By Mike McEvoy
An analysis of 294 prehospital trauma arrest patients meeting criteria for field pronouncement but nonetheless resuscitated in Chicago found no positive outcomes. Worse yet, EMS efforts caused over $3.85 million in unnecessary medical costs. Writing in the October 2011 issue of the Journal of Trauma, Nathan Mollberg and colleagues describe their retrospective review of patients over an 8-year period between 2003 and 2010 using widely adopted guidelines from the American College of Surgeons (ACS) on field termination or withholding resuscitation in traumatic cardiopulmonary arrest (TCPA). By violating resuscitation guidelines in 294 TCPA cases, six patients were resuscitated with catastrophic neurologic damage, four subsequently being declared brain dead, one had care withdrawn for medical futility at family request, and one went to a long term care facility with a CGS of 6.
Given the extremely poor outcomes and incredible waste of resources and healthcare dollars, the authors speculate on opportunities for improvement. Firstly, as suggested in other studies, paramedics did fail to recognize traumatic arrests. There was 100 percent agreement on presence or absence of pulses between medics. Noting that ED teams are likely to continue futile resuscitations started in the field, opportunity exists for better attention to termination on arrival. While the ACS guidelines are well circulated, it is possible that field providers may not be thoroughly familiar with protocols. Lastly, the fact that so many patients meeting criteria for field termination were transported is a giant quality review issue that needs attention--most likely in every department.
1. Mollberg NM, Wise SR, Berman K, Chowdhry S, Holevar M, Sullivan R, and Vafa A. The Consequences of Noncompliance With Guidelines for Withholding or Terminating Resuscitation in Traumatic Cardiac Arrest Patients. J Trauma. 2011; 71(4):997-1002.
2. Hopson LR, Hirsh E, Delgado J, Domeier RM, McSwain NE, Krohmer J, National Association of EMS Physicians, and American College of Surgeons Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest: joint position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2003; 196(1):106-112.