if you read those carefully, a number of patients were not in arrest, but were just hypotensive), and I have never seen a discharge from hospital rate for blunt arrest over 1%. We have had discharge alive in blunt patients who arrested in the ED, but these patients arrived with vital signs, and lost them in the ED in front of us, making return of circulation and aortic clamping almost immediate. Even with that, the vast number of patients with trauma who have arrested in front of me do not survive.

To make the right decision, you need to know the data.

JY