Traumatic Cardiac Arrest Isn’t Hopeless but it is Time-Critical

Author: Kaleb Lachenicht

Transforming EM through patient safety systems, Just Culture development, and clinical excellence! Passionate about connection, building systems, and developing teams.

For years, traumatic cardiac arrest (TCA) has been treated as a near-futile endpoint. And in a lot of ways, especially in the South African environment, it is still is. Long response times, resource limitations (ambulances especially in rural spaces are few and far between). 

But some contemporary data, and modern trauma systems, tell a slightly different story.

Survival is possible and good neurological outcomes do occur. The difference is rarely luck... it’s timing, prioritisation, and systems.

This narrative review by Carenzo et al. reframes TCA not as a single event, but as a dynamic physiological spectrum, and that framing matters at the bedside, in the back of the aircraft, and in the emergency centre. 

Traumatic Cardiac Arrest Is Not One Thing

One of the most useful contributions of this review is the reminder that “TCA” is an umbrella term.

The authors distinguish between:

• LOST (Low-Output State in Trauma)

• NOST (No-Output State in Trauma)

Why does this matter?

Because LOST has survival potential, if we can get to the patient rapidly and bring the interventions that might change the outcome to them. 

NOST, especially after prolonged downtime, is almost never recoverable. 

Peri-arrest...that grey zone just before collapse, is where our interventions matter most. Recognising we are heading in that direction is often the most important start. 

HOTT Is Necessary... But its NOT ENOUGH

Most of us are fluent in HOTT:

• Hypovolaemia

• Oxygenation (hypoxia)

• Tension pneumothorax

• Tamponade

The review reinforces a key principle:

These must be treated simultaneously, not sequentially.

But it also pushes us further.

A contemporary approach adds a second layer:

• Metabolic failure (especially hyperkalaemia)

• Haemostatic collapse

• Coronary perfusion pressure as the true target

This explains why chest compressions often fail in TCA, not because CPR is “bad”, but because there is no preload, no coronary flow, and no physiology to support it.

In hypovolaemic or obstructive arrest, restoring circulation beats compressing an empty heart.

Chest Compressions: Context Matters

This paper challenges dogma in a nuanced way, and the nuance is ALWAYS where the magic is for me...

• In exsanguination or tamponade, chest compressions alone do little

• In isolated TBI, asphyxia, or unclear aetiology, they may still matter

• If you have the manpower to do both, treat causes and compress, do both

The key message isn’t “don’t do CPR”. It’s don’t let CPR delay definitive action.

Penetrating vs Blunt Trauma: Different Games, Different Odds

The outcomes are stark:

• Penetrating TCA: ~10% survival

• Blunt TCA: ~2–3% survival

Why?

Penetrating injuries are often:

• Single-system

• Surgically correctable

• Temporally reversible

Blunt trauma is usually multisystem, diffuse, and metabolically catastrophic.

This distinction should influence:

• Decision-making

• Aggressiveness of intervention

• Team expectations and psychological framing

Advanced Interventions: Timing Is Everything

Resuscitative Thoracotomy (RT)

RT is not heroic, it’s physiology-driven. When used for the right patient at the right time and with the right intention, it 

Indications are narrow but powerful:

• Penetrating chest trauma

• Signs of life

• Short downtime

When tamponade is present, RT is the treatment, not an option.

REBOA

REBOA has shifted the landscape for sub-diaphragmatic haemorrhage.

Key takeaways:

• Zone 1 for TCA

• Early femoral access matters

• It’s a bridge — not a solution

Importantly, REBOA does not replace RT in penetrating thoracic trauma — and using the wrong tool at the wrong time can worsen outcomes.

The Forgotten Killers: Potassium and Calcium

One of the most under-appreciated sections of this review is metabolic failure.

• Hyperkalaemia occurs early in haemorrhagic shock

• It correlates strongly with failure to achieve ROSC

• Massive transfusion worsens it

Aggressive correction — calcium, insulin, glucose — may be the difference between electrical silence and meaningful cardiac activity.

Similarly, hypocalcaemia:

• Impairs coagulation

• Reduces myocardial contractility

• Worsens shock

This is advanced resuscitation thinking — and it belongs in retrieval medicine.

Systems Matter More Than Any Single Skill

The authors are clear about this: outcomes improve when advanced care happens early and on scene, delivered by trained teams within mature systems.

This isn’t about individual heroics. Survival is also linked to the THINKING PRACTITIONER - we cant expect our teams to operate like robots, using abnormal algorithms to guide each step and never engaging our brains.... We need to ask more of our providers and teams if we want to see better survival from the cardiac arrest trauma patient 

It’s about:

• Algorithms

• Training

• Governance

• Rehearsed decision-making under pressure

TCA survival is a system achievement.

Bottom Line

• Traumatic cardiac arrest is not futile, but it is unforgiving

• Treat causes before rhythms

• HOTT plus metabolic control is the modern approach

• USE YOUR BRAIN - and treat the patient not the algorithm

• Chest compressions are contextual, not automatic

• RT and REBOA demand clarity, timing, and training (obviously in the prehospital space in SA this still a way off for most patients and in most towns)

• Survival lives in the peri-arrest window... not after prolonged arrest. Catch the deterioration early and treat it aggressively. 

Over to you

How does your service approach traumatic peri-arrest?

Where do you think the biggest gains still lie, training, access to interventions, or decision-making under pressure?

Reference

Carenzo, L. et al. (2024). Contemporary management of traumatic cardiac arrest and peri-arrest states: a narrative review. Journal of Anesthesia, Analgesia and Critical Care, 4:66.