traumatic arrest
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Traumatic arrest
Amy McAllisterAugust 2014
Case
4am on Saturday morning, bat phone rings….
29 year old male with bread knife lateral to left sternum
Initially had recordable vitals, then lost output – CPR in progress
ETA 2 minutes
What would you do?
Contents
Epidemiology Causes Blunt Penetrating Management Emergency Thoracotomy
What is traumatic arrest?
Cardiac arrest caused by trauma, usually penetrating or blunt thoracic injury
Can also include abdominal and head injury, as well as drowning, asphyxiation, electrocution
Differences to medical arrest
Patients usually young and healthy Usually not primary cardiac event
Statistics
Various papers with differing mechanisms and standards
1990s survival to hospital discharge 2.5%
2000s 4-8% Poor survival persists
Causes
Hypoxia airway obstruction – vomit, foreign
body, facial fractures tracheobronchial injury CNS depression open/tension pneumothorax
Causes
Hypoperfusion Haemorrhage hypovolaemia Cardiac tamponade
When to start resuscitation?
EMS Physicians and the American College of Surgeons Committee on Trauma (COT) guidelines 2003:
WITHOLD RESUS… Blunt trauma patient who is found apnoeic,
pulseless, and without organized ECG activity upon the arrival of EMS at the scene
Penetrating trauma found apnoeic and pulseless by EMS, without signs of life
injuries obviously incompatible with life Rigor mortis
When to stop resuscitation?
15-20 minutes of unsuccessful CPR Transport to trauma centre >15
minutes
Special circumstances
Paediatrics Pregnant women – perimortem
caesarean “Medical” arrest Hypothermia
Appropriate guidelines?
London air ambulance retrospective over 10 years
Almost 1000 patients included - 740 dead at scene 7.5% survived to hospital d/c Up to 64% breached guidelines
Blunt trauma
Blunt trauma arrest - management
Airway Bilateral open thoracostomies Haemorrhage control Blood/ fluid Defib as necessary USS
External chest compressions
No venous return in TCA patients Delay procedures May cause further thoracic damage
Needle Vs Knife thoracostomy
Needle approach conventionally 2nd IC space, midclavicular line
Danger of going too medial and hitting vessels
Can kink, cause pneumothorax or not reach
Suggestion to go laterally or do finger thoracostomies
Needle Thoracostomy
Finger/open thoracostomy
Penetrating trauma
Penetrating trauma - management
ABCs as with blunt injury Chest compressions not warranted Bilateral open thoracostomies Emergency thoractomy
Emergency Thoracotomy
"The surgeon who should attempt to suture a wound of the heart would lose the respect of his surgical colleagues" - Theodore Bilroth, 1882
Indications for thoracotomy
Blunt trauma: limited to those with vital signs on arrival and witnessed cardiac arrest or unresponsive hypotension (BP < 70mmHg)
Or Rapid exsanguination from chest tube (>1500ml)
Penetrating cardiac injuries who arrive at the trauma centre within 20minutes with witnessed signs of life or ECG activity
Exsanguinating abdominal vascular injury
Emergency thoracotomy
Primary aims: Release of cardiac tamponade Control of haemorrhage – direct finger
pressure internal cardiac massage Secondary aims: cross-clamping of the descending
thoracic aorta
Approach supine anterolateral thoracotomy rapid skin preparation Incision 5th intercostal space; sternum to mid-
axillary line Incise through subcutaneous tissues to reach
intercostal musculature Enter chest bluntly with a finger through
intercostal muscles Extend opening with heavy scissors and blunt
dissection Insert the rib spreaders between the ribs and
open
Release of cardiac tamponade
Contraindications
Massive head trauma prehospital CPR performed for >15 minutes
after penetrating chest injury without response
prehospital CPR performed for >10 minutes after blunt chest injury without response
asystole is the presenting rhythm, and there is no pericardial tamponade
no hope of providing definitive surgical interventions following the procedure.
Risks
Risk to provider – needle stick, scalpel – broken ribs in blunt trauma
Resuscitation of a patient without likely neurological outcome
Resource consumption – OT without benefit, costs
Risks of further injury to patient
Simultaneously…
Get blood/ trauma pack Get access – IO/IV Permissive hypotension Look for sources of bleeding and close ?head – scalp wound ?FAST exam Pelvic binder Traction on long bones Call surgeons
Prognostic indicators
Signs of life Previous documented vital signs USS showing cardiac activity Age Rhythm Isolated penetrating cardiac injury Stab wounds vs gunshot
Back to the case…
PREPARE Major trauma call Staff - Call in consultant and
cardiothoracics…..GOWN UP! Trauma bay Equipment - thoracotomy kit, USS Call for trauma pack Know limitations of yourself and
colleagues
Learning points
Traumatic cardiac arrest has grim survival rates
Should be carried out in correct setting and with appropriate surgical backup
Emergency thoracotomy for penetrating wounds, otherwise bilateral thoracostomies
DON’T use closed CPR or vasopressors
References
http://emcrit.org/podcasts/traumatic-arrest/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3672499/ http://www.trauma.org/index.php/main/article/361/ http://
www.alabmed.com/uploadfile/2014/0515/20140515070229503.pdf
http://www.biomedcentral.com/content/pdf/cc10558.pdf
http://resuscitation-guidelines.articleinmotion.com/article/S0300-9572(10)00441-7/aim/8i-traumatic-cardiorespiratory-arrest
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