Field triage of the pulseless trauma patient

Hypothesis: Trauma patients who are pulseless at the scene of injury and whose electrical cardiac activity is less than 40 beats/min cannot be revived. Design: Retrospective review. Setting: University hospital, level I trauma center. Patients: Pulseless trauma patients who had cardiopulmonary resuscitation at the scene, en route, or in the emergency department and presented between January 1, 1991, and July 1, 1996. Main Outcome Measure: Survival after traumatic cardiopulmonary arrest. Results: Sixteen thousand seven hundred twenty-four trauma patients were admitted. The study cohort comprised 604 victims of traumatic cardiopulmonary arrest, 304 as a result of blunt injury and 300 as a result of penetrating injury. Transport time for the study patients was 11 +/- 6.1 minutes (mean +/- SD). Cardiopulmonary resuscitation was performed on them for 22 +/- 11 minutes. Three hundred four patients (50%) had resuscitative thoracotomy in the emergency department; 160 patients were taken to the operating room for further resuscitation and treatment of their injuries. Sixteen patients (2.6%) survived to discharge from the hospital; 7 had severe neurologic disabilities. No patient (0/212) with electrical asystole survived. Five of 134 patients with an initial electrical heart rate between 1 and 39 beats/min survived long enough to reach the intensive care unit but died within 48 hours (4 died within 24 hours). No patient survived to leave the hospital if the initial electrical heart rate was less than 40 beats/min. All 16 survivors had an initial heart rate of 40 beats/min or greater. Conclusion: Trauma victims who are pulseless and have asystole or agonal electrical cardiac activity (heart rate <40 beats/min) should be pronounced dead at the scene of injury.