Downloaded from http://emj.bmj.com/ on June 25, 2016 - Published by group.bmj.com Review Challenging the dogma of traumatic cardiac arrest management: a military perspective J E Smith,1,2 S Le Clerc,1,3 P A F Hunt1,3
▸ Additional material is ABSTRACT addition, we used the keywords ‘military’ and published online only. To view Attempts to resuscitate patients in traumatic cardiac ‘combat’ to refine the search. Reference lists of rele- please visit the journal online (http://dx.doi:10.1136/ arrest (TCA) have, in the past, been viewed as futile. vant papers were hand-searched to identify further emermed-2015-204684). However, reported outcomes from TCA in the past evidence. Guidelines on cardiac arrest management five years, particularly from military series, are improving. from the UK and European Resuscitation Councils 1Academic Department of Military Emergency Medicine, The pathophysiology of TCA is different to medical were included in the review. Most evidence is in Royal Centre for Defence causes of cardiac arrest, and therefore, treatment the form of observational studies and case series Medicine (Research & priorities may also need to be different. This article (levels II and III), which limits the robustness of the Academia), Birmingham, UK reviews recent literature describing the pathophysiology evidence supporting some of the observations 2Emergency Department, Derriford Hospital, Plymouth, of TCA and describes how the military has challenged made in this paper. Some of the evidence comes UK the assumption that outcome is universally poor in these from military experience, and this should be borne 3Emergency Department, patients. in mind when considering external validity. James Cook University Hospital, Middlesbrough, UK Survival following TCA Correspondence to INTRODUCTION Survival from TCA has previously been considered Professor Jason E Smith, Attempts to resuscitate patients in traumatic cardiac extremely poor. The European Resuscitation Academic Department of arrest (TCA) have, in the past, been viewed as Guidelines from 2010 included a review of 18 arti- Military Emergency Medicine, futile. In our experience, patients in TCA are an Royal Centre for Defence cles with a total of 3032 patients presenting with Medicine, Institute of Research emotive source of anxiety and stress for resuscita- TCA following blunt trauma, of whom 94 (3.1%) and Development, Vincent tion teams, rivalled only by patients with severe survived, and 1136 patients with TCA following Drive, Birmingham B15 2SQ, burns, and critically ill and injured children. penetrating trauma, of whom 37 (3.3%) survived.4 UK; [email protected] Recent military operational experience has However, more recently, there have been several Received 23 January 2015 resulted in large numbers of patients with TCA reports of higher survival rates in various series, par- Revised 11 June 2015 being delivered to deployed resuscitation facilities. ticularly from the military. In a prospective study of Accepted 28 September 2015 The frequency and volume of such casualties has 52 adult casualties (mean age of 25 years) suffering Published Online First led to significant improvements in their manage- fi 22 October 2015 TCA presenting to a military eld hospital in ment. While some of these evolving management Afghanistan, Tarmey et al5 recorded a rate of return fi strategies currently lack de nitive evidence, the of spontaneous circulation (ROSC) of 27%, with 8% production of such evidence is ongoing. surviving to discharge. Of the survivors, all achieved Historically, and despite a paucity of clear evidence a good neurological recovery. The principal mechan- to date, it is clear from our experience in the mili- ism of injury was noted to be blast from improvised fi tary that a signi cant proportion of patients explosive device with exsanguination as the most deemed to be in TCA by personnel at scene are in common cause of cardiac arrest. In another paper fact in a critically low cardiac output state (LCOS) describing military outcomes, Russell et al2 found rather than true cardiac arrest. This distinction is that 18 of 78 (24%) patients with TCA survived. The extremely important as patients in an LCOS could remarkable survival in this group was put down to be salvageable if offered aggressive, timely and the advanced resuscitation strategies employed by the appropriate treatment. As recently as 2006, it was UK military, and in particular, the ability to effect- thought that patients with TCA secondary to hypo- ively stop and treat catastrophic haemorrhage follow- 1 volaemia were not salvageable, but recent military ing combat trauma. In another paper looking 2 experience has proven this to be overly pessimistic. specifically at 65 patients with TCA who underwent The experience of clinicians in some civilian resuscitative thoracotomy, Morrisson et al6 describe trauma systems is also challenging the previously ROSC in 33 patients (51%) and survival in 14 held belief that cardiopulmonary resuscitation patients (21%), with survival in 11 of 26 patients 3 (CPR) is a futile intervention in TCA. who underwent thoracotomy in the emergency This article attempts to share the accumulating department (ED). A further detailed analysis of all evidence on the pathophysiology of TCA, the inter- patients with TCA included on the UK Joint Theatre ventions that can work and those that do not, and Trauma Registry is underway. the military experience of managing TCA, to Recent civilian data have also shown an improve- enable others to provide a pragmatic and targeted ment in survival following TCA. Leis et al7 reported approach in this important group of patients. an ROSC of 49% in 167 patients with TCA, similar to the rates quoted above. There was an eventual survival METHODS rate of 6.6% with intact neurology, which was higher To cite: Smith JE, Le We searched the MEDLINE database, using the (9.4%) when the responding ambulance included a Clerc S, Hunt PAF. Emerg Ovid Interface, using the terms ‘traumatic cardiac physician. Another study from Australia of 89 – Med J 2015;32:955 960. arrest’ and ‘traumatic arrest’ as keywords. In patients with TCA reported a survival rate of 4.5%.3
Smith JE, et al. Emerg Med J 2015;32:955–960. doi:10.1136/emermed-2015-204684 955 Downloaded from http://emj.bmj.com/ on June 25, 2016 - Published by group.bmj.com Review
Novel concepts in TCA management In practice, some patients who present with TCA have devas- Patients with TCA have different pathophysiological processes tating neurological injury. In this group of patients, no interven- to those suffering cardiac arrest from medical causes. Three tion will reverse the primary neurological injury, and therefore, algorithms have been described recently, all highlighting the TCA in this group is also irreversible. – difference between medical and TCA management.8 10 Patients suffering cardiac arrest due to medical conditions will Reversible causes of TCA usually have a full circulating volume, and therefore, the stand- Some causes of cardiac arrest are potentially reversible as ard elements of resuscitation such as external chest compres- described in traditional resuscitation guidelines as the ‘the 4Hs sions (ECCs) can restore a proportion of normal cardiac and 4Ts’.15 Those specific to TCA are hypoxia, hypovolaemia, output. In contrast, the majority of patients with reversible tension pneumothorax and cardiac tamponade. These patho- TCA will have either critical hypovolaemia, tension pneumo- logical processes are potentially amenable to aggressive early thorax or cardiac tamponade, the physiology of which cannot treatment. be reversed by delivering CPR alone; in the absence of cardiac injury, it is likely that the heart is healthy, but the circulation is Control of haemorrhage and fluid resuscitation the issue that needs to be addressed. The concept of a critic- Given the likelihood of a LCOS state in TCA, initial resuscita- ally low-flow state is one that has been demonstrated in the tion measures should focus on aggressive control of haemor- military trauma context.5 Although a central pulse may not rhage, and addressing hypovolaemia and hypoxia. Although a palpable, organised cardiac electrical activity (described as detailed review of these measures is beyond the scope of this pulseless electrical activity (PEA)) may still be present. In these paper, current standard of care includes pressure dressings, instances, the ventricles demonstrate appropriate hyperdy- novel haemostatic agents and/or tourniquets to control bleeding. namic contractility but appear underfilled when viewed with Mitigation of non-compressible haemorrhage can be initiated ultrasound.11 This reversible cause may, therefore, be targeted with pelvic binder placement for blunt trauma patients where by aggressive resuscitation. suspicion of injury is high, and long bone traction for identified Distinguishing between cardiac mechanical ‘standstill’ and a fractures. Hypovolaemia is addressed with rapid volume replace- critically LCOS is a key factor when considering the platinum ment using blood products in order to maximise oxygen- 10 minutes, often described as the window when interventions carrying capacity, circulating volume and treatment of will determine the survivability or otherwise of a trauma trauma-induced coagulopathy. The use of crystalloids can patient.12 According to the European Resuscitation Guidelines, exacerbate traumatic coagulopathy and should be avoided unless the diagnosis of TCA is a clinical one in trauma victims present- there is no alternative and emergency transport is prolonged.4 ing unresponsive, apnoeic and pulseless, with or without orga- Obtaining large vessel circulatory access is paramount in nised (electrocardiographic) cardiac activity. If the concept that order to facilitate rapid infusion of blood products. However, if LCOS exists is accepted, it becomes extremely difficult to ascer- there is a delay in obtaining venous access, rapid infusion can tain the start point of true cardiac arrest (although ultrasound still be achieved through an intraosseous needle.16 As resistance can guide this, as described below). The distinction also needs to flow is higher, an appropriate infusion system is required to to be made between TCA and commotio cordis,13 or medical deliver blood products; this could involve a three-way tap and causes of cardiac arrest that may lead to secondary trauma, in 50 mL syringe in the circuit with which to draw and infuse which case standard ALS care, including CPR, may be appropri- through the intraosseous needle system. Although concern ate.4 The challenge for the trauma team is to rapidly determine regarding the potential for haemolysis has been raised,17 there is which of the trauma victims arriving in suspected TCA still have no scientific evidence to suggest this is a limitation.18 residual cardiac output with a potentially reversible cause, and Military practice includes routine near-patient testing for therefore, could benefit from aggressive resuscitation. haemoglobin, [Ca2+], blood gas analysis and rotational thom- One potential method is to visualise the rate and quality of boelastometry (ROTEM) as a guide to administration of blood myocardial contractility and cardiac filling using ultrasound. In products including PRC, FFP, platelets and cryoprecipitate in a military trauma teams, a consultant radiologist will usually be bespoke, targeted fashion.19 This approach has been supported available to provide this, although all senior emergency physi- by evidence from a civilian study of patients requiring more cians in the UK are now trained in the ultrasound skills neces- than five units of red blood cells in a 24 h period.20 However, a sary to assess cardiac motion, detect free fluid in the abdomen, recent Cochrane systematic review failed to find convincing evi- pericardial effusion and pneumothoraces. dence in support of the use of ROTEM for trauma-induced coa- gulopathy and called for further research before it is instituted into routine clinical practice.21 Irreversible causes of TCA Typically, the causes of TCA are divided into those deemed Airway potentially reversible and those that are not. Examples of cases As in medical cardiac arrest, intubation improves oxygen deliv- where patients are identified by the Joint Royal Colleges ery to the tissues and should be performed early. There is some Ambulance Liaison Committee ( JRCALC) as irreversible and animal evidence that permissive hypoventilation can optimise where resuscitation should not be attempted include massive venous return.22 cranial and cerebral destruction; hemicorporectomy; massive truncal injury incompatible with life, including decapitation; Drugs in TCA decomposition or putrefaction; incineration; hypostatis (blood It is currently accepted practice that during the management of pooling) and rigor mortis. medical cardiac arrest intravenous adrenaline is administered in Additionally, according to guidance from the JRCALC, resus- accordance with ALS guidelines. It is believed that this supports citation is deemed futile when there has been asystole >15 min an increase in venous return by increasing systemic vascular without bystander CPR or submersion for >1 h in adults, or resistance, and consequently, improves cardiac output; however, 1.5 h for children.14 there is limited evidence for the efficacy of any drugs during
956 Smith JE, et al. Emerg Med J 2015;32:955–960. doi:10.1136/emermed-2015-204684 Downloaded from http://emj.bmj.com/ on June 25, 2016 - Published by group.bmj.com Review cardiac arrests of medical cause. A recent randomised control is under investigation as a potential option in the management trial has questioned the role of adrenaline; although associated of patients with TCA.32 with increased incidence of ROSC, there was no improvement in survival to hospital discharge.23 In the TCA patient, adren- Tension pneumothorax aline may adversely affect cerebral microvascular flow, worsen- Ongoing intrapleural accumulation of air from a bronchopleural ing cerebral ischaemia in an already severely acidaemic and leak, open pneumothorax or injudicious positive airway pressure maximally vasoconstricted victim. The role of other vasopres- will lead to a rise in intrathoracic pressure. If untreated, this will sors in TCA is unclear, with a limited evidence base involving eventually lead to mediastinal shift and reduced venous return, mainly case reports. However, results from a prospective cohort resulting in obstructive shock and subsequent cardiac arrest. study of patients in severe haemorrhagic shock suggest that Spontaneously breathing patients may tolerate tension pneumo- early vasopressors may worsen outcome and result in an 80% thorax for some time before becoming critically compromised higher risk of mortality.24 by the lack of venous return, leading to a sudden loss of cardiac Drugs that may be indicated in TCA include tranexamic acid output. Unlike medical cardiac arrest, chest compressions are for those with life-threatening haemorrhage25 and administra- unlikely to be of benefit and efforts should instead be focused tion of parenteral calcium to offset the effects of citrate in on proactive decompression of the tension pneumothorax by – stored blood for those receiving massive transfusion.26 27 bilateral open thoracostomies.33 35 Conventional needle thora- cocentesis techniques are prone to failure due to mechanical obstruction or kinking, not reaching the pleural space effectively The role of resuscitative thoracotomy or causing iatrogenic injury.36 37 Open thoracostomies are A meta-analysis of 42 outcome studies including 7035 emer- effective in allowing complete lung re-expansion and much gency department thoracotomies (EDTs) demonstrated an quicker to perform than tube thoracostomies. overall survival rate of 7.8%, of which 15% survived with some degree of neurological deficit.28 The outcome following EDT in Cardiac tamponade blunt trauma victims with witnessed TCA is poor, with an esti- Cardiac tamponade is more common in penetrating trauma, par- mated survival rate of 1.6%. The survival rate is highest, esti- ticularly secondary to knife-related cardiac wounds, although it mated as 31%, following penetrating cardiac injuries with a can occur following blunt trauma. Compression of the heart by short on-scene and transport time, witnessed signs of life or blood building up within the pericardial sac leads to a rise in ECG activity.28 diastolic pressure, impairing cardiac filling with a resultant fall However, resuscitative thoracotomy should not be seen as in stroke volume and consequently cardiac output. The use of purely a last-ditch resort in those who are destined to die6 and ECCs in this group of patients will be ineffective as the under- should be considered in all those presenting in TCA. Similarly, lying physiological process is obstructive, and attempts to mech- the time-critical 10 min window from point of witnessed anically compress the heart will fail to restore stroke volume or cardiac arrest to thoracotomy29 is likely to be challenged when cardiac output. There is no evidence of benefit from needle current evidence is reviewed and the concept of LCOS gathers pericardiocentesis, and it may cause myocardial injury and delay wider acceptance. other more effective therapeutic measures.4 The treatment of In the military population, the role of resuscitative thoracot- choice is immediate surgical release of tamponade via omy was questioned in one early series,30 but there are later thoracotomy. descriptions of successful resuscitation following thoracotomy by the same authors,56who conclude that resuscitative thora- External chest compressions: a waste of energy? cotomy following combat injury will yield survivors. Best out- It is well recognised that early and effective ECCs with minimal comes are in patients who arrest in the ED or on admission to interruptions improve outcomes in patients suffering medical the hospital.6 cardiac arrest. ECCs are less likely to be effective in hypovol- As a body cavity access technique, the practice of thoracot- aemic TCA compared with cardiac arrest from other causes, omy is arguably relatively straightforward and can be performed although the only evidence to guide practice is from a small with commonly available, non-specialist equipment in any clin- animal study, which showed no haemodynamic benefit in per- ical setting as demonstrated by numerous prehospital helicopter forming ECC.38 emergency medical services (HEMS) systems operating around In patients with normovolaemic cardiac arrest, ECC has been the world. However, the key to successful resuscitation is in the shown to deliver around one-third of normal blood flow to the subsequent identification and control of bleeding, where pos- brain, although this relies on adequate venous return.39 In a crit- sible. As part of a protocolised TCA approach, existing incisions ically hypovolaemic patient, it will be much lower. The authors, for bilateral thoracostomies can be extended anteriorly to the therefore, recommend withholding ECC in a patient with clear midline and slightly posteriorly in a clamshell approach.31 This signs of hypovolaemic TCA, certainly while more urgent inter- technique allows clinicians to gain access to the pericardium, ventions are carried out, and until adequate circulating volume myocardium, lungs and great vessels. The primary indication for has been restored. However, due to the complex nature of EDT in the management of TCA is to relieve cardiac tampon- severe injuries and often multiple factors leading to TCA, com- ade, but it will also facilitate interventions aimed at controlling pressions should not be considered as a futile measure in all bleeding from the heart, lungs or great vessels. This can be cases.34 achieved in a variety of methods including direct pressure, haemostatic compounds, sutures or surgical clips. Thoracotomy Ultrasound also enables cross-clamping of the descending aorta or simply Emergency ultrasonography is a proven investigation in trauma direct pressure applied posteriorly against the vertebrae in order resuscitation and is a sensitive test for pericardial tamponade.40 to control ongoing haemorrhage below the diaphragm. Other important findings, such as haemoperitoneum and hae- Resuscitative endovascular balloon occlusion of the aorta mothorax or pneumothorax, can also be diagnosed reliably with achieves a similar mechanical effect to aortic cross clamping and ultrasound, and it has been shown to reduce time to definitive
Smith JE, et al. Emerg Med J 2015;32:955–960. doi:10.1136/emermed-2015-204684 957 Downloaded from http://emj.bmj.com/ on June 25, 2016 - Published by group.bmj.com Review surgery in trauma patients.41 As a portable bedside technique, it able to function effectively with a shared understanding of key can be integrated unobtrusively into TCA protocols. Prehospital objectives, enabling safe, rapid and decisive treatment within the ultrasound includes simple thoracic ultrasound and focused first few seconds and minutes of the patient’s arrival. This is assessment with sonography in trauma.10 Two of the authors developed during individual and team training in a simulated (PAFH and SLC) have practical experience of using prehospital environment at a whole hospital exercise42 and the Military ultrasound successfully and safely in both military and civilian Operational Surgical Training course.43 helicopter-based primary retrieval systems, with good image There are few differences between military and civilian quality and utility for assessment; aiding interventions such as trauma teams, but some key features should be highlighted. In central venous access and regional anaesthesia. addition to an airway clinician and assistant, the team includes another senior clinician standing by in order to obtain rapid The military approach central venous access; the preferred site being the right sub- The military approach begins with the training of resuscitation clavian vein using a large bore (usually 8.5F gauge) trauma line. teams (box 1). Military resuscitation teams discuss TCA in detail Other personnel are specifically tasked to manage the rapid and rehearse decision-making, team-working and individual infusion devices (one device on each side of the patient) to skills in a simulated environment well in advance of providing facilitate rapid transfusion of blood products. Within the mili- trauma care on operations. Criteria for patients in whom we tary system, pre-alerts are reliably passed from prehospital will perform chest compressions or administer adrenaline to (it medical platforms to the receiving facility so that units of is possible that neither may be indicated in TCA) are agreed in packed red blood cells and thawed plasma are prepared, advance by consensus within clear, defined operating proce- checked and ready for immediate transfusion. The rapid infu- dures. From a human factors perspective, the team is, therefore, sion devices are run through with crystalloid solution so that they are ready to be used. A consultant radiologist is part of the trauma team and provides rapid diagnostic information with ultrasound, offering the benefit of early visualisation of the Box 1 The military approach heart in order to guide subsequent targeted treatment if required, such as the release of cardiac tamponade at thoracotomy. 1. Protocols: traumatic cardiac arrest (TCA) protocols are developed to create shared understanding of approaches. 2. Teams: teams rehearse regularly, focusing on trauma team Post-resuscitation care management in a ‘real-life’ resuscitation setting with full Once ROSC has been achieved, access to definitive surgical multidisciplinary involvement, including senior representation haemorrhage control is key to optimising outcome. Military from: experience has emphasised the benefit of having a functional ▸ Emergency department personnel operating theatre adjacent to the resuscitation room. However, ▸ Anaesthesia and critical care physical proximity is only part of the solution—the ▸ Surgical teams with general, orthopaedic, mindset also needs to be right. Trauma team leaders should rec- cardiothoracic and vascular capability ognise when to transfer the patient rapidly to an operating ▸ Radiology theatre or even to move directly there on arrival—a process 3. Initial management:
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Challenging the dogma of traumatic cardiac arrest management: a military perspective
J E Smith, S Le Clerc and P A F Hunt
Emerg Med J 2015 32: 955-960 originally published online October 22, 2015 doi: 10.1136/emermed-2015-204684
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