Clinical
Traumatic cardiac arrest:
what’s HOT and what’s not
Aidan Brown, Specialist Trauma Paramedic, West Midlands Ambulance Service & Midlands Air Ambulance.
Email for correspondence: aidanbrown7@hotmail.com
Abstract
Traumatic cardiac arrest (TCA) is a rare event in the pre-hospital setting and has
a varied aetiology. Paramedic management has changed significantly over the
past 5 years. Chest compressions have been de-emphasised in guidelines, and
the ‘HOT’ principles have been adopted. This principle stands for hypovolaemia;
oxygenation; tension pneumothorax/tamponade. The recommendation is that
these should be addressed prior to performing chest compressions. There may
however be patient groups in TCA who benefit from chest compressions. A
management plan including ‘no chest compressions’ for TCA is not supported
in the evidence, and they should be commenced as soon as appropriate
reversible causes have been addressed. In addition, chest compressions may
take precedence over the administration of fluid if both cannot be performed
simultaneously. Ambulance services may improve management of TCA by the
introduction of an aide-memoire to support clinicians.
Key words
l Traumatic cardiac arrest (TCA) l Chest compressions l HOT principles
l Resuscitation l Advanced life support
Accepted for publication 16 January 2018
T raumatic cardiac arrest (TCA) is a rare event
in the pre-hospital setting, with only 0.3%
of 227 994 submissions to Trauma Audit and
Research Network (TARN) (Barnard et al, 2017a),
estimated at 4 per 100 000 of the population annually
(Irfan et al, 2017). Outcome following TCA has
been widely debated over many years, and the
problem is exacerbated by a wide range of outcome
measures being quoted as survival, such as return of
spontaneous circulation (ROSC) on scene, ROSC at
hospital, and neurological outcome at discharge.
A 2016 review of TARN data by Barnard et
al (2017a) reported 30-day survival following
pre‑hospital TCA as 7.5%. Konesky and Guo (2017)
retrospectively analysed outcome in 124 patients
who suffered TCA. They found 7.3% survival with
complete neurological recovery. As a comparison,
Irfan et al (2017) report overall survival as 2.4% in
410 patients who suffered TCA. A systematic review
by Zwingmann et al (2012) reported overall survival
194
at 7.2%, with varying degrees of neurological
outcome. It is important to note that, in England,
the introduction of the Major Trauma Networks has
significantly changed the way major trauma patients
are managed, and this may have an impact on
mortality.
HOT approach
Treatment and management is increasingly being
directed at the rapid identification and reversal
of potential causes. Reversing hypovolaemia,
oxygenation and tension pneumothorax (HOT) as
a priority is an increasingly accepted guideline (The
HOT Approach) (Lockey et al, 2013).
This is based on the theory that treating these
reversible causes in a rapid manner gives the patient
the best chance of survival having suffered a TCA.
The current article discusses application of HOT
principles to paramedic practice.
Along with these recommendations is the
de‑emphasis on the role of chest compressions
while reversible causes are addressed. The reason
for this is two-fold. Firstly, chest compressions may
take up one of the vital and usually under-resourced
members of staff attending the incident, and they
will therefore be unable to address the reversible
causes identified in the HOT approach. Secondly,
it is argued that chest compressions are futile if the
heart is empty, or is being obstructed from beating
(hypovolaemia/tension pneumothorax/cardiac
tamponade) (Watts et al, 2017).
Impact of social media
Social media is increasingly used to educate and
promote discussion on best practice in medicine
(Grajasles et al, 2014). However, issues such as
governance and ethics are complex and remain
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unanswered. There have been a number of
discussions, posts and polls on social media showing
that many clinicians don’t believe there is a role for
chest compressions in TCA. This de-emphasis has
possibly expanded beyond what can be supported
by the current evidence base.
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 Clinical
Causes of TCA
It is important to understand that the review of
TARN data by Barnard et al (2017a) showed that
of the 705 patients in TCA who had complete data
submitted between 2009 and 2015, 85% had a
blunt trauma mechanism of injury. There were no
statistically significant survival differences in the
penetrating and blunt trauma groups. In addition,
the highest surviving sub-group was of those who
had an ROSC in the pre-hospital setting following
blunt trauma.
Examining outcomes
There were 86.8% of patients with a severe traumatic
brain injury (TBI) and/or a severe haemorrhagic
injury; with 38.2% having both. Patients with a
combination of these injuries had a lower chance of
survival than those with only haemorrhagic injury
or TBI. In the current review, patients with the
best outcome were those who had suffered a TBI
in isolation; 15.2% of this patient group survived
to discharge, with 90% having good neurological
outcomes (Barnard et al, 2017a).
In patients who had not suffered a TBI or severe
haemorrhagic injury, the most prevalent aetiology
was spinal injury, followed by thoracic injuries.
Survival in these sub-groups were higher than overall
(12.9% vs. 7.5%). Lockey et al (2006) performed a
retrospective review on patients who had suffered
TCA over a 10-year period, and reported that those
with the highest survival are those who had a
hypoxic insult (44% of 68 survivors). Those who
have a thoracotomy following penetrating trunk
trauma have also displayed improved outcome in
various studies and systematic reviews (Narvestad
et al, 2016). Importantly, Lockey et al (2006) found
survival following hypovolaemic TCA to be very low,
with only one survivor.
When HOT isn’t so hot
Incidentally, 16% of 68 survivors were deemed to
have had a primary medical event leading to the
trauma. This is replicated in other studies and many
authors recognise the difficulty in differentiating
between medical and traumatic cardiac arrest. In
these medical patients, it is vitally important to
perform chest compressions, as recommended by a
large evidence base (European Resuscitation Council,
2015). Adopting the HOT approach in these patients
therefore may not be the optimal management plan.
HOT resuscitation
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Lockey et al (2013), who developed the HOT
algorithm, recommend that patients in TCA should
have basic life support and chest compressions
started. They state that patients in TCA may still
benefit from the blood flow provided from chest
Journal of Paramedic Practice • Vol 10 No 5195
compressions, but recognise that in hypovolaemia,
they may be futile. This is reciprocated in the
European Resuscitation Council (2015) Guidelines.
Despite this, however, there has been an alarming
anecdotal trend of clinicians suggesting they do not
believe there is a role for chest compressions in TCA.
The European Resuscitation Council (2015) state:
‘Chest compressions provide some blood flow
during cardiac arrest and should be continued
whilst the history and mechanism of injury
have been accurately established.
‘In profound hypovolaemia, chest compressions
are likely to be minimally effective due to poor
cardiac filling and external compressions of an
empty heart.’
They go on to state that:
‘immediate diagnosis of hypovolaemia can be
difficult and, if in doubt, chest compressions
should be continued.
‘The patients with the best chance of
survival are normovolaemic and chest
compressions can be at least partially effective
whilst reversible causes are addressed
simultaneously.’
Once reversible causes have been addressed, it is
imperative to perform chest compressions to begin
the blood flow in order to allow the interventions
performed to take effect.
Theory of impact brain apnoea
There is increasing research on the theory of impact
brain apnoea (Wilson et al, 2016). This refers to a
pathology following a TBI whereby a patient may
have a prolonged period of apnoea, eventually
leading to cardiac arrest. Wilson et al (2016) refers
to the cessation of breathing following a TBI, which
is commonly precipitated by a large catecholamine
surge, which presents initially as hypertension
and then cardiovascular collapse. Clearly, in these
patients, chest compressions may provide a benefit
to restore blood flow. It is theorised that patients
who have an impact brain apnoea can have positive
outcomes if apnoea and hypoxia is reversed in a
timely manner.
Hypovolaemia and
chest compressions
In the civilian setting, in true and established
hypovolaemia leading to cardiac arrest, survival
is reported to be very low (Lockey et al, 2006).
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Clinical
Sal+CCC
Sal
WB+CCC
WB
CCC
0 2 4 6 8
Dead Partial ROSC ROSC
Figure 1. Number of animals attaining ROSC
Outcome following resuscitation of hypovolaemic
TCA may be improved in the setting of enhanced
care, in the hospital and in the military setting.
This may be attributed to damage control surgery
and massive transfusion protocols, which cannot
currently be replicated to civilian ambulance service
care. The military adopt an approach of treating
hypovolaemia with a massive transfusion protocol
including blood products. It is important to note that
the military are almost always treating hypovolaemic
cardiac arrest, which is not replicated in the civilian
setting (Barnard et al, 2017b). In addition, the vast
majority of civilian responses to TCA do not have the
capability for massive blood product transfusion.
Watts et al (2017) performed an animal study
comparing ROSC and survival in hypovolaemia
with various treatment measures (closed chest
compressions (CCC)) vs. saline vs. CCC and saline
vs. whole blood (WB) vs. WB and CCC) (Figure 1).
Their method was inducing hypovolaemic TCA
in monitored and terminally anaesthetised large
swine. Watts et al (2017) concluded that CCC were
associated with increased mortality compared with
intravenous fluid resuscitation. Resuscitation with
WB demonstrated the greatest physiological benefit
as demonstrated by the highest numbers of animals
achieving ROSC. This study supports the theory
that it may be better to perform fluid resuscitation
and not chest compressions when managing TCA
if there are not sufficient resources to perform
both simultaneously. In this study, however,
the population had hypovolaemia as the only
mechanism of arrest, which is not representative of
the population of TCA treated by NHS ambulance
services. Furthermore, owing to the immediate
commencement of treatment following deterioration
of mean arterial pressure, the pigs will likely have
196
been in a ‘low-flow’ state, whereby the heart is
still beating, but is unable to produce a pulse, as
there is not enough volume. Unless the arrest is
witnessed by the attending clinicians, it is unlikely
that the patient will present in a low-flow state, and
chest compressions may be required to facilitate
blood flow and achieve ROSC.
Of note is that in the pre-hospital setting,
usually ‘at the side of the road’, intravenous (IV)/
intraosseous (IO) access can be time-consuming;
studies have reported average time-to-insertion
of between 2 and 5 minutes (Carr et al, 2008;
Engels et al, 2014). It is often more challenging in
hypovolaemia patients as a result of them being
peripherally shut down. This represents a significant
period of time without any chest compressions.
Therefore, in the civilian setting, without the use
of blood products, where established hypovolaemia
has significantly low survival, with some patients
having aetiology which may benefit from chest
compressions, it is difficult to recommend from the
evidence performing fluid therapy as a priority over
chest compressions in all cases of TCA.
Oxygenation
Intubation as a paramedic skill is a widely debated
issue, following concern about success rates, lack
of training, supervised practice and frequency of
insertion (College of Paramedics, 2017). Intubation
is widely accepted to bring more challenges than
the insertion of a supra-glottic airway (SGA) (Taylor
et al, 2016). Intubation is recommended to be a
two‑person intervention (one person assisting). In
the initial management of TCA, there are multiple
actions that need to be taken simultaneously.
It could be recommended that an SGA is inserted
as the first airway adjunct in TCA. It can be rapidly
inserted by an individual, and this can then be
changed to an endotracheal tube at a later point in
the resuscitation (if required) when other reversible
causes have been addressed.
As discussed, those with the highest survival are
those who have a hypoxic insult (Lockey et al, 2006).
Once hypoxia has been addressed, it is essential to
perform chest compressions to begin the blood flow,
in order to allow the blood to be oxygenated in the
hopes of achieving ROSC (European Resuscitation
Council, 2015)
Tension pneumothorax
Patients in TCA may have a tension pneumothorax
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as a primary cause of their collapse (Huber-Wagner
et al, 2007; Peters et al, 2017). Needle decompression
is a skill that can be performed by NHS paramedics.
The procedure can often fail owing to the needle not
reaching the pleural space because of the thickness
of the chest wall (Laan et al, 2016).
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 Clinical
Despite this, it is simple and rapid to perform
and may be able to provide temporary reversal
of a tension pneumothorax, so should be
recommended as a priority in TCA. The procedure
should be performed on both sides of the chest, as
assessing and identifying the signs and symptoms
of significant chest trauma such as tension
pneumothorax can be difficult. Various studies
have concluded that the sensitivity and specificity
of identifying significant chest pathologies with
auscultation is relatively low (Chen et al, 2001;
Kong et al, 2015; Ramsingh et al, 2016).
HOT in paramedic practice
Although providing guidance and support in a
difficult subject HOT may not encompass optimal
treatment for all patients who have suffered TCA.
Furthermore, it must be acknowledged that care
delivered in the military, hospital and enhanced
care team settings differ from that delivered
by NHS ambulance services. Without access to
thoracostomies and blood products, it is unlikely
that tension pneumothorax and hypovolaemia can
be truly reversed.
TCA is a rare event for NHS ambulance service
responders. It makes up an extremely low
proportion of their overall work load, and to
expect a complex, detailed understanding of the
epidemiology, pathology and treatment regimes of
TCA is onerous. It is imperative to provide simple,
easy-to-follow guidelines which ‘do the most for
the most’. NHS ambulance services can support
their staff in handling these difficult cases by
providing a laminated reference card for use while
en route to the case. This may look like the one in
Table 1.
Adherence to best practice
In 2014, Yorkshire Air Ambulance Charity
developed a treatment guideline for blunt TCA,
similar to the one in Table 1 and introduced
it into their service. They found that ‘all standards
met’ improved from 5.9% to 40.7% (Mickwitz
and Syrat, 2016). Mickwitz and Syrat (2016)
reported ROSC on scene improvements from 17.6
to 37%; however, no patients were followed up
post discharge.
This study, at minimum, shows that the
introduction of a TCA guideline can improve
adherence to what is currently thought to be best
practice. A literature review by Chen et al (2016)
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on the introduction of checklists in pre-hospital
emergency medicine demonstrated that safety,
outcome and adherence to guidelines can be
improved. Kerner et al (2017) also demonstrated
improved adherence to treatment guidelines by the
introduction of checklists and algorithms.
Journal of Paramedic Practice • Vol 10 No 5197
Key points
ll Traumatic cardiac arrest (TCA) has a varied aetiology
ll Management aimed at reversible causes is probably best
ll Chest compressions may benefit some patients who have suffered TCA
ll‘HOT’ principles may not be appropriate management for all TCA
Table 1. Example of simple guidelines for TCA
llControl CAT haemorrhage and apply chest seals
llClear airway, insert SGA and ventilate
llPerform bi-lateral needle decompression
llLarge volumes fluid replacement
llChest compressions
IF RESOURCES ARE LIMITED, PRIORITISE TREATING
SUSPECTED CAUSE OF ARREST.
Then Consider:
llChanging SGA to ETT if required
llReduce femur fractures and splint the pelvis
llControl all further bleeding
llVasopressor/inotrope if required
Conclusion
To conclude, the de-emphasis of chest
compressions may not benefit the UK civilian
population who suffer TCA. In addition, both
Lockey et al (2013) and the European Resuscitation
Council (2015) guidelines emphasise the benefits
of chest compressions. The benefit of chest
compressions is well supported in the evidence
for cardiac arrests from medical causes (European
Resuscitation Council, 2015); however, limited
evidence is available for and against chest
compressions in trauma.
Many patients who have suffered a TCA following
aetiology such as TBI or neurogenic shock may
benefit from chest compressions, and those who
have had a medical event leading to trauma will
certainly benefit from chest compressions.
The principle of early treatment of reversible
causes in TCA is likely to improve outcomes.
HOT is a memorable acronym and has significant
momentum in guiding treatment in the management
of TCA. However, HOT should not be misquoted as
advocating no chest compressions, as this could lead
to ineffective treatment of a group of patients who
may otherwise have had favourable outcomes. First
resources on scene should concentrate on control
of haemorrhage, managing the airway rapidly by
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Clinical
insertion of an SGA, chest decompression and
beginning chest compressions.
Other interventions may be more appropriately
performed when further resources have arrived
on scene. Where clinicians strongly suspect
hypovolaemia as the primary cause of arrest, it may
be appropriate to gain vascular access and begin
volume replacement prior to chest compressions
if there are insufficient resources to perform both
simultaneously. JPP
Conflict of interest: None.
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