The management of a traumatic cardiac arrest is undoubtably stressful. Practices varies from centre to centre and clinician to clinician. A lot of attention in Emergency Medicine is now being paid to cognitive readiness. If a critical decision on how you are going to act can be made before the event this significantly reduces the stress and errors made in such a situation.
The ERC 2015 guidelines that were published yesterday may go someway towards easing that burden and unifying practice. The algorithm of traumatic cardiac arrest (TCA) is below and it’s worth knowing them back to front. The documents highlights the fact that TCA carries a high mortality but when a ROSC can be achieved survivors are more likely to have good neurological outcomes.
So it’s probably worth taking each part of the guideline and considering exactly what it means.
Firstly when the patient arrives and there has been a history of trauma you need to consider whether this is a primary traumatic arrest or whether a medical event has led to secondary trauma. The patient that collapses at the wheel of the car travelling 30 mph with chest pain that then hits their head and chest on the steering wheel and has a VF arrest, is incredibly unlikely to benefit from the treatment suggested in the traumatic arrest algorithm and their outcome is much more likely to benefit from good ALS.
Once you’ve determined that this is a primary traumatic cardiac arrest then the emphasis is on correcting the reversible causes as quickly as possible. This takes priority over chest compressions (the topic of external cardiac compressions ever having a place in trauma is a controversial topic on it’s own but we’ll just stick with the guideline for now), so chest compressions should wait until efforts have focussed and addressed the reversible causes (cardiac compressions aren’t likely to work in cardiac arrest secondary to hypovolaemia, cardiac tamponade or tension pneumothorax.
- Endotracheal intubation if possible
- Relieve tension pneumothoraces with finger thoracotomies in the 4th intercostal space (a chest drain need not be inserted until after the resuscitation phase is complete if positive pressure ventilation is taking place)
- Thoracotomy for penetrating or blunt trauma to the epigastrium or chest with less than 10 minutes of prehospital CPR by joining the 2 thoracostomies and opening the chest as a clamshell. Thoracotomy must have the 4 following prerequisites, expertise, equipment, appropriate environment and elapsed time (less than 10 minutes)
- Compress external haemorrhage with direct pressure, tourniquets and haemostats dressings as required
- Pelvic splints, blood products (in a ratio PRBC’s, FFP and platelets of 1:1:1) (or crystalloid if none available to restore a radial pulse)
- Rapid surgical control of the bleeding
- Tranexamic acid (TXA) 1g loading (1g infusion over 8 hours)
So at this point having provided the interventions the guideline leads on to performing CPR, looking for a ROSC and then considering termination of CPR if no response.
ERC suggests termination of resuscitation in TCA if;
- No signs of life within the preceding 15 minutes
- Massve trauma incompatible with survival (e.g decapitation)
and although written slightly ambiguously probably both
- No response to the revisable causes and cardiac standstill on ultrasound
Having an algorithmic approach helps everyone have a clear idea of the priorities in the event. This is especially important if you work at a centre that receives infrequent traumatic arrests.
In Summary if you have a cardiac arrest due to trauma
- Secure an ET tube and ventilate
- Bilateral finger thoracostomies (no need for a drain in arrest)
- Thoracotomy if indicated (less than 10 minutes in arrest)
- Splint the pelvis and control external haemorrhage
- Infuse blood products and get TXA on board
- Get the patient to the destination they require ASAP
Arrange the team to complete these tasks swiftly and simulateously. Obviously treatment can be tailored to specific cases but if you can keep these 5 actions in the back of your mind as the actions required in a TCA you’ll be well prepared for the next case you see.