ICU Basics

Prehospital and transport

Traumatic Cardiac Arrest Algorithm

Bleeding, chest, airway, volume, then go: treat causes before compressions

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Pulseless after injury: start or withhold?

  • Scene safe; bring the bleeding kit, airway kit, monitor and pelvic binder
  • Look for signs of life: pupillary reflexes, breathing effort, spontaneous movement, response to pain, electrical activity on the monitor (NASEMSO V3)
  • Decide first whether the mechanism explains the arrest; a collapse before the crash is a medical arrest

Decapitation, transection, decomposition, rigor, lividity or other injury incompatible with life → step 2Blunt trauma: apneic, pulseless and asystolic on EMS arrival → step 2Penetrating trauma: apneic, pulseless, no other signs of life → step 2Mechanism does not explain the arrest → step 3Arrest in front of EMS, or recent with signs of life → step 4

2 Withhold resuscitation

  • NAEMSP/ACS-COT (2013): withholding is appropriate when death is the predictable outcome; NASEMSO V3 lists these findings
  • Penetrating trauma: NASEMSO V3 stops resuscitation through medical direction when signs of life are absent; follow your protocol
  • Preserve the scene for law enforcement; document every finding that supported the decision
  • Support the family and the crew

End of this path.

3 Treat it as a medical arrest

  • Standard ALS: compressions, rhythm analysis, defibrillation and epinephrine as in the cardiac arrest algorithm (NASEMSO V3)
  • Still control major bleeding and protect the spine as you go

Injuries turn out to be the cause → step 4

4 X: stop catastrophic bleeding first

  • Tourniquets for limb wounds that take one; packing with direct pressure, or a junctional tourniquet, for groin and axilla (NASEMSO V3)
  • Pelvic binder on every blunt or blast traumatic arrest (NASEMSO V3)
  • Compressions come second: fix reversible causes first, even if compressions pause briefly (ERC 2025; FPHC 2024)
  • Pregnant beyond about 20 weeks or fundus above the umbilicus: manual left uterine displacement; resuscitative hysterotomy may be considered, decided early and done within a few minutes of the decision (FPHC 2024), so transport early

Bleeding controlled: decompress the chest → step 5

5 Decompress both sides of the chest

  • Bilateral rapid chest decompression is part of every traumatic arrest (NASEMSO V3); FPHC 2024 calls for rapid bilateral thoracostomy
  • Finger thoracostomy where trained and allowed; otherwise needle decompression at your protocol site
  • A standard 5 cm 14 G anterior needle has an expected failure rate of 42.5% (CT estimate); commercial large-bore needle devices are the alternative when thoracostomy is not available (FPHC 2024)
  • Cover open chest wounds with a semi-occlusive dressing (NASEMSO V3)

Chest decompressed: airway → step 6

6 Airway and oxygen

  • High-flow oxygen at once; open the airway with spinal care (FPHC 2024; NASEMSO V3)
  • Supraglottic airway or intubation by skill; surgical airway only for cannot intubate, cannot ventilate (FPHC 2024)
  • Continuous waveform capnography once an advanced airway is in (FPHC 2024)
  • Ventilate gently: 1 breath every 6 seconds (NASEMSO V3); positive pressure can worsen hypovolemia, tamponade and tension pneumothorax (FPHC 2024)

Airway managed: volume and transport → step 7

7 Volume and TXA, started en route

  • IV or IO access and volume during transport, to shorten scene time (NASEMSO V3)
  • Best to worst: whole blood, balanced blood products, red cells alone, plasma alone, no fluid; large crystalloid volumes may harm (NASEMSO V3)
  • Crystalloid only if arrest is imminent and blood is not available (FPHC 2024)
  • TXA within 3 hours of injury: 1 g IV/IO (the hospital gives 1 g over 8 hours) or a single 2 g IV/IO dose (NAEMSP/ACEP/ACS-COT 2025)

Return of spontaneous circulation → step 8Penetrating chest wound, possible tamponade → step 9Still pulseless: transport → step 10

8 Return of circulation: keep the fixes in place

  • Leave tourniquets, packing and pelvic binder on; reassess the chest decompressions
  • Blood products if carried; avoid large crystalloid volumes (NASEMSO V3)
  • Ventilated: tidal volume 4–6 mL/kg, aim for normal oxygen and CO₂ (FPHC 2024)
  • Straight to the trauma center with prenotification

End of this path.

9 Penetrating chest: get to a surgeon fast

  • ERC advises resuscitative thoracotomy only within 15 minutes of arrest, where expertise and equipment allow (quoted by FPHC 2024); survival is higher when it is done at, or minutes after, the arrest: prenotify the trauma center
  • Tamponade needs a thoracotomy; needle pericardiocentesis has no role in penetrating cardiac trauma (FPHC 2024)
  • Ultrasound, if you are trained, must not delay treatment (FPHC 2024)

Transport now → step 10Return of spontaneous circulation → step 8

10 Load and go to the closest appropriate trauma center

  • Survival is best when hospital arrival is within minutes (NASEMSO V3)
  • CPR, if done at all, en route and only when it is safe and effective for the crew (NASEMSO V3)
  • Keep tourniquets, binder and decompression in place; reassess the chest if ventilation worsens
  • Talk with online medical direction about how long to continue (NASEMSO V3)

Return of spontaneous circulation → step 8No response after every reversible cause is treated → step 11

11 Consider stopping

  • Termination is indicated when there are no signs of life and no ROSC despite appropriate field treatment with minimally interrupted CPR (NAEMSP/ACS-COT resource document, Millin 2013); the CPR duration is not set
  • NASEMSO V3 traumatic termination: patient 18 or older, every crew member agrees, consider medical direction first
  • FPHC 2024 notes consensus to consider stopping when there is no ROSC after every reversible cause is treated, or no cardiac activity on ultrasound
  • Document the mechanism, findings, procedures, times and who agreed

End of this path.

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