Traumatic Cardiac Arrest

Why this matters

The monitor shows pulseless electrical activity, called PEA, which is a rhythm without a pulse. The team reaches for epinephrine by habit. In blunt or penetrating trauma, empty vessels, a vena cava kinked by tension, and an airway that is not ventilating kill faster than a missed heart-rhythm drug. Medical advanced cardiac life support, called ACLS, is not the template.

First, stop bleeding, open the airway with the least invasive method that works, and decompress tension if chest trauma makes it a concern. Check whether those reversible problems are fixed before you talk about epinephrine. Epinephrine is not routine traumatic-arrest care. Some of these patients can survive if you fix what you can and move toward a surgeon. Some cannot. Your rules for stopping resuscitation exist so you do not create a second tragedy on a highway.

Clinical sequence

1. Do the reversible actions first. Stop hemorrhage. Use the least invasive airway that actually ventilates. Decompress if tension is a concern and chest trauma is suspected.
2. Do not place needles in both sides of the chest without suspected chest trauma.
3. Treat compressions as secondary to those actions. Do not give epinephrine routinely. If your protocol allows it at all, do not give it before the reversible actions.
4. Stop or continue only under written termination rules and medical direction. This is not a hallway decision.

Priorities

NAEMSP 2025 teaching on traumatic out-of-hospital circulatory arrest puts the reversible actions first. Medical ACLS is not the template. Combat teaching can be more aggressive for torso traumatic arrest. Your protocol decides.

1. Make the scene safe. Control external hemorrhage with direct pressure, packing, and tourniquets.
2. Open the airway with the least invasive method that actually ventilates and oxygenates. Do not make the tube the whole call.
3. Decompress the chest if there is clinical concern for tension pneumothorax. A tension pneumothorax is air under pressure that obstructs blood return to the heart. Empiric needles in both sides, placed without suspected chest trauma, are not indicated.
4. Do not rock the pelvis. If your protocol still uses a binder, place it on the greater trochanters, turn the legs inward, and secure the feet. The greater trochanters are the bony bumps on the outside of each upper thigh. Outcome evidence for prehospital binders is weak. Look for other bleeding. Move toward a trauma center that can operate, when transport is still appropriate.
5. External chest compressions may be considered. They are secondary to those reversible actions.
6. Epinephrine should not be used routinely in traumatic arrest. If it is used, it should not be given before the reversible actions. If this looks like a medical arrest that caused a crash, treat the medical cause. Do not treat a gunshot wound to the chest as if it were ventricular fibrillation from coronary disease.

When to Stop

• Know your protocol. Termination of resuscitation, called TOR, is a written decision, not a guess. Unwitnessed blunt arrest with asystole, a long downtime, and no reversible cause is often a reason to stop. A fresh penetrating arrest may still get a short, aggressive attempt plus transport in some systems.
• This lesson does not authorize you to stop or to continue. Medical direction and written termination rules do.

Common errors

• Giving epinephrine for 20 minutes for a gunshot wound to the torso.
• Never looking at the chest or the bleeding.
• Calling it traumatic arrest when the patient clutched their chest and then crashed the car. That may be a medical arrest first.

Practice

Related: Tension, Hemorrhage.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol decides
• NAEMSP / ACS-COT / ACEP 2025: Prehospital Management of Adults with Traumatic Out-of-Hospital Circulatory Arrest
• TCCC guidelines (Committee on TCCC) — combat teaching may be more aggressive; your protocol decides
• Do the reversible actions first: hemorrhage control, the least invasive airway that works, and decompression if tension is a concern. Empiric needles in both sides of the chest are not indicated without suspected chest trauma. Compressions are secondary. Epinephrine is not routine, and it is not given before those actions. Stop only under written protocol and medical direction.