Time to stop compressions in TRAUMATIC Cardiac Arrest?

Traumatic cardiac arrest (TCA) has for the longest time been viewed as a futile situation. A 2024 narrative review by Carenzo et al. changes the conversation, and asks us to think a little deeper.

In certain patients, survival with good neurological outcomes is possible, but only if we shift our resuscitation priorities and think about this problem as the unique problem it is, different from the medical cardiac arrest!

FIRST! Understand the Arrest Type

The article makes refernce to two different types of cardiac arrest in trauma:

• LOST (Low-Output State in Trauma): Unconscious, no pulse, but some organized activity on POCUS = salvageable.

• NOST (No-Output State): Bradycardia or agonal rhythm with no cardiac motion = almost universally fatal.

SECOND! Focus on Reversible Causes - HOTT + M

• Hypovolaemia → control bleeding, fluid admin rapid if rapid blood product infusion is not available

• Oxygenation → maintain a patent airway; skip intubation early (consider SGA)

• Tension pneumothorax → bilateral decompression immediately (almost empirically)

• Tamponade → think thoracotomy, not POCUS delay

• + Metabolic → fix hyperkalaemia, calcium deficits, coagulopathy

Prioritise These Early Interventions

• Hemorrhage control: Pack, bind, tourniquet, then REBOA or surgery (where available)

• Access: Go big and fast — IO first if needed, but central venous asap for flow

• Blood early, not crystalloids. Consider whole blood if possible (in SA, this is not always or pretty much ever an option - think MTP!)

• Thoracostomies over needles. Especially if skilled and safe

• Thoracotomy and REBOA: Not a last resort, early decisions save lives

Relevance to SA Retrieval Teams

In South Africa’s prehospital and rural contexts, managing TCA is even more nuanced:

• Transport times can kill. Time-sensitive interventions (e.g., chest decompression, transfusion) must be done on scene

• DO NOT DELAY TRANSPORT - time on scene is time not in theatre - MOVE!

• Training matters. If your team can perform a finger thoracostomy or thoracotomy, do it. If not, train for it. We need to be pushing for a scope change where necessary.

• System planning. Pre-activation of massive transfusion protocols, access to warmed fluid and blood products, and clear decision trees for advanced interventions are essential. TAKE blood with you if you can!

• Metabolic tweaks are not just ICU games. Prehospital calcium and insulin+glucose can meaningfully change outcomes

Reflections:

TCA is no longer an automatic death sentence, but ACLS alone is also possibly not relevant for the patient! The message is clear: fix the cause, not the rhythm.

We need trauma-informed resuscitation, with decision-making based on physiology, not protocol. SA teams should adapt these principles to our context: combine practical know-how with high-performance clinical execution.

Take-home Message:

🟢 Focus on HOTT causes, not CPR (follow the SA guideline linked here, and where there are enough people, CPR can still be done so long as it is not in the way of the surgical interventions needed).

🟢 Advanced interventions like REBOA are time-sensitive and team-dependent

🟢 Prehospital metabolic correction, blood, and airway strategies matter

🟢 TCA is not one thing — treat the cause, not the label

Reply and share how your service approaches TCA in the field? What protocols do you follow, and what’s possible and realistic in your system?