Would You Work This Code?

[Kaisu]

I would not work this code. The bystander stated that he had a pulse - but I have PEA. I don't know that I believe there was a pulse. Traumatic arrest is traumatic arrest. We can't fix it.

[MedicRN]

But why waste the resources on someone who will obviously not survive (or is not meant to survive)? At that moment, your skills/resources could be needed across town for someone who will survive - but only if you are available with intact resources.

I frequently work with patients who are 'survivers' of some massive blunt force multisystem trauma accident. In order for them to 'continue' in life, they now breath through a hole in their neck, 'eat' baby formula through a tube in their stomach wall, pee and poop like babies, have open sores on their butts because of peeing and pooping like babies, are dependent on others to clean their pee and poop, to put Desitin on their open sores caused by the pee and poop and must have the the drool wiped off their chin. And this is the result of someone giving them a 'fighting chance.' Some injuries are meant to be survived.

Remember, a bed sore killed Superman (Christopher Reeves).

[bigj1130]

While I agree with p3medic that he has a massive blunt traumatic injury, and in my system that is an indication to field pronounce off-line, there are still some considerations.

PEA- rate? first responders say they had pulses. We all know this is not always reliable and maybe they were feeling their own pulse. However, I would be wrong to not suspect a pulse if the rate that was "felt" was awfully close to the PEA.

Other tools to determine a ROSC- Was ETCO2 available? More often ETCO2 is a better indicator of return of perfusion than a palpable pulse. A perfusing body is not a dead body. While you may not be able to feel a pulse, if there is a spike in ETCO2 with that PEA, you might well feel pulses soon enough.

H's and T's- while this is a blunt traumatic injury is this patient in arrest due to an H or T? If so Early intervention and aggressive treatment can make a difference. A tamponade or tension pneumo or hypoxia perhaps?

Protocol- From a system standpoint, It might be a standing order to transport a cardiac arrest or traumatic arrest in public to the closest appropriate facility. If we, as a system can not obstruct the view of the public or if it is an obvious crime scene with obvious signs of death then we have to transport. It is also possible that this system doesn't pronounce blunt traumatic arrest in the field at all.

Confidence of the provider- While we all like to think that every medic out there is competent and confident, maybe this provider wasn't confident in what he or she was seeing or finding is his/her assessment in relation to the patients injuries. It is possible that a mistake was made and he/she could not put the pieces of the puzzle together. High speed collision with minimal exterior trauma but in arrest? The possibility of second guessing oneself could be pretty high in a provier that hasn't seen this before or doesn't see it often enough. It might be feasible to think that this s a MEDICAL arrest and the trauma happened because of the medical event. Based on the description of the call that is highly unlikely but I don't know I wasn't there.

So to answer the question based on the information I have in the post and my protocols and guidelines, Yes I would work the Arrest, Especially without 100% certainty of the presence of a pulse.

If I had my little toys with me, ETCO2 etc. and I don't have a good reading or waveform and the PEA is a confirmed PEA after assessment and a quick r/o of H's and T's, I still think I would work the Arrest even with such a low success rate.

[fiznat]

I'm sorry, but how can anyone justify not working this code? "Traumatic arrest" does not equal "we can't do anything about it." Not in the least! Unless this patient had "injuries incompatible with life" (like decapitation, transection, ejection of brain matter, etc) which it doesn't sound like he did, this patient needs an ED assessment and potentially an OR. It isn't up to us to decide what can and cannot be done for this person when he gets to the hospital.

[tniuqs]

In my opinion I feel that we should not have worked this code

Heres My Opinion .... FAIL just based on the pithy information provided.

Call this man dead without FAR better documentation that you have provided here and your going to be talking with a medical director and a lawyer right quick IMHO. With electrical activity documented recorded on ECG one could be between a rock and a hard spot in a court, if one is a Basic and calling the shots you would most likely be looking for a job in food services.

ps when in doubt WORK IT, besides you can't hurt a dead man.

This report and request for support for your opinion may be just self serving and second guessing the lead medic is ill advised for any longevity in this industry.

On the monitor the patient shows a rhythm of what I'm told is PEA.

Told ? Did you look and also stated was return of pulse on scene was that with CPR or without CPR Did you personally check pulses ?

Asystole is DOA and confirmed in 2 leads and OBVIOUS signs of death like decapitation, gravity dependent lividity and rigor mortus.

Jeepluv77: Makes a good discussion and if one takes the time to review Hippocrates perspective on head injuries, I believe her personal anecdotal experience it is quite clear that premature "judgment" is not always correct .. and most pleased to hear of the positive outcome.

http://classics.mit.edu/Hippocrates/headinjur.html

but if there's obvious signs of death, who are we trying to fool???

Hindsight is always 100 % when the outcome is past history.

The fool is YOU because you have provided no clear criteria on signs of death.

Please review Criteria of Death Harvard ad Hoc committee and Croakers comments.

Unfortunately without a much more detailed description, evaluation of chest, abdo, or possibility of long bone fractures, position found, down time, any reflexes, lividity, rigor, time of day or night, smell of ETOH, PMHX, weather conditions, response times, ALS or BLS availability, transport times to ER, level of care in recieving facility .. ie Neuro on consult ? and Dusts comment .. how many patients ?

OR even what has been done for the patient ... ie intubated ? IVs ? Volume infused, any meds given ... was this PEA was it a Tachy or Brady ?

Hey man ... all these are serious mitigating factors and should be included in any scenario before asking for support for ones opinion.

Further Shredding.

The only visible injuries to this patient are some lacerations to his head, but only one of the being deep enough to see the skull.

How do you know ... did you actually palpate, again without xray vision your just "guessing" if this was a possible open or closed head injury.

When we arrived on scene and I looked at the patient his eyes were already fixed and staring off to the side.

Eyes deviated are not a sign's of devastating head injury, actually quite diagnostic they could be an indication of sub dural.

When you say fixed, again did you evaluate, no where did you state unresponsive to light either consensual or direct.

Seriously:

If I were your Supervisor and I saw this on line ... it would be a very hard Dinozzo HEADSLAP !

cheers

Edited May 14, 2009 by tniuqs

[tskstorm]

I just have one comment, I've always been taught, If the death is questionable enough for you to put the monitor on its good enough to be worked, because obviously you had doubts on whether or not the patient was dead to begin with.

I don't see any reason to not work this code, especially being as CPR was in progress.

[zzyzx]

"I'm sorry, but how can anyone justify not working this code? "Traumatic arrest" does not equal "we can't do anything about it." Not in the least! Unless this patient had "injuries incompatible with life" (like decapitation, transection, ejection of brain matter, etc) which it doesn't sound like he did, this patient needs an ED assessment and potentially an OR. It isn't up to us to decide what can and cannot be done for this person when he gets to the hospital."

I'd have to respectfully disagree. It is up to us to decide. We all know that if he is a traumatic full arrest, he has just a tiny slither of a 1% chance of surviving, esp. since it's blunt, not penetrating trauma. Obviously you have to follow your local protocols, which in my case would mean picking up my cell phone and talking to my base hospital. What good will an ED assessment do? Are we ambulance drivers too stupid to figure out that he's dead? Of course, if he still has agonal breaths or if you're not sure if he has a pulse or not, then yes, work him up.

[croaker260]

Are we ambulance drivers too stupid to figure out that he's dead?

The question is better phrased, Are we ambulance drivers too stupid to determine between DEAD and REALLY DEAD? Because after this thread I am begining to wonder.

PEA is DEAD, but not REALLY DEAD AND GONE.

Remember that PEA is just as likely a LOW FLOW STATE as it is TRUE PULSELESSNESS in a trauma situation...The Concept of the H's and T's, while sometimes over simplified and over used, was created and designed for PEA. Especially PEA in trauma.

I work in a very progressive service, with very involved medical directors, and very seasoned and experianced medics, and we run a fair number of calls, and I can assure you that while we all recognize that this patient has a SLIM chance, he is a working code at my service. Again, 99.9% of the time, this is a WORKING CODE. And not a "we ran a round of EPI and called it good" code ..BUT A WORKING BALLS OUT CODE.

Bilateral Decompressions, ETT, Pericardial Tap, central lines with 2 liters or more, tons of EPI, and other drugs PRN.

WHo ever said that traumatic arrest equals automatic death? WHere?

Now, traumatic arrest isnt a reason to FLy, I agree.

And Traumatic arrest has a very poor survival , I agree.

But Traumatic arrest is not hopeless. Traumatic arrest refractory to interventions in the field likely is, but not traumatic arrest on the front end. Not as it is described here.

I am unaware of any ..ANY research that says that you find a fresh patient in traumatic arrest (without injuries incompatable with life) and you do basically nothing.

Some of you mentioned ETCO2, very good thought process, but this involves working the code to get to that point. Some of you mentioned decompression..again, this invovles working the code.

Now, TRANSPORT is a debatable topic depending onlocal factors...but thats not what we are talking here..we are talking working this patient on the front end of the call.

SOme of you mentioned using your heads to make educated descisions..I couldnt agree more. It seems in this case some of us are using our heads to find a reason to walk away, a reason NOT to treat, a reason to minimize and ignore the patient.....never a good thought process in our buisness...and we are not using our heads and efforts to find a correctable cause (wich involves working the code).

Edited May 14, 2009 by croaker260

[HERBIE1]

In my system- he would be worked- no question. The injuries listed were a deep skull lac, and he obviously had a bleed with the deviated gaze. That is NOT massive trauma. PEA is certainly dead, but depending on your system protocols and transport time, he should be worked. Would he stay dead- undoubtedly, but a closed head injury is not what I would consider enough trauma to justify withholding efforts.

Since bystanders said he had a pulse,(allegedly), go through the motions. Just because CPR was started however, does NOT mean it cannot be stopped- call medical control and explain the situation. I've seen CPR being performed on people with rigor so severe they rocked with each compression. I've also seen CPR performed on someone who was already beginning to decompose. Does that mean you cannot stop CPR under those circumstances?

Again, depending on local protocols, I know some systems do NOT work a traumatic arrest who is asystolic(considering the futility of these situations, it makes sense to me)- regardless of the severity of their injuries. With a PEA, I would say that goes into a grey area and again- I'd work 'em unless told otherwise.

[croaker260]

Again, depending on local protocols, I know some systems do NOT work a traumatic arrest who is asystolic(considering the futility of these situations, it makes sense to me)- regardless of the severity of their injuries.

Just want to make the point that although any pulsless rythm is bad news......PEA is not asytole. No where close.