Algorithm for traumatic cardiac arrest

tension

While traditional teaching is that resuscitation on scene in traumatic cardiac arrest is futile, recent studies have demonstrated higher survival rates than previously thought.

The authors (UK emergency medicine and aeromedical specialists) of this paper have reviewed the literature regarding traumatic cardiac arrest and generated an algorithm that is applicable to both pre-hospital and hospital settings.

“The algorithm aims to rapidly identify and correct reversible causes of TCA. Transport of TCA patients from the pre-hospital to hospital setting with on-going cardiopulmonary resuscitation is usually futile and key interventions need to be performed as soon as possible, usually on-scene. Patients arriving at a hospital in traumatic peri- or cardiac arrest need reversible causes immediately excluded and managed prior to transfer for diagnostic imaging or surgical intervention. The treatment priorities in this algorithm have been applied by a physician-led pre-hospital trauma service to over a thousand TCA’s attended over an eighteen year period. Published results demonstrate that adherence to these principles can result in good survival rates from TCA.”

The algorithm focuses on treatment of reversible pathology that may have led to an arrest:

  • Correction of hypovolaemia
  • Oxygenation
  • Decompression of tension pneumothorax
  • Thoracotomy in the setting of penetrating chest/epigastric trauma
  • Consideration of non-traumatic causes of cardiac arrest

Full text pdf of this paper is available here (secure area limited to ADHB staff only – ADHB has online subscription access to this journal via the Philson Library at the University of Auckland School of Medicine)

Pre-hospital thoracotomy in the Journal of Trauma

Recently Scott put up a post on this topic and given it’s infrequent occurrence, we don’t mean to spend lots of time but this editorial/article came up so I couldn’t resist mentioning it once more (plus, let’s be serious emergency thoracotomies are pretty awesome especially given they can be life-saving).

I’m not sure how I feel about the idea of pre-hospital thoracotomy (followed by helicopter transport), especially given the often dismal outcomes and the potential for considerable harm. Nevermind the fact that once you performed the procedure, you then have to pack up the patient who has an open chest and get them via helicopter to the ED (wow…).  I have to say I’m not particularly in favor of it, but willing to look at the evidence, which this article presents. The authors review the literature and summarize that among those with penetrating trauma (a key distinction), that there’s a survival rate of 11%. Looking at this superficially, that means that there’s a bunch of people that were actually dead who were subsequently saved. What we don’t know is much about the potential for harm (e.g needlestick injuries to healthcare provides, prolonged ICU stays without benefit). In summary, the authors cite the successes from London HEMS and they are clear supporters of this procedure but correctly address the minimal role in blunt trauma. Furthermore they suggest that additional research is needed…realistically, probably hard to gather much more than case series unfortunately. I won’t hold my breath for a large randomized trial in the New England Journal.

An editorial critique follows the article by Dr. Ken Mattox (the world renowed surgeon from Houston of permissive hypotension fame). In looking at both sides he uses the Altemeier axiom “sometimes a solution to a problem creates 4 times as many problems” and I think that definitely could be applied to this procedure. However, he doesn’t exclude the possibility that pre-hospital thoracotomies might have a role in the correct circumstances. He mentions the following overriding principles that would have to be applied

  • Protocol overseen by established trauma program and approved by IRB
  • Adequate training and appropriate instruments and equipment
  • Ability to have communication with the trauma center and trauma surgeon in case of any “surprises”
  • All cases must be carefully reviewed by the trauma program for quality assurance

So while it remains controversial, there’s some new discussion among the leaders in trauma resuscitation about pre-hospital thoracotomy. As Scott, has pointed out that it unlikely has much role in Auckland, its definitely interesting to see what’s being discussed.

Source: Roberton and Bulstrode,  Emergency department thoracotomies: Is it time we took them to the field? J Trauma vol 73 (no 5): 1070.

Full text pdf is available here (secure area limited to ADHB staff only – ADHB has subscription access for staff to these journals through the Philson Library at the University of Auckland School Of Medicine)