Treatment of traumatic arrest

[jwraider]

Hello,

I'm wondering what your thoughts might be on this subject. The reason I've started this discussion is I am a new medic and I've now had two very strong opposing opinions given to me by those who are more experienced.

(For arguments sake we are talking about patients who are not being pronounced for whatever reason or due to protocol)

When dealing with a traumatic arrest you want to focus on treating the underlying cause if possible. For example fixing a pneumo or airway obstruction. There are a bunch of airway breathing problems we can fix. We can also stop bleeding and replace volume.

Where my two mentors disagreed was in the treatment of a hemorrhagic patient. One person says "ACLS drugs are just going to make him bleed faster" while the other says "treat with ACLS anyway". These are blanket statements of course.

So what do you do? Are there situations where you withold ACLS (let's say NSR / PEA with a ton of blood loss) ?

My opinion is blanket statements like these suck and special care must be given to these situations. So I'm curious what everyone's line of thinking is they use to make their treatment decisions.

Thanks!

[AnthonyM83]

I have not heard of evidence promoting the idea of withholding ACLS drugs to minimize hemorrhage. Doesn't mean it's not a possibility.

I do, though, wonder if that mentor based his stance on evidence, personal theory, or if he was taught that by a 'reliable' source. Did he tell you more on the theory? Does EPI/ATR decrease clotting factors? Something along those lines? Is it a vasoconstriction issue? If one is so volume depleted that they went into cardiac arrest, I'm guessing the vasoconstriction is going to help fix the container/volume ratio more than it's going to cause further bleeding from increasing vascular pressure (that's just conjecture).

[Diazepam618]

If it's traumatic why bother, there is a possibility that so much is going on within the body that you are a waisting your time without the use of hospital equipment, but if you must try to work it go with ACLS just to cover your ass, less liability that way your medical director will thank you.

[jwraider]

Anthony he was actually in conversation with the fire medic and they both agreed with each other. The idea being the faster you send the blood around the system the faster it spills out the hole(s).

[AnthonyM83]

Anthony he was actually in conversation with the fire medic and they both agreed with each other. The idea being the faster you send the blood around the system the faster it spills out the hole(s).

Which drugs send the blood around faster, though? The blood's already hardly circulating...perfect CPR only gives 1/3 of cardiac output.

[itxtme]

Where my two mentors disagreed was in the treatment of a hemorrhagic patient. One person says "ACLS drugs are just going to make him bleed faster" while the other says "treat with ACLS anyway". These are blanket statements of course.

So what do you do? Are there situations where you withold ACLS (let's say NSR / PEA with a ton of blood loss) ?

Your reversible causes for cardiac arrest include hypovalemia which is what the apperent problem is here. I have no idea why your mentor would think giving Adrenaline will lead to increased bleeding!? PEA is a loss of mechanical movement of the heart adrenaline looks to increase this to sustain a pulse. Yes given a pulse will lead to increased blood loss, however no pulse will lead to death....

Furthermore consider the pharmacokinetics of adrenaline. When given IV adrenaline has notiable effects on Beta and Alpha receptors. Specifically you want the effects of the ALpha receptor in regards to Systemic Vasoconstriction leading to "shunting" of blood back to the core of the body!

Once you have pulses it is a different story/ consideration and continued fluid resus and chrono/ino trophic drugs..

If it's traumatic why bother, there is a possibility that so much is going on within the body that you are a waisting your time without the use of hospital equipment, but if you must try to work it go with ACLS just to cover your ass, less liability that way your medical director will thank you.

I feel sorry for people living in your area. I suggest you do some further research on current Traumatic Arrest literature, you may be very suprised at people that may have lived if you had a different attitude..

Have a look at "Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest." a 2007 article

[ERDoc]

itxtme, thank you for posting a well thought out post which included a journal reference (-5 though for, "I feel sorry for people living in your area."). I agree with you on one of your points. Which is the least of all evils, a heart that is pumping blood out of the body or a heart that isn't pumping at all? Without any scientific evidence to back it up, I'll take the pumping heart. Lost volume can be replaced and we can control the bleeding in many cases. Let's take a look at the article that you sited:

Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest.

Huber-Wagner S, Lefering R, Qvick M, Kay MV, Paffrath T, Mutschler W, Kanz KG; Working Group on Polytrauma of the German Trauma Society (DGU).

Klinikum der Universität München, Chirurgische Klinik und Poliklinik, Campus Innenstadt, Nussbaumstrasse 20, D-80336 München, Germany. stefan.huber@med.uni-muenchen.de

BACKGROUND: Resuscitation of traumatic cardiorespiratory arrest patients (TCRA) is generally associated with poor outcome, however some authors report survival rates of more than 10% in blunt trauma patients. The purpose of this investigation was to determine predictive factors for mortality in trauma patients having received external chest compressions (ECC). PATIENTS AND METHODS: Twenty thousand eight hundred and fifteen patients from the Trauma Registry of the German Trauma Society were analysed (mean ISS=24.0). Inclusion criteria were ISS>/=16 and available information on ECC either on-scene and/or during trauma room treatment. Included into the Trauma Registry were only patients with ECC and transportation into a hospital. Patients declared dead on-scene without transportation to a hospital were not recorded in the data base. A Logistic regression was performed to find out predictive factors for mortality. RESULTS: Ten thousand three hundred and fifty nine patients fulfilled the inclusion criteria. N=757 patients received ECC, 415 prehospital, 538 during trauma room (TR) treatment and 196 prehospital and in-hospital. Blunt trauma occurred in 93.2%, mean age was 40.3 and median ISS was 41.0. 23.2% of the patients were treated with a chest tube, 5.7% had a tension pneumothorax and 10.2% underwent emergency thoracotomy. The overall survival rate was 17.2%. 9.7% of the TCRA patients with ECC achieved good recovery or moderate disability (Glasgow outcome scale>/=4). Logistic regression showed thromboplastin time lower than 50% to be the strongest predictor for non-survival (OR 5.2, 95% CI 2.3-11.9), followed by massive blood transfusion of more than 10 units of packed red blood cells (OR 4.8, 95% CI 2.0-11.5), on-scene blood pressure of 0 (OR 4.3, 95% CI 1.6-11.3), age over 55 (OR 2.9, 95% CI 1.1-7.3), base excess lower than -8 (OR 2.7, 95% CI 1.2-5.9). The insertion of a chest tube on-scene could be detected as a factor significantly increasing the probability of survival (OR 0.3, 95% CI 0.13-0.8). CONCLUSIONS: Prehospital chest tube insertion was found to be a strong predictor for survival. On-scene chest decompression of TCRA patients is recommended in case of the decision to start with ECC. Based on our data, resuscitation after severe trauma seems to be more justified than the current guidelines state.

I have a few issues with this article (I will admit to reading only the above abstract). "Patients declared dead on-scene without transportation to a hospital were not recorded in the data base." I think this leads to a selection bias and skews the results. Was CPR attempted on these pts? If so they should have been included in the study. I realize that the authors are working with the databse they have available but it leaves out a potentially large and important population that should have been included in the study.

They have 415 people who suffered from TCRA in the prehospital setting. Did these people have a pulse/BP upon EMS arrival and then arrest during transport? If so they should be accounted for differently than people who were found to be in TCRA upon EMS arrival. I would hypothesize that if you compare the survival rates of these two groups you would see a much higher survival rate in the people who arrested in the ambulance versus the people who arrest prior to EMS arrival.

Here is another article from Annals in 2006:

Traumatic cardiac arrest: who are the survivors?

Lockey D, Crewdson K, Davies G.

London Helicopter Emergency Medical Service, Royal London Hospital, London, United Kingdom. djlockey@hotmail.com

STUDY OBJECTIVE: Survival from traumatic cardiac arrest is poor, and some consider resuscitation of this patient group futile. This study identified survival rates and characteristics of the survivors in a physician-led out-of-hospital trauma service. The results are discussed in relation to recent resuscitation guidelines. METHODS: A 10-year retrospective database review was conducted to identify trauma patients receiving out-of-hospital cardiopulmonary resuscitation. The primary outcome measure was survival to hospital discharge. RESULTS: Nine hundred nine patients had out-of-hospital cardiopulmonary resuscitation. Sixty-eight (7.5% [95% confidence interval 5.8% to 9.2%]) patients survived to hospital discharge. Six patients had isolated head injuries and 6 had cervical spine trauma. Eight underwent on-scene thoracotomy for penetrating chest trauma. Six patients recovered after decompression of tension pneumothorax. Thirty patients sustained asphyxial or hypoxic insults. Eleven patients appeared to have had "medical" cardiac arrests that occurred before and was usually the cause of their trauma. One patient survived hypovolemic cardiac arrest. Thirteen survivors breached recently published guidelines. CONCLUSION: The survival rates described are poor but comparable with (or better than) published survival rates for out-of-hospital cardiac arrest of any cause. Patients who arrest after hypoxic insults and those who undergo out-of-hospital thoracotomy after penetrating trauma have a higher chance of survival. Patients with hypovolemia as the primary cause of arrest rarely survive. Adherence to recently published guidelines may result in withholding resuscitation in a small number of patients who have a chance of survival.

It looks encouraging, but let's break it down a little. These were pts that were cared for by physicians in the field who were able to perform chest tubes and thoracotomies. In your (meaning all of the EMS providers on the site) practice, how often is this resource available to you? I think very few are able to have a doc come to their scene and crack a chest so this particular article is not relevant to your current practice. Again, this article does not discuss the differences in outcomes for pts who were in TCRA prior to EMS arrival versus those who arrested during transport.

As for the OP's question of ACLS for a traumatic arrest, keep in mind that ACLS guidelines are developed based on research involving medical cardiac arrests. They do not study traumatic arrests so it is impossible to say that the ACLS guidelines are appropriate/inappropriate in a trauatic arrest. However, we have nothing else to go on, so they are probably your best bet.

[fiznat]

The AHA has a section on this in their most recent (2006) guidelines. This is the same place we get our ACLS algorithms from.

Part 10.7: Cardiac Arrest Associated With Trauma

Edited May 18, 2009 by fiznat

[Kaisu]

You guys totally rock! This is the sort of information I was looking for in an earlier thread. I have downloaded and saved these files and intend to print them out and share them with my colleagues. Thank you for posting.

[jwraider]

Anthony - Duh right? If the heart isn't beating giving Epi isn't going to make it beat faster. Some peripheral vasoconstriction could be a good thing too. Thanks that was the point that was missing. In the case we were discussing the PTs blood was left on scene and nothing we could have done would have helped.

Blood replacement hopefully is in the future because that is the fix that is needed.

Fiznat - Nice article thank you. The one part that is specific to my question says Epi is not effective but it does not say contraindicated.