When should we stop resuscitation efforts after blunt traumatic arrest?

In a recent issue of Injury, Galluccio et al. presented a stimulating case 8 which should provoke us to reconsider the boundaries of what is possible after cardiac arrest secondary to apparent blunt trauma. This report follows a previous study in Injury reporting survival after cardiac arrest after trauma. 24 Their patient, a 42-year-old male driver, crashed his vehicle at 60 km/h and was found slumped and unresponsive with no obvious external injuries to account for his clinical state. Prolonged prehospital and inhospital resuscitation led to the eventual return of spontaneous circulation. Apparently, this man was the victim of blunt major trauma; he had been arrested for some time, and then resuscitated successfully in the emergency department (ED) — the reflex reaction must have been to suspect severe internal injuries. But the facts as presented would dispute that assumption: the arrest rhythm was ventricular fibrillation (rare in blunt trauma), and there were few, if any, signs of significant injury. The distinction is clearly critical, primarily due to the fact that the treatment of the first condition is to stop bleeding, whereas the treatment of the second is to restore coronary blood flow, including systemic anticoagulation and antiplate-let therapy. So what made the difference in this case? Firstly, he was fortunate to crash close to a competent bystander who was able and willing to provide immediate basic life support (BLS). BLS is considered universally as one of the key steps in the chain of survival for victims of cardiac arrest. 10 However, BLS in trauma is considered by some to be futile, but clearly in the non-trauma situation, there is value in instituting effective BLS at the first opportunity. It is difficult, though, to identify with any certainty which patients may or may not benefit from BLS in those first critical seconds, and this is why the current advice is to provide BLS to all patients with cardiac arrest regardless of aetiology. 10 Secondly, he had a short period of prehospital advanced life support (ALS). Prehospital ALS is itself controversial. There is little evidence that any interventions , other than rapid defibrillation, make any difference to outcome after sudden cardiac arrest in the prehospital arena. Seminal studies from Scotland suggest that the benefits of paramedics in the treatment of cardiac arrest were overstated. 9,16,17 Recent evidence from Singapore 18 confirms that allegedly advanced interventions such as adrenaline make little difference in …