Prehospital Trauma Compendium: Prehospital Management of Adults with Traumatic Out-of-Hospital Circulatory Arrest – A Joint Position Statement and Resource Document of NAEMSP, ACS-COT, and ACEP

NAEMSP, ACEP, and ACS-COT recommend: EMS resuscitation of adults with TOHCA should:Prioritize prompt identification of patients who may benefit from transport to definitive care at trauma centers when safe and appropriate.Emphasize the identification of reversible causes of traumatic circulatory arrest and timely use of clinically indicated life-saving interventions (LSIs) within the EMS clinician's scope of practice. These include: External hemorrhage control with direct pressure, wound packing, and tourniquetsAirway management using the least-invasive approach necessary to achieve and maintain airway patency, oxygenation, and adequate ventilation.Chest decompression if there is clinical concern for a tension pneumothorax. Empiric bilateral decompression, however, is not indicated in the absence of suspected chest trauma.External chest compressions may be considered but only secondary to other LSIs.Epinephrine should not be routinely used, and if used should not be administered before other LSIs.If point-of-care ultrasound (POCUS) demonstrates no evidence of cardiac motion, this may have utility in TOHCA management for prognostication.Emphasize that placement of cardiac monitors and/or use of POCUS should occur after indicated LSIs have been appropriately performedConditions where resuscitation attempts should be withheld, include TOHCA patients with: Injuries that are incompatible with life (e.g., decapitation, hemi-corpectomy, incineration, open skull injury with extruding brain matter).Evidence of prolonged circulatory arrest (e.g., rigor mortis, dependent lividity, decomposition).Advance care planning documents that indicate Do Not Resuscitate (DNR)/ Do Not Attempt Resuscitation (DNAR)/Allow Natural Death medical orders.Conditions where resuscitation attempts are discontinued for TOHCA patients should recognize: Mechanism of injury should not be used as the sole determinant to discontinue resuscitation efforts<b>.</b>Electrical rhythm should not be used as the sole determinant to discontinue resuscitation efforts. Of note, non-shockable rhythms (Pulseless Electrical Activity/Asystole) are associated with an extremely low likelihood of return of spontaneous circulation (ROSC) or survival with neurologic recovery.There is insufficient evidence to support any specific universal standardized time-based cutoffs to discontinue resuscitation efforts based on the duration of resuscitation or transport times to definitive care. EMS decisions to transport or discontinue resuscitation should be locally determined based on EMS and trauma system resources and proximity.Implementation of protocols for TOHCA should consider: Risks and benefits of resuscitation attempts and transport for public safety and EMS clinician safety.Individual patient cost and organ donation should not be a factor in EMS clinical decision-making on-scene.Local provisions for specific clinical resources (e.g. regional trauma capabilities), environmental (e.g. avalanche, etc.), or population-based situations are important and require active EMS physician oversight in collaboration with local trauma system stakeholders.