Our guideline doesn't mention trauma specifically in cardiac arrest. I would be attempting to correct 5Hs/5Ts. Hypoxia, Hypovolaemia and Tension pneumo being the 3 I would have the best chance of being able to address. 30 minutes of resus if they don't appear to have injuries incomparable with life and less or none if they do.

I am extremely reluctant to transport under CPR. I would only do it if I thought that the patient had something correctable (Hypothermia or Toxins??) that I couldn't address and hospital was close. I agree mobile CPR is nearly useless.

Just my perspective as a road clinician.

Thank you for the response Scott. Usually with major trauma, the cause requires urgent surgery to be reversed (if at all possible). The issue for me is the clinical decision making and the credibility of those decisions. Let me clarify...I work in the Middle East where there is still some reluctance (from the medical fraternity) to trusting decisions made by Critical Care Paramedics. Further, the general public do not understand the capabilities of paramedics. The decision making regarding termination of traumatic resus is therefore difficult and confounded by these issues. Has anybody had similar dilemmas?

The question of whether to perform chest compressions in traumatic cardiac arrest (TCA) is an interesting one. Most Advanced Life Support guidelines do not really address this issue in detail.

The physiology of TCA is different to medical cardiac arrest. The potentially reversible pathologies are hypoxia, tension and hypovolaemia. If all three of these have been reversed, and the patient is still in cardiac arrest, then further resuscitation is usually unsuccessful. Chest compressions will not help a patient with hypovolaemia or tension.

However, some patients with cardiac arrest in a civilian system will have a medical cause for their cardiac arrest (e.g. the patient with acute MI who crashes their car), and therefore a solution to all situations cannot be captured in a simple single algorithm.

There are institutional guidelines on the management of traumatic cardiac arrest and a review in Resuscitation last year puts out one such protocol (see below). However, the field treatment of these difficult patients is not really the focus of these guidelines.

Lockey DJ. Lyon RM. Davies GE. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation. 84(6):738-42, 2013 Jun.

I'm not sure there is a simple answer, but I hope these comments are helpful.

Dear Yugan,

Your question is one of those questions that is both simple and difficult in that it appears simple, but is in fact quite difficult.  As a Mobile Intensive Care Ambulance Paramedic in Victoria, Australia, I worked in a system which permitted ambulance officers of all levels to declare a patient deceased at the scene.  The written certification of death and the completion of the final 'death certificate' were restricted to medical practitioners.  However, the field declaration of death by an ambulance paramedic entailed the cessation of all treatment and, very often, the leaving of the body at the scene.

Although I cannot speak with any authority, I have suspicions that a percentage of these declarations lacked rigour and were conducted on the spur of the moment.  This does not mean that the decision taken was wrong, just that no one knows.  In the absence of a closely monitored process for making such decisions, there will be a degree of institutional blindness as to the appropriateness of the practice. This is the crux of the problem as flexibility and control collide.

In researching this question it would pay for you to look at the experience in the USA.  Until recently, many US jurisdictions restricted the declaration of death to qualified medical practitioners.  This led to many, many corpses being transported under emergency conditions to already overcrowded emergency departments.  This practice killed and injured ambulance personnel who were performing CPR when their vehicles suffered accidents.

It also ensured that hospital mortuaries were constantly overflowing with remains and it tied up valuable time in the emergency department, particularly physician time, as the legal paperwork was completed.

For all of these reasons and more, jurisdictions began to move towards legally empowering ambulance paramedics to declare death in the field.  The fears of some were that there would be a spate of declarations as paramedics wielded their new powers.  However, and I have no evidence for this assertion, I suspect the real problem will be breaking the culture of performing CPR en-route to the hospital.  I would be interested to hear what our US colleagues have to say on this matter.

Some of my thoughts on the pros of allowing paramedics to declare death are:

1. It quickly releases valuable ambulance resources for the next emergency or case

2. It lowers the administrative overhead on physicians by keeping the deceased out of the hospital and it removes the risk of the physician being called before the courts to give routine evidence on the process used.

3. It reduces the cost of handling the deceased as the funeral arrangements can be done from the home resulting in a single ambulance trip to the scene and a return funeral vehicle trip from mortuary to home and back.  This also reduces the number of times the deceased needs to be lifted and moved from nine to four.  With hospital based declarations there can be up to three other transportation legs and nine lifts involved.

4.  It leaves the deceased within the control of the family.  This lowers stress, allows grieving and leaves the family in charge of what actually happens to the remains.  This is, as far as I am concerned, the major benefit of the system.

5.  Paramedics in many jurisdictions have proven themselves highly competent in declaring death.  With good training, proper peer review of cases and transparency of medical oversight, I believe the system works well.

The Cons.

1.  There will be a level of risk that mistakes will be made.

2.  There needs to be an acceptance for field declarations by paramedics within the culture of the medical practitioners over-sighting the system.  The US experience of keeping medical control of declarations of death before then relaxing and removing the restrictions on paramedics may be due to the growth in confidence of the medical profession in the reliability of their paramedics.  In your own situation, this is the starting point.  You need to win the confidence of your peers.

3.  Public expectations.  This cannot be discounted.  There are some ethnic and religious groups who require that everything possible be done for the sick or injured patient.  This expectation needs to be met.  This again requires the creation of confidence within the community concerned and this may take some time.  This confidence will only arise from knowledge imparted by those whom the public respects.  Education and information from the medical profession concerned is essential, particularly where the highly skilled paramedic is a new addition to the health care team.

4.  There will be a reduction in the transportation of patients suffering the more extensive and untreatable injuries that are presently being seen.  When surgeons or physicians are attempting to push the boundaries of what can be done, the declaration of death by paramedics on scene will impact the availability of the very marginal case.  This requires that a system of varying the procedures be available for research purposes so that recently deceased patients fitting particular clinical criteria are transported.  Again, this will require close co-ordination with ethics committees and other stake holders.

5.  Too tight a procedure or protocol for declaring death in the field will not work.  There has to be a balance between flexibility and central control.  Usually, the best way forward is a graduated approach where field declarations can be used on the most obvious cases and, as confidence in the capacity of the paramedics increases, the range of cases can be widened.

I believe that paramedics are more than capable of declaring death in the field and that by doing so, they lower the pressure on physicians and hospitals.  However, the oversight of the medical system is vested in the physician and the first thing that must be done is to interest the physicians in how this practice will benefit them.  If this can be demonstrated, then it is essential to show them how their standards will be maintained by the paramedics, so that they can become confident that their patients are getting the best available care.

Field declarations of death by paramedics can only really occur where physicians feel confident.

Hope this helps you.