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Traumatic Cardiac Arrest

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Traumatic Cardiac Arrest Traumatic Cardiac Arrest INTRODUCTION Arrested on arrival at the scene: Traumatic cardiac arrest is a very different condition ● resuscitation can be stopped in blunt traumatic from the more usual cardiac arrest which is often cardiac arrest when the patient is apnoeic, related to ischaemic heart disease. Management of pulseless, without organised cardiac electrical traumatic cardiac arrest must be directed toward activity and without pupillary light reflexes on identifying and treating the underlying cause of the arrival and where there has been no change after arrest or resuscitation is unlikely to be successful. five minutes of cardio-pulmonary resuscitation with full resuscitative effort Traumatic cardiac arrest may develop as a result of: ● in penetrating traumatic cardiac arrest, 1. Hypoxia caused by manageable issues such as resuscitation should be continued for 20 minutes obstruction of the airway (e.g. facial injury or while transferring rapidly to hospital. If a patient decreased level of consciousness) or breathing has not responded after 20 minutes of Advanced problems (e.g. pneumo/haemothorax). Life Support (ALS) (refer to advanced life support 2. Hypoperfusion caused by compromise of the heart guideline) then resuscitation can be terminated. (e.g. stab wound causing cardiac tamponade) or hypovolaemia (either occult or revealed haemorrhage). & Arrhythmias Arrest Cardiac Arrested in the presence of Emergency Medical Services (EMS): MANAGEMENT: ● termination of resuscitative effort in the patient who Ventricular fibrillation/ventricular tachycardia (VF/VT) has suffered a trauma related cardiac arrest (blunt may be present, although this is unlikely. However, if or penetrating) in the presence of the EMS crew present it should be managed by defibrillation should be considered if the patient has not according to the standard shockable rhythm algorithm responded to 20 minutes of ALS. (refer to advanced life support guideline) and If no cause amenable to treatment is found by followed by treatment of any identified potential cause. following the above interventions and circulation is not The potential causes should be addressed by applying restored, then survival is not possible and further standard trauma management principles (refer to intervention is medically inappropriate.1-9 The only trauma emergencies guideline). Any problem should exceptions to this are pregnancy (when the patient be dealt with adequately before moving on to the next: should be rapidly transferred to hospital to deliver the infant), in the presence of hypothermia and with A – Airway obstruction; ensure the airway is open trauma involving children. In this case the JRCALC and clear. guideline on paediatric cardiac arrest should be B – Impaired breathing; search for and manage a followed and the patient transported rapidly to a sucking chest or a tension pneumothorax (refer to hospital Emergency Department. thoracic trauma guideline). If not absolutely certain After stopping resuscitation, the Recognition of Life then needle thoracocentesis should be performed on Extinct by Ambulance Clinicians (ROLE) (refer to both sides. Support and assist ventilation. ROLE guideline) procedure should be followed and C – Hypovolaemia as a result of major blood loss; the Police informed (See also Appendix 1). apply external haemorrhage control and secure vascular access while transferring without delay to definitive treatment. D – Major head injury (refer to head trauma guideline) or spinal cord injury (refer to neck and back trauma guideline) impairing ventilation through CNS depression or loss of neuromuscular function. The international literature and published evidenced- based guidelines over the last five years are quite clear: Cardiac Arrest and Arrhythmias October 2006 Page 1 of 3 Traumatic Cardiac Arrest 6 Key Points –Traumatic Cardiac Arrest Pasquale M, Rhodes M, Cipolle M, Hanley T, Wasser T. Defining “dead on arrival”: impact on a level I Cardiac Arrest & Arrhythmias Arrest Cardiac ● Traumatic cardiac arrest is different from trauma center. J Trauma 1996;41((4):726-30. cardiac arrest due to primary cardiac disease. 7 Fulton R, Voigt W, Hilakos A. Confusion surrounding ● Assessment and management should follow the treatment of traumatic cardiac arrest. J Am Coll the trauma guideline, treating problems as they Surg 1995 181(3):209-14. are found. ● If the patient is in blunt traumatic cardiac arrest 8 Battistella FD, Nugent W, Owings JT, Anderson JT. on crew arrival and there is no change after 5 Field Triage of the Pulseless Trauma Patient. Arch minutes of full resuscitation, further effort is Surg 1999;134(7):742-746. futile. 9 Pickens JJ, Copass MK, Bulger EM. Trauma ● If the patient suffers a traumatic cardiac arrest Patients Receiving CPR: Predictors of Survival. from penetrating trauma or arrests in the Journal of Trauma-Injury Infection & Critical Care presence of the crew and there is no response 2005;58(5):951-958. to resuscitation after 20 minutes of active resuscitation while moving to hospital, further effort is futile. METHODOLOGY ● The ROLE procedure should be followed if resuscitation is terminated. Refer to methodology section. REFERENCES 1 Powell DW, Moore EE, Cothren CC, Ciesla DJ, Burch JM, Moore JB, et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring pre-hospital cardio- pulmonary resuscitation? Journal of the American College of Surgeons 2004;199(2):211-215. 2 Hopson LR, Hirsh E, Delgado J, Domeier RM, McSwain JNE, Krohmer J. Guidelines for withholding or termination of resuscitation in pre-hospital traumatic cardio-pulmonary arrest: joint position statement of the national association of EMS physicians and the american college of surgeons committee on trauma. Journal of the American College of Surgeons 2003;196(1):106-112. 3 Martin SK, Shatney CH, Sherck JP, Ho C-C, Homan SJ, Neff J. Blunt Trauma Patients with Prehospital Pulseless Electrical Activity (PEA): Poor Ending Assured. Journal of Trauma-Injury Infection & Critical Care 2002; 53(5):876-881. 4 Rosemurgy A, Norris P, Olson S, Hurst J, Albrink M. Prehospital traumatic cardiac arrest: the cost of futility. J Trauma 1993;35(3):468-73. 5 Pepe PE, Swor RA, Ornato JP, Racht EM, Blanton DM, Griswell JK, et al. Resuscitation In The Out-Of- Hospital Setting: Medical Futility Criteria For On-Scene Pronouncement Of Death. Prehospital Emergency Care 2001 5(5):79 – 87 Page 2 of 3 October 2006 Cardiac Arrest and Arrhythmias Traumatic Cardiac Arrest Appendix 1 – Traumatic Cardiac Arrest Ensure airway is open and clear – Look for signs of life CPR 30:2 – Until defibrillator/monitor attached Assess rhythm Shockable Non-shockable (VF/ pulseless VT) (PEA/asystole) 1 shock 150-360 Joules or 360 Joules monophasic Immediately resume Immediately resume & Arrhythmias Arrest Cardiac CPR 30:2 CPR 30:2 For 2 mins For 2 mins Transfer to hospital rapidly Address treatable causes (continue ALS) Airway obstruction Impaired breathing Major injury to head, Hypovolaemia Ensure the airway Search for and manage neck, back May impair Apply external is open and clear – a sucking chest or ventilation because of haemorrhage control if necessary with tension pneumothorax CNS depression/loss Secure vascular adjuncts e.g. LMA/ET if not absolutely certain of neuro-muscular access en-route undertake needle function – therefore thoracocentesis improve ventilation Arrested on arrival at scene? Arrested in the presence of EMS? Blunt Traumatic Cardiac Arrest IF on arrival the patient is aponoeic, pulseless, with no organised cardiac electrical activity and no pupillary light reflexes AND where there has been no change after FIVE minutes of ALS, resuscitative efforts may cease Penetrating Traumatic Cardiac Arrest Blunt or Penetrating Traumatic Cardiac Arrest Rapidly transfer patients to hospital performing Rapidly transfer patients to hospital performing ALS. IF there has been no change after TWENTY ALS. IF there has been no change after minutes of ALS, resuscitative efforts may cease TWENTY minutes of ALS, resuscitative efforts may cease EXCEPTIONS Pregnant women, patients suffering from hypothermia and children – continue resuscitative effects and transfer to hospital rapidly. ROLE After ceasing resuscitation follow the recognition of life extinct protocol. Cardiac Arrest and Arrhythmias October 2006 Page 3 of 3.
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