Helicopter Emergency Medical Services for Traumatic Cardiac Arrest
Date First Published:
July 5, 2019
Last Updated:
July 5, 2019
Report by:
Sara Russcher, MD, Lindsey Rauch, MD, EM Senior Residents (Spectrum Health/Michigan State University Emergency Medicine Residency Program)
Search checked by:
Todd Chassee MD, Spectrum Health/Michigan State University Emergency Medicine Residency Program
Three-Part Question:
In [trauma patients with out-of-hospital cardiac arrest] does a [helicopter emergency medical service] improve [survival]?
Clinical Scenario:
A 32 year old female was driving home on a cold winter night and lost control at the wheel. On EMS arrival, the patient is obtunded, cool, and clammy. She loses pulses at the scene and EMS personnel begin CPR. After a significant delay in extrication and travel via ambulance, the patient arrives at your hospital. She undergoes multiple rounds of CPR, bilateral chest tube placement, pericardiocentesis and was found to have a large pericardial effusion in the ED trauma bay. Unfortunately, time of death was called as it is now approaching an hour-long resuscitation without ROSC. You consider if her outcome would have changed had her out of hospital traumatic arrest been managed by a helicopter emergency medical service.
Search Strategy:
Medline 1966-07/19 using PubMed, Cochrane Library (2019), and Embase
Search Details:
[("Air Ambulances" OR "Aeromedical" OR "helicopter" OR "aircraft") AND ("trauma" OR "traumatic") AND ("cardiac arrest" OR "heart arrest")]. Limit to English language.
Outcome:
88 studies were identified; eight addressed the clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| HEMS vs. Ground-BLS care in traumatic cardiac arrest Di Bartolomeo S, Sanson G, Nardi G, Michelutto V, Scian F. Jul-09 Italy | 129 blunt traumatic cardiac arrest patients | Prospective cohort study | Patient characteristics, mechanism of injury, on scene CPR, ROSC and survival to discharge | There is no significant benefit in long-term survival for blunt TCA patients undergoing advanced life support interventions with HEMS versus basic life support interventions by ground EMS. | Small sample size; limited HEMS response; initial cardiac rhythms not recorded; ground transport group younger in age; unknown actual duration of TCA; lower frequency of CPR performed in ground transport group; increased number of providers on scene in HEMS group; physician on all flights |
| Air Medical Transport for the Trauma Patient Requiring Cardiopulmonary Resuscitation: A 10-Year Experience Falcone RE, Herron H, Johnson R, Childress S, Lacey P, Scheiderer G. Sep-95 USA | Injured patients requiring CPR before or during air medical transport | Retrospective chart review | Survival to hospital admission | Air medical transport for the injured patient without signs of life following prehospital intervention appears futile. | Retrospective; primarily a rural setting only; patients were primarily male; primarily blunt injured patients; differing initial heart rhythms at scene; data from 1990s; flight crew bias regarding survivability and calling time of death at scene. |
| Advanced life support for out-of-hospital cardiac arrest--the changing role of a hospital-based flying squad Gleeson AP, Mitchell RG, Robertson CE. Sep-98 UK | Adult patients who sustained a non-traumatic cardiac arrest | Retrospective cohort study | Survival to hospital admission and discharge | Interventions by a hospital based flying squad have only a small effect on overall survival of patients with out of hospital cardiac arrest who have been primarily treated by ambulance crews provided with semi-automatic defibrillators | Retrospective analysis; male predominance; only requested after EMS on scene and assessed patients condition; initial rhythm and responsiveness to defibrillation |
| Response after Out-of-Hospital Cardiac Arrest in the Trauma Patient Should Determine Aeromedical Transport to a Trauma Center. Margolin DA, Johann DJ Jr, Fallon WF Jr, Malangoni MA. Oct-96 USA | 67 patients with out of hospital traumatic cardiac arrest transported to a Level 1 trauma center | Retrospective cohort study | Survival rate, Trauma Score, Injury Severity Score, Sinus-based cardiac rhythm at arrival, and neurological outcomes | Trauma patients resuscitated to a normal sinus rhythm after OHCA should be transported to a trauma center; The revised trauma score and Injury Severity Scores do help predict survival retrospectively, however, neurological outcome cannot be predicted accurately by this model. | Retrospective; small sample size; majority of patients transported from outside hospital (vs scene); flight crews with very experienced staff (nurses >5 years critical care experience, physician on every flight); primarily blunt injury; data from 1990s |
| Emergency medical dispatch recognition, clinical intervention and outcome of patients in traumatic cardiac arrest from major trauma: an observational study Prentice C, Jeyanathan J, De Coverly R, Williams J, Lyon R. Sep-15 Netherlands | 144 patients with traumatic cardiac arrest (TCA) having undergone thoracostomy performed by helicopter emergency services (HEMS) teams | Retrospective cohort study | Number and outcomes of TCA patients having undergone thoracostomy performed by HEMS | Outcomes of TCA in patients having undergone prehospital thoracostomy were poor. There was no objective way to identify tension pneumothorax and it is unclear whether or not unnecessary thoracic interventions could be avoided | Retrospective; external validity of study; bystander bias for arrest and recognition needed for 911 call; presumed medical cause of arrest excluded; short time-frame of case review. |
| Out-of-hospital cardiac arrest following trauma: What does a helicopter emergency medical service offer? Ter Avest E, Griggs J, Prentice C, Jeyanathan J, Lyon RM. Dec-18 UK | 263 patients with traumatic cardiac arrest who were attended to by a non-urban (Kent, Surrey and Sussex Air Ambulance trust) helicopter emergency medical services (HEMS) transport crew | Retrospective cohort study | Number of patients with ROSC at the scene, number and type of HEMS specific advanced interventions occurred and how they related to ROSC and number of patients who survived to hospital discharge | HEMS teams can perform significant interventions such as blood product administration and RSI which increase ROSC in traumatic arrest patients in addition to providing additional advanced interventions such as thoracostomies and thoracotomies. | Retrospective; small sample size; physician on all flights; incomplete outcome data; unable to formally identify casual relation between outcomes and HEMS interventions; ROSC as primary outcome as opposed to survival. |
| Aeromedical Transport of Patients With Post-Traumatic Cardiac Arrest Wright SW, Dronen SC, Combs TJ, Storer D. Jan-89 USA | Patients who experienced traumatic cardiac arrest before the arrival of the flight team | Retrospective chart review | Improved survivability | Physician intervention at the scene and rapid aeromedical transport are not likely to improve mortality after traumatic cardiac arrest. | Retrospective; primarily blunt injury; data from 1980s; male predominance |
| Prehospital thoracostomy in patients with traumatic circulatory arrest: results from a physician-staffed Helicopter Emergency Medical Service Peters J, Ketelaars R, van Wageningen B, Biert J, Hoogerwerf N. Sep-15 Netherlands | 144 patients with traumatic cardiac arrest (TCA) having undergone thoracostomy performed by helicopter emergency services (HEMS) teams | Retrospective cohort study | Number and outcomes of TCA patients having undergone thoracostomy performed by HEMS | Outcomes of TCA in patients having undergone prehospital thoracostomy were poor. | Retrospective; no objective way to identify tension pneumothorax in prehospital setting; incomplete documentation; too low of survival rate to evaluate post thoracotomy infections; physician staffed HEMS |
Author Commentary:
Seven out of eight studies included are retrospective chart reviews, speaking to the limited availability of data addressing this topic. Previous studies showed little improvement with the interventions of helicopter emergency medical services (HEMS) in traumatic cardiac arrest patient outcomes. However, more recent studies do suggest a potential benefit with HEMS teams including increases in ROSC and survival with advanced interventions (such as thoracostomy).
Bottom Line:
In a specific subgroup of patients with traumatic out-of-hospital cardiac arrest, helicopter emergency medical services do improve survival.
References:
- Di Bartolomeo S, Sanson G, Nardi G, Michelutto V, Scian F.. HEMS vs. Ground-BLS care in traumatic cardiac arrest
- Falcone RE, Herron H, Johnson R, Childress S, Lacey P, Scheiderer G.. Air Medical Transport for the Trauma Patient Requiring Cardiopulmonary Resuscitation: A 10-Year Experience
- Gleeson AP, Mitchell RG, Robertson CE.. Advanced life support for out-of-hospital cardiac arrest--the changing role of a hospital-based flying squad
- Margolin DA, Johann DJ Jr, Fallon WF Jr, Malangoni MA.. Response after Out-of-Hospital Cardiac Arrest in the Trauma Patient Should Determine Aeromedical Transport to a Trauma Center.
- Prentice C, Jeyanathan J, De Coverly R, Williams J, Lyon R.. Emergency medical dispatch recognition, clinical intervention and outcome of patients in traumatic cardiac arrest from major trauma: an observational study
- Ter Avest E, Griggs J, Prentice C, Jeyanathan J, Lyon RM.. Out-of-hospital cardiac arrest following trauma: What does a helicopter emergency medical service offer?
- Wright SW, Dronen SC, Combs TJ, Storer D.. Aeromedical Transport of Patients With Post-Traumatic Cardiac Arrest
- Peters J, Ketelaars R, van Wageningen B, Biert J, Hoogerwerf N. . Prehospital thoracostomy in patients with traumatic circulatory arrest: results from a physician-staffed Helicopter Emergency Medical Service