Survival following Prehospital Traumatic Cardiac Arrest Resuscitation in the Israel Defense Forces: A Retrospective Study

Figures & data

Figure 1. Traumatic cardiac arrest algorithm in the Israel Defense Forces Medical Corps of 2023.

Figure 2. Flow diagram of casualties included in the study. IDF-TR: Israel Defense Forces Trauma Registry; TCA: traumatic cardiac arrest.

Table 1. Demographics and injury characteristics of the study population undergoing TCA resuscitation.

	Study population by event type
	Nonmilitary event	Military event	Total	p-value^a
	(N = 65)	(N = 84)	(N = 149)
Age – Median (IQR), years	21 (19–31)	21 (19–25)	21 (19–27)	0.491
Missing	26	29	55
Sex – N (%)
Male	57 (89.1)	76 (90.5)	133 (89.9)	0.790
Missing	1	0	1
Body region involvement – N (%)
Head	27 (41.5)	9 (10.7)	36 (24.2)	<0.001
Face	10 (15.4)	5 (6.0)	15 (10.1)	0.097
Neck	2 (3.1)	9 (10.7)	11 (7.4)	0.114
Upper extremity	10 (15.4)	18 (21.4)	28 (18.8)	0.402
Torso	44 (67.7)	52 (61.9)	96 (64.4)	0.494
Pelvis	2 (3.1)	7 (8.3)	9 (6.0)	0.300
Lower extremity	14 (21.5)	17 (20.2)	31 (20.8)	0.842
Penetrating injury – N (%)	20 (30.8)	72 (85.7)	92 (61.7)	<0.001
Mechanism of injury – N (%)
Blast	0 (0.0)	15 (17.9)	15 (10.1)	<0.001
Fall	3 (4.6)	1 (1.2)	4 (2.7)
Gunshot	11 (16.9)	54 (64.3)	65 (43.6)
Motor vehicle collision	41 (63.1)	6 (7.1)	47 (31.5)
Other	6 (9.2)	7 (8.3)	13 (8.7)
Shrapnel	1 (1.5)	1 (1.2)	14 (8.7)
Blunt object strike	3 (4.6)	0 (0.0)	15 (8.7)
Interval from report of injury to arrival of first ALS team on-scene – Median (IQR), minutes	11 (4–16)	12 (5–20)	11 (5–18.75)	0.311
Missing	10	17	27
Timing of arrest – N (%)
Witnessed by ALS team	20 (30.8)	41 (48.8)	61 (40.9)	0.010
Unwitnessed	39 (60.0)	42 (50.0)	81 (54.4)
Could not be determined	6 (9.2)	1 (1.2)	7 (4.7)
Indication for intervention – N (%)
Indicated according to TCA protocol	39 (65.0)	65 (80.2)	104 (73.8)	<0.001
Unindicated due to arrival >5 min after loss of signs	18 (30.0)	11 (13.6)	29 (20.6)	0.133
Could not be determined	2 (3.3)	4 (4.9)	6 (4.3)	<0.001
Unindicated due to injuries incompatible with life	1 (1.7)	1 (1.2)	2 (1.4)	<0.001
Injury survivability according to postmortem report – N (%)
Could not be determined/undocumented	41 (63.1)	43 (51.2)	84 (56.4)	<0.001
Non-survivable	24 (36.9)	38 (45.2)	62 (41.6)
Survivable	0 (0.0)	3 (3.6)	3 (2.0)

^ap values acquired from Fisher’s exact test, Kruskal-Wallis test, or chi-square test.

ALS – advanced life support, IQR – interquartile range, TCA – traumatic cardiac arrest.

Table 2. Prehospital traumatic cardiac arrest interventions and injury characteristics of the study population.

	Study population by event type
	Nonmilitary event	Military event	Total	p-value^a
	(N = 65)	(N = 84)	(N = 149)
Completed full protocol (Airway/ventilation, chest decompression and volume resuscitation)	24 (37.5)	32 (38.1)	56 (37.8)	1.000
Airway management/ventilation – N (%)
Any airway management	62 (95.4)	77 (91.7)	139 (93.3)	0.514
Bag mask ventilation	33 (50.8)	32 (38.1)	65 (43.6)	0.136
Endotracheal intubation	50 (76.9)	66 (78.6)	116 (77.9)	0.844
Cricothyroidotomy	8 (12.3)	11 (13.1)	19 (12.8)	1.000
Chest decompression – N (%)
Any chest decompression procedure	64 (98.5)	84 (100.0)	148 (99.3)	0.436
Needle application	56 (86.2)	70 (83.3)	126 (84.6)	0.820
Chest tube	26 (40.0)	46 (54.8)	72 (48.3)	0.098
Volume resuscitation – N (%)
Any volume resuscitation	25 (39.1)	37 (44.0)	62 (41.9)	0.615
Crystalloids	13 (20.0)	22 (26.2)	35 (23.5)	0.438
Freeze-dried plasma	9 (13.8)	12 (14.3)	21 (14.1)	1.000
Packed red blood cells	0 (0.0)	6 (7.1)	6 (4.0)	0.036
Whole blood	3 (4.6)	4 (4.8)	7 (4.7)	1.000
Intravenous access	38 (58.5)	44 (52.4)	82 (55.0)	0.509
Intraosseous access	17 (26.2)	25 (29.8)	42 (28.2)	0.715
Other prehospital interventions – N (%)
Tourniquet application	2 (3.1)	10 (11.9)	12 (8.1)	0.068
Tranexamic acid	9 (13.8)	14 (16.7)	23 (15.4)	0.404
Evacuation – N (%)
Air medical evacuation	6 (9.2)	18 (21.4)	24 (16.1)	0.071
Return of vital signs and survival – N (%)
≥1 vital sign^ˠ	1 (1.6)	4 (4.9)	5 (3.4)	<0.001
Survived to hospital admission	0 (0.0)	0 (0.0)	0 (0.0)	–

^ap values acquired from Fisher’s exact test, Kruskal-Wallis test or chi-square test.

^ˠ Refers to palpated pulse/spontaneous breathing/pupil reaction/measurable blood pressure.

Table 3. Description of casualties with return of vital signs during traumatic cardiac arrest treatment.

Case	Age	Sex	Injury setting	Trauma mechanism	Injury description	Loss of vital signs description	TCA interventions	Return of vital signs description*	Outcome	Postmortem report	Injury survivability
1	20	Male	Military – combat	Gunshot wound	Single gunshot wound in the left upper hemithorax.	Upon initial examination at the point-of-injury: Unconscious, pale, apneic, no palpable pulse, dilated pupils.	Airway: Endotracheal intubation Chest: Unilateral needle decomplression, followed by chest tube placement draining large volumes of blood Volume: 500 ml crystalloids via intarosseus access	Return of palpable carotid pulse several minutes following needle decompression	Declared dead prior to hospital arrival	Massive hemopneumothorax, lung laceration, pericardial laceration	Non-survivable
2	36	Male	Military – combat	Gunshot wound	Single gunshot wound through upper back and neck.	Upon initial examination following evacuation from point-of-injury to forward medical team: Unconscious, apneic with no palpable pulse.	Airway: Cricothyroidotomy Chest: Bilateral needle decomplression, followed by bilateral chest tube placement draining large volumes of blood from left hemithorax Volume: 500 ml crystalloids and 1 g of tranexamic acid via intraosseus access	Return of "color" to the patient’s face and palpable carotid pulse following needle decompression	Declared dead during air medical evacuation to hospital	Massive hemopneumothorax, emphysema of soft tissues in the neck area, pneumomediastinum, sharpnel induced laceration of lung	Potentially survivable
3	20	Male	Military – terror attack	Gunshot wound	Gוunshot wound with entry in the scapular area and exit in the left hemithorax.	Upon initial examination at point-of-injury: Glasgow Coma Scale score 12, tachycardic (120 beats per minute), and tachypneic with uneven lung expansion, peripheral cyanosis. After several minutes loss of palpable pulse and visible breathing.	Airway: Bag-mask ventilation followed by endotracheal intubation Chest: Unilateral needle decompression in left hemithorax (x2) Volume: 500 ml crystalloids and 1 g of tranexamic acid via intraosseus access	Return of weakly palpable pulse during interventions, followed by second loss of vital signs.	Declared dead prior to hospital arrival	N/A	N/A
4	19	Male	Civilian	Blunt trauma in motor vehicle accident	Blunt chest and abdominal trauma following high speed collision	Upon initial examination at point-of-injury: Unresponsive, carotid pulse of 140 beats per minute, tachypneic (40 breaths per minute). Loss of vital signs during assessment.	Airway: Bag mask ventilation with oxygen Chest: Unilateral needle decompression in left hemithorax (x2) Volume: 500 ml crystalloids and 1 g of tranexamic acid via intravenous access	Return of palable pulse and blood pressure measurment 135/80 mmHg, oxygen saturation of 93%, followed by second loss of vital signs.	Declared dead prior to hospital arrival	N/A	N/A
5	43	Male	Military – training	Helicopter crash	Blunt multisystem trauma in head, neck upper limbs, chest and lower limbs.	Upon initial examination at point-of-injury: Unresponsive, no palpable pulse or visible breathing, dilated pupils.	Airway: Cricothyroidotomy Chest: Unilateral chest tube placement. Volume: N/A	Return of pupil constriction according to team.	Declared dead prior to hospital arrival	Massive intracranial bleeding (subarachnoid), fractures of cranial, facial, chest, and pelvic bones.	Non-survivable

*Data ascertained from review of cases in the IDF-TR.