Traumatic Cardiac Arrest

Traumatic cardiac arrest is an arrest caused by injury. The 2025 joint position statement calls it traumatic out-of-hospital circulatory arrest (TOHCA). The statement lists the possible causes: massive hemorrhage, airway obstruction, obstructive shock, respiratory disturbance, cardiogenic causes and massive head trauma. Several of these are mechanical or volume problems. Start with the cause, not the medical arrest algorithm.

• Mechanism: Compressions come second. The joint statement puts the life-saving interventions first (hemorrhage control, airway, and chest decompression for suspected tension pneumothorax) and advises against routine epinephrine before them.
• Published outcomes: The numbers are low. Survival to discharge was 1.9% in a Nova Scotia population-based registry (1,042 adults, 2007–2023). One Level 1 center’s resuscitative thoracotomy cohort reported 5.8% (467 patients). A multicenter cohort of 996 children and adults (2010–2019) reported 7.4% survival at 30 days.
• Blunt and penetrating injury: Blunt trauma made up 71.7% of the Nova Scotia cohort. Where penetrating injury is rare, a 2026 Austrian Delphi consensus stresses strict indications, trauma-center and physician-led prerequisites, and the clamshell technique.

Presentation

• Arrest after injury: unresponsive with no pulse and no effective breathing after a penetrating or blunt mechanism.
• Hidden source: the bleed may sit in the chest, abdomen, pelvis or thigh. A small external wound does not exclude major bleeding.

Red Flags

• Penetrating trauma with no pulse
• Non-shockable rhythm (PEA or asystole): an extremely low likelihood of return of spontaneous circulation (ROSC) or survival with neurologic recovery
• Clinical concern for tension pneumothorax
• Any withhold criterion (see Assessment & Diagnostics)

You make this diagnosis at the bedside. Life-saving interventions come first, before the monitor and before POCUS. The checks below decide whether to continue, withhold or stop.

• Medical arrest with an unclear cause: When the cause is unclear, especially without clear signs of life-threatening trauma, standard BCLS and ACLS apply. See Adult Cardiac Arrest.
• Hemorrhagic shock with a pulse: not arrest yet. Resuscitate per Hemorrhagic Shock.
• Tension pneumothorax without arrest: clinical concern is reason enough to decompress. See Pneumothorax, Tension Pneumothorax and Hemothorax.

1. Scene safety and mechanism: note the mechanism, time of injury, and any anticoagulant or antiplatelet use.
2. Stop external bleeding: direct pressure, wound packing and tourniquets, per protocol. The joint statement lists these first. See Hemorrhage Control.
3. Airway: use the least invasive approach that keeps the airway patent, oxygenation and ventilation adequate.
4. Compressions secondary to the steps above: external chest compressions may be considered, but only secondary to the life-saving interventions. Do not delay or interrupt bleeding control or airway care to compress.
5. Notify and decide on transport early: identify patients who may benefit from a trauma center when transport is safe and appropriate, and request ALS.

Doses vary by protocol; follow local protocols and medical direction. Your scope sets the limit on each action.

• Life-saving interventions first (Paramedic/RN/CCT): tourniquet, hemostatic packing or pelvic binder per protocol, before any drug. See Hemorrhage Control.
• Volume or blood resuscitation (Paramedic/RN/CCT): for suspected hemorrhage, go by protocol and the Hemorrhagic Shock page. It is not on the joint statement’s life-saving-intervention list. Observational data tie fluid infusion to better sustained ROSC and 30-day survival. The page gives no dose.
• Chest decompression (Paramedic/RN/CCT): clinical concern of tension pneumothorax is the trigger, per protocol. Without suspected chest trauma, bilateral decompression on a guess is not indicated. See Needle Decompression and Figure 1.
• Access (Paramedic/RN/CCT): IV or IO access per protocol. See IO Access.
• Monitor after the life-saving interventions: place the cardiac monitor and POCUS once the indicated interventions are done, not before.
• Epinephrine (Paramedic/RN/CCT): not routine. Where the protocol uses it, give 1 mg IV/IO every 3–5 min, and never before the life-saving interventions above. See Epinephrine IV.
• Shockable rhythm (Paramedic/RN/CCT): defibrillate per the adult pathway. See Defibrillation.
• Airway device (Paramedic/RN/CCT): supraglottic airway or intubation per protocol. See Supraglottic Airway and Intubation.

• Definitive hemorrhage control: surgery, angioembolization or other procedures per the Hemorrhagic Shock page.
• Resuscitative thoracotomy (hospital decision): criteria differ by system, so know which set yours uses. EAST looks first at signs of life. WTA looks at prehospital arrest time. In a 2026 single-center cohort of 467 patients, 98.5% met EAST criteria and 5.8% survived to discharge. A 2026 Austrian multisociety consensus calls for strict indications and major trauma-center and physician-led prerequisites, and it prefers the clamshell technique.
• Blood, tranexamic acid and calcium: follow the Hemorrhagic Shock page for product ratio, TXA (see Tranexamic Acid) and calcium.
• After ROSC: post-arrest care and a search for a surgical or interventional source. See Post-Cardiac Arrest Care.
• Head injury: massive head trauma is on the cause list. Manage per Traumatic Brain Injury.

• Destination: the target is a trauma center inside the local trauma system. The joint statement stresses regional trauma capability and active EMS physician oversight.
• Transport or stop: decide per local protocol. There is no universal time cutoff. Mechanism or rhythm alone is not a reason to stop.
• In transit: reassess the chest, bleeding sites and airway after each move.
• On-scene factors: cost and organ donation stay out of on-scene decisions, per the joint statement.
• Handoff: time of injury and arrest; each life-saving intervention with its time (tourniquet, packing, decompression side and placement, airway); epinephrine doses and times; rhythm history; prehospital CPR duration.

• Pediatrics: the evidence is thin. A 2026 meta-analysis of 13 studies found survivors reached ROSC early (pooled mean resuscitation about 6 min). No survivor was identified after resuscitation longer than 45 min. Doses are weight-based. See Pediatric Cardiac Arrest and weight-based dosing. The joint statement covers adults only. Pediatric traumatic arrest needs local pediatric protocols and PALS for weight-based equipment and doses. The adult sequence on this page does not cover children.
• Pregnancy: the mother comes first. Resuscitate her with left uterine displacement. Perimortem delivery follows the Cardiac Arrest in Pregnancy pathway.
• Patients on Anticoagulants: bleeding risk runs higher. Reversal depends on the agent, per the Hemorrhagic Shock page.
• Traumatic Brain Injury: massive head trauma appears on the cause list. Brain matter extruding from an open skull injury is a withhold criterion. See Traumatic Brain Injury.

• Error: Starting the medical arrest drug pathway first. Epinephrine is not routine in traumatic arrest, and it does not come before the life-saving interventions.
• Error: Decompressing both sides on a guess, with no chest trauma suspected.
• Error: Stopping on mechanism or rhythm alone. The joint statement says neither is enough by itself.
• Error: Continuing resuscitation past a withhold criterion. Those are injuries incompatible with life, signs of prolonged arrest, or a valid DNR, DNAR or allow-natural-death order.
• Error: Long on-scene CPR that holds up hemorrhage control. In a 2026 cohort of 487 patients who reached the ED and had resuscitative thoracotomy, longer prehospital CPR went with worse outcomes. That is an association. It is not a transport cutoff.
• Error: Letting a POCUS finding make the call. It may inform prognosis after the interventions. It does not make the decision.