Its 01:00 and the resus emergency bell rings out across the department. On your arrival you find a young male in cardiac arrest and nursing staff have initiated Basic Life Support (BLS). His friends have brought him to the Emergency Department (ED) after he was stabbed twice in the chest 5 minutes ago, following an altercation in a nearby street.
You are the ED clinician allocated to resus and now the clinician who will to lead this Traumatic Cardiac Arrest (TCA).
The International Liaison committee on Resuscitation (ILCOR) produced an international guideline on how to manage a TCA by production of an algorithm similar to that used in ‘traditional’ resuscitation (figure 1), this algorithm is not dissimilar to the standard Advanced Life Support (ALS) algorithm but pushed the leader into early decision making around advanced interventions such as thoracostomies or indeed resuscitative thoracotomy (ILCOR 2010).
Figure 1 – Traumatic cardiac arrest algorithm. Available at: https://www.resus.org.uk/resuscitation-guidelines/prehospital-resuscitation/
TCA is different to the more common cardiac causes of cardiac arrest. The heart is often healthy with the primary cause for arrest due to hypoxia, hypovolaemia, obstructive shock, or a combination of these factors (Sherren et al 2013).
It is important to have a pre-planned and thought-out strategy to how you may lead this arrest in your department, as it is recognised that traditional methods may make a bad situation worse for the patient in front of you. For example, in a study by Irfan et al (2017) patients in Out of Hospital Traumatic Cardiac Arrest (OHTCA) who received adrenaline were demonstrated to have worse outcomes.
TCA’s remain challenging for many reasons, not least relating to the lack of a true consensus on the management of these patients.
There is however some common agreement around certain interventions which is summarised below (Barnard et al 2017, Smith et al 2015, Sherren et al 2013 + Lockey et al 2013).
Haemorrhage control by early use of blood and blood products in patients suffering haemorrhage; and compression of external and internal haemorrhage.
- Get large bore vascular access (IV or IO).
- Use blood rather than crystalliod where haemorrhage is the likely cause.
- Compress external haemorrhage with novel haemostatics and/or tourniquets.
- Splint fractured long bones to reduce further haemorrhage.
Decompress chest bilaterally when any suspicion of pneumothorax/haemothorax is present.
- In TCA, this should be done with finger/tubed thoracostomies rather than by needle decompression.
- Needle decompression can be useful in decompressing tension pneumothorax and is skill which can be utilised by most clinicians working in emergency medicine with a regularly carried 14-gauge cannula. However, this can fail to decompress due to increased muscle tissue and the 14-gauge needle not being long enough to reach the pleura. Additionally, it can easily kink and lead to re-tensioning of the pneumothorax.
- Finger thoracostomy is the first stage of an standard open chest drain insertion, by making a hole with a scalpel and forceps and placing a finger into the thorax to feel for lung. This will allow release of any air or blood causing pneumo/haemothorax. This also avoids the times delays of inserting a chest drain, which may in turn kink or become blocked. The added benefit is the thoracostomy can be ‘re-fingered’ in the case of repeated tension (Lockey et al 2013).
Airway and ventilation management to prevent secondary Traumatic Brain Injury (TBI)
- Early Intubation and control of oxygenation and ventilation to allow normocapnia and normoxia.
- The benefits of early advanced airway include adequate oxygenation of the TCA patient where 44% have arrested due to asphyxia, controlled positive pressure ventilation with control over minute and tidal volumes to avoid tension pneumothorax and also improve venous return to already shocked circulation.
- There are concerns over hyper-oxygenation however, (especially surrounding ischemic reperfusion injury and mortality) so it is advised to control oxygen and aim for saturation of 94-98% in the patient with Return of Spontaneous Circulation (ROSC).
Appropriate thoracotomy within 5-10 minutes of loss of output
- Immediate or within 10 mins of loss of output if there is penetrating injury to chest/epigastrium (Sherren et all 2013).
- The reported survival rates from UK military TCA patients demonstrated an improved mortality rate from 9% to 21% (Barnard et al 2017).
- This is not currently recommended in blunt traumatic injuries and it is thought to be unlikely to improve outcome.
- Performance of this procedure in the emergency department cannot be expected address all possible cardiothoracic pathology’s causing TCA and access to trauma surgical/cardiothoracic teams should be available as soon as possible after the procedure.
- The immediate availability of blood and blood products may improve outcome after this procedure, but there is yet to be sufficient literature around this (Lockey et all 2013).
Another area which has yet to reach a consensus is around chest compressions in those patient in TCA. The current thinking suggests immediate BLS/ALS should be commenced at least where a clear history is not immediately available to the clinicians. In patients with profound hypovolaemia they are likely to be of benefit and should not prevent other reversible causes being implemented.
It should however be remembered that the correction of the underlying cause of the arrest should receive primacy. Many of the interventions to correct the potential causes involve invasive procedures in and around the thorax. Performing these with ongoing chest compressions has the potential to make performing these even more challenging and also increase the risk of sharps injury to all clinicians involved.
The aforementioned studies looking at TCA management all talk of having a bespoke algorithm or treatment bundle that you add in these cases.
By adapting this algorithm to your specific patient, this is likely to give the opportunity to address
As a clinician it is important to have thought in advance about how you will manage these cases, so you have a plan in your head of the how you may brief your team, allocate your roles differently, treatment priorities and what you will do if you get a successful ROSC.
In true social media style, follow #TCAnotFUTILE for more links to this fascinating subject.
Some other FOAMed resources worth checking out:
Barnard. E, Yates. D, Edwards. A, Fragoso-Iniguez. M, Jenks. T, Smith. J. Epidemiology and aetiology of traumatic cardiac arrest in England and Wales- Retrospective database analysis. Resuscitaiton; 110: 90-94.
Irfan. F. B, Consunji. R, El-Menyar. A, George. P, Peralta.R, Al-Thani. H, Thomas. S.H, Alinier. G, Shuaib. A, Al-Suwaidi. G, Singh.R, Castren. M, Cameron. P. A, Djarv. T. Cardiopulmonary resuscitation of out-of-hospital traumatic cardiac arrest in Qatar. International Journal of Cardiology; 240: 438-443.
Lockey DJ, Lyon RM, Davies GE. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation 2013;84:738–42.
- Soar, G.D. Perkins, G. Abbas, A. Alfonzo, A. Barelli, J.J.L.M. Bierens, et al., European Resuscitation Council guidelines for resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation; 81(10): 1400–1433.
Sherren PB, Reid C, Habig K, Burns BJ. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care 2013;17:308.