The Trauma Patient in Extremis: Modern Peri-Arrest Management of the Injured Patient

Abstract Purpose of Review Traumatic cardiac arrest (TCA) and the peri-arrest trauma patient represent one of the most challenging populations encountered by trauma teams. Contemporary evidence has demonstrated that TCA is frequently a reversible condition when the underlying pathophysiology is rapidly identified and treated. This review summarizes current evidence regarding the evaluation and management of injured patients in extremis, with particular emphasis on trauma-specific resuscitation priorities, the role of conventional advanced cardiac life support (ACLS) interventions, and indications for emergency department thoracotomy (EDT). Recent Findings Modern trauma resuscitation has shifted away from traditional ACLS algorithms toward rapid correction of reversible causes of arrest, emphasizing hemorrhage control, balanced blood product resuscitation, treatment of hypoxia, and management of obstructive shock etiologies (e.g. tension pneumothorax and cardiac tamponade). Contemporary evidence suggests that routine use of chest compressions, vasopressors, and mechanical compression devices provides limited benefit unless reversible causes have been addressed, while defibrillation should remain restricted to shockable rhythms. Patient selection for EDT continues to evolve, with current guidelines favoring a mechanism- and physiology-based approach. Emerging technologies, including resuscitative endovascular balloon occlusion of the aorta (REBOA), prehospital advanced resuscitative measures, and extracorporeal cardiopulmonary resuscitation (ECPR), may further improve outcomes in carefully selected patients. Summary Successful management of TCA depends on timely recognition of reversible traumatic pathology and coordinated, trauma-specific resuscitation rather than adherence to conventional medical cardiac arrest algorithms. Continued advances in prehospital systems, damage control resuscitation, and emerging technologies will likely further refine patient selection and improve survival while reducing futile interventions.