Prehospital Management of Adults With Traumatic Out-of-Hospital Circulatory Arrest—A Joint Position Statement

The National Association of Emergency Medical Services Physicians (NAEMSP), American College of Surgeons Committee on Trauma (ACS-COT), and American College of Emergency Physicians (ACEP) believe that evidence-based, pragmatic, and collaborative protocols addressing the care of patients with traumatic out-of-hospital circulatory arrest (TOHCA) are needed to optimize patient outcomes and clinician safety. When the etiology of arrest is unclear, particularly without clear signs of life-threatening trauma, standard basic and advanced cardiac life support (BCLS/ACLS) treatments for medical cardiac arrest are appropriate. Traumatic circulatory arrest may result from massive hemorrhage, airway obstruction, obstructive shock, respiratory disturbances, cardiogenic causes, or massive head trauma. While resuscitation and/or transport is appropriate for some populations, it is appropriate to withhold or discontinue resuscitation attempts for TOHCA patients for whom these efforts are nonbeneficial. This position statement and resource document were written as an update to the 2013 joint position statements.

NAEMSP, ACEP, and ACS-COT recommend:

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  Emergency medical services (EMS) resuscitation of adults with TOHCA should:

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    Prioritize prompt identification of patients who may benefit from transport to definitive care at trauma centers when safe and appropriate.
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    Emphasize the identification of reversible causes of traumatic circulatory arrest and timely use of clinically indicated life-saving interventions (LSIs) within the EMS clinician’s scope of practice. These include:

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      External hemorrhage control with direct pressure, wound packing, and tourniquets.
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      Airway management using the least-invasive approach necessary to achieve and maintain airway patency, oxygenation, and adequate ventilation.
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      Chest decompression if there is clinical concern for a tension pneumothorax. Empiric bilateral decompression, however, is not indicated in the absence of suspected chest trauma.
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      External chest compressions may be considered but only secondary to other LSIs.
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      Epinephrine should not be routinely used, and if used should not be administered before other LSIs.
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    If point-of-care ultrasound (POCUS) demonstrates no evidence of cardiac motion, this may have utility in TOHCA management for prognostication.
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    Emphasize that placement of cardiac monitors and/or use of POCUS should occur after indicated LSIs have been appropriately performed.
  • Conditions where resuscitation attempts should be withheld include TOHCA patients with:
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    Injuries that are incompatible with life (eg, decapitation, hemicorpectomy, incineration, open skull injury with extruding brain matter).
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    Evidence of prolonged circulatory arrest (eg, rigor mortis, dependent lividity, decomposition).
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    Advance care planning documents that indicate Do Not Resuscitate/Do Not Attempt Resuscitation/Allow Natural Death medical orders.
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  Conditions where resuscitation attempts are discontinued for TOHCA patients should recognize:

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    Mechanism of injury should not be used as the sole determinant to discontinue resuscitation efforts.
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    Electrical rhythm should not be used as the sole determinant to discontinue resuscitation efforts. Of note, nonshockable rhythms (Pulseless Electrical Activity/Asystole) are associated with an extremely low likelihood of return of spontaneous circulation or survival with neurologic recovery.
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    Local provisions for specific clinical resources (eg, regional trauma capabilities), environmental (eg, avalanche, etc), or population-based situations are important and require active EMS physician oversight in collaboration with local trauma-system stakeholders.