Traumatic Cardiac Arrest

Cardiac Arrest in Trauma

This is my approach to the reception of the peri-arrest trauma patient. It is a short post with some useful links included and has a short whiteboard video laying out the distribution of staff around the resus room.

Enjoy

Pathophysiology

  • Hypovolaemia
  • Obstructive
  • Hypoxia
  • Neurogenic
  • Commotio cordis
  • Incidental
    • Electrocution
    • Medical arrest
    • Hypothermia

Outcome

  • Traditionally seen as dismal
  • In fact, overall survival is better than medical arrest
  • In some series children do significantly better than adults (in contrast to medical arrest)
  • Survival can be hard to estimate from the literature and it is important to distinguish between ROSC, survival to hospital discharge and neurologically intact (or at least acceptable) survival.
  • Studies also vary greatly in their selection criteria. Patients in arrest on EMS arrival do differently from those who arrest on the way to hospital, on arrival at hospital or in the ED or theatre.
  • Optimistic figures are about 50% ROSC and 5% neurologically intact survival. [1-4]
  • Predictors of survival are also hard to tease out. Children do better in some series, perhaps because of stronger protoplasm. It is interesting that children do worse in medical cardiac arrests. In the medical cardiac arrest it is usually thought that kids do worse because the arrest is the end result of a long chain of insults rather than a single reversible cause (shock and hypoxia gradually leading to cerebro-circulatory collapse vs single vessel coronary occlusion in adults); probably paediatric survivors of traumatic cardiac arrest have arrested due to a single hyperacute and reversible insult (e.g. tension pneumothorax)

From whom is it reasonable to withhold resuscitation?

Poisition statement from 10 years ago from the American National Association of EMS Physicians and the American College of Surgeons Comittee on Trauma available here.

In summary:

  • Blunt trauma with apnoea, no pulse, no organised ECG on EMS arrival;
  • Penetrating trauma with apnoea, no pulse, no “signs of life” (meaning spontaneous movement, organised ECG or pupil reaction) on EMS arrival
  • Patients cut in half,  with no head or with decomposition in process
  • 15 minutes of resus without success or patients more than 15 minutes from hospital
  • Special consideration given to situations like lightning strike, electrocution, drowning, hypothermia etc

The problem is that a lot of surviviors of traumatic cardiac arrest (13/14 in Seattle, 3/4 in Victoria, 13/36 in London HEMS) breach these guidelines with the “15 minute rules” the most problematic.[2, 3, 5].

Who can be expected to do “well”?

Mechanism of injury

Traditional teaching is that blunt trauma all do poorly and that penetrating trauma cases do better. In fact, the data can be examined in more detail. Stab wounds do best (especially single stab wounds), blunt trauma comes next, handguns are next and rifles/high velocity weapons do worst.

Based on Pathophysiology

Medical cardiac arrest occuring during trauma (the coronary artery disease patient who has an AMI and arrest with the stress of trauma) do well

Commotio cordis 15 % survival and 25% if resus intitiated within 3 minutes

Asphyxia (isolated laryngeal injury, conflagration, high spinal injury)

Obstructive (tension pneumothorax or massive haemothorax due to isolated chest injury)

Cardiac tamponade (only if thoractomy performed promptly after arrest)

Electrocution

Physical signs

ECG >40/min, sinus rhythm, pulse or respiratory effort at some stage after EMA arrival, GCS >3, RTS >0, ISS <25

Who can be expected to do badly?

Isolated head injuries with cardiac arrest all die.

Hypovolameic traumatic cardiac arrests all die except for anectodes and case reports.

Practical approach to traumatic cardiac arrest

Aggressive approach seems justified

  • Consider medical cause if trauma seems minimal
  • A
    • Intubate early
      • Doubles the period of tolerated CPR
  • B
    • HYPERVENTILATION KILLS
      • You only need to oxygenate the patient
      • Remember that PPV drops venous return dramatically in the hypovolaemic patient.
    • Bilateral thoracostomies are probably highest yield procedures
  • C
    • CPR remains the standard of care but has much less to offer than in medical arrest
    • Stop bleeding
    • Pressure, splint limbs, staple scalp, bind pelvis
    • Fluid resuscitation (blood as early as possible) is likely to be valuable
    • Remember permissive hypotension if ROSC is acheived
  • Clam shell or left anterior thoracotomy
    • Some high volume centres use pericardiocentesis however most authorities recommend thoracotmy. Evidence is lacking to settle the argument. In the low volume centre where this is a once or twice a career experience it will come down to the comfort level and skill set of the operator.
    • Wondering how to do it? See this poster from the American College of Surgeons

A short (5 minutes) white-board video here outlines the way I like to arrange my team for reception of a peri-arrest trauma patient.

References

1. Leis, C.C., et al., Traumatic cardiac arrest: should advanced life support be initiated? The Journal Of Trauma And Acute Care Surgery, 2013. 74(2): p. 634-638.

2. Lockey, D., K. Crewdson, and G. Davies, Traumatic cardiac arrest: who are the survivors? Ann Emerg Med, 2006. 48(3): p. 240-4.

3. Pickens, J.J., M.K. Copass, and E.M. Bulger, Trauma patients receiving CPR: predictors of survival. J Trauma, 2005. 58(5): p. 951-8.

4. Jeschke, M.G., D.N. Herndon, and R.E. Barrow, Long-term outcomes of burned children after in-hospital cardiac arrest. Crit Care Med, 2000. 28(2): p. 517-20.

5. Willis, C.D., et al., Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile. Injury, 2006. 37(5): p. 448-54.

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