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