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The heart of the matter: Utility of ultrasound of cardiac activity during traumatic arrest

Cureton, Elizabeth L. MD; Yeung, Louise Y. MD; Kwan, Rita O. MD, MPH; Miraflor, Emily J. MD; Sadjadi, Javid MD, FACS; Price, Daniel D. MD; Victorino, Gregory P. MD, FACS

Journal of Trauma and Acute Care Surgery: July 2012 - Volume 73 - Issue 1 - p 102–110
doi: 10.1097/TA.0b013e3182569ebc
ORIGINAL ARTICLES

BACKGROUND The clinical utility of determining cardiac motion on ultrasound has been reported for patients presenting in pulseless medical cardiac arrest. However, the relationship between ultrasound-documented cardiac activity and the probability of surviving pulseless electrical activity has not been examined in populations with trauma. We hypothesized that cardiac activity on ultrasound predicts survival for patients presenting in pulseless traumatic arrest.

METHODS We conducted a retrospective analysis at our university-based urban trauma center of adult patients with trauma, who were pulseless on hospital arrival. Results of cardiac ultrasound performed during trauma resuscitations were compared with the electrocardiogram (EKG) rhythm and survival.

RESULTS Among 318 pulseless patients with trauma, 162 had both EKG tracings and a cardiac ultrasound, and 4.3% of these 162 patients survived to hospital admission. Survival was higher for those with cardiac motion than for those without it (23.5% vs. 1.9% for patients with EKG electrical activity, p = 0.002, and 66.7% vs. 0% for patients without EKG electrical activity, p < 0.001). The sensitivity of ultrasound cardiac motion to predict survival to hospital admission was 86% (specificity, 91%; positive predictive value, 30%; negative predictive value, 99%). When examined by mechanism, sensitivity was 100% for the 111 patients with penetrating trauma and 75% for the 50 patients with blunt trauma.

CONCLUSION Survival in pulseless traumatic arrest is very low, but survival for patients with no cardiac motion on ultrasound is also exceedingly rare. Cardiac ultrasound had a negative predictive value approaching 100% for survival to hospital admission. For patients with prolonged prehospital cardiopulmonary resuscitation, ultrasound evaluation of cardiac motion in pulseless patients with trauma may be a rapid way to help determine which patients have no chance of survival in the setting of lethal injuries, so that futile resuscitations can be stopped. (J Trauma Acute Care Surg. 2012;73: 102–110. Copyright © 2012 by Lippincott Williams & Wilkins)

LEVEL OF EVIDENCE Diagnostic study, level III.

From the Department of Surgery (E.L.C., L.Y.Y., R.O.K., E.J.M., J.S., G.P.V.), University of California, San Francisco-East Bay; and Department of Emergency Medicine (D.D.P.), Alameda County Medical Center, Oakland, California.

Submitted: October 28, 2011; Revised: January 11, 2012; Accepted: January 19, 2012.

This study was performed at the University of California, San Francisco-East Bay, Alameda County Medical Center, Oakland, California.

Address for reprints: Gregory P. Victorino, MD, FACS, Department of Surgery, University of California, San Francisco-East Bay, 1411 East 31st St, Oakland, CA 94602; email: gregory.victorino@ucsfmedctr.org.

© 2012 Lippincott Williams & Wilkins, Inc.