Treatment of traumatic arrest

[chbare]

Actually, no solid evidence points to any medication being particularly effective. Unless, you have a case of early or near arrest with a known and correctable cause such as hyperkalemia.

Take care,

chbare.

[Dustdevil]

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".

It seems we are discussing the broad concept of trauma resuscitation here. What I thought the OP was talking about was very specifically haemorrhagic arrest, such as from an arterial bleed, without other life threatening trauma. There is a big difference between the multi-system trauma patient who is bleeding, and a patient who has simply bled out from an isolated wound.

[itxtme]

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.

Thanks for the thorough reply ERdoc; I completely agree with the realities of traumatic arrest and what skills are realistically required to decrease mortality rates. My statement in regards to Diazepam618 was disappointment with the age old attitude that I hear see and live through (at my own service) with traumatic arrest, in that its futile so don’t bother!

Studies like this one provide insight into possible changes we could/need to make internationally in the prehospital environment if we want to get serious about improving decreasing mortality rates. Interesting what you are saying about ACLS drugs and lack of proven efficacy in traumatic arrests – this is one thing I certainly wasn’t aware of!

[Ridryder 911]

Studies like this one provide insight into possible changes we could/need to make internationally in the prehospital environment if we want to get serious about improving decreasing mortality rates. Interesting what you are saying about ACLS drugs and lack of proven efficacy in traumatic arrests – this is one thing I certainly wasn’t aware of!

Most traumatic arrests (multi trauma) are not worked for a reason. They have very poor outcome as evidence based of survivalbility. I know of very few EMS that even have traumatic arrest protocols unless the cessation occured during after treatment had started, even then many have other measures to cease resuscitative efforts. If you are surprised by the lack of efficacy of medication therapy in trauma, then of course you should not be alarmed as the resuts and poor effects in non-trauma patients too.

Most traumatic arrests are decleared dead upon arrival and no resuscitation is attempted for a reason, as most have learned it is a futile attempt.

[HERBIE1]

I worked in a Level 1 Trauma center for 15 years. When I first started, "cracking chests" upon arrival was the thing to do. The trauma center heyday was in full swing, and hospitals were just starting to realize how much money trauma centers cost to operate- staff, equipment, salaries, ancillary staff- not to mention the fact that most of these patients were indigent or underinsured. In the countless cases I saw, I can count on one hand how many were successful, and those were because the person crashed as they hit the ER doors. Because of the poor outcomes, in most cases, the policy has since gone by the wayside. There has to be a darn good reason to do a crash thoracotomy- as in an arrest witnessed by the surgeon.

Massive, multiorgan trauma that results in an arrest is essentially a death sentence- there is a reason why most places do NOT work these patients. In these cases- as opposed to a medical arrest, the dead stay dead. Resources and money need to be saved for someone that has a real chance of survival.

[cynical_as_hell]

Most traumatic arrests (multi trauma) are not worked for a reason. They have very poor outcome as evidence based of survivalbility. I know of very few EMS that even have traumatic arrest protocols unless the cessation occured during after treatment had started, even then many have other measures to cease resuscitative efforts. If you are surprised by the lack of efficacy of medication therapy in trauma, then of course you should not be alarmed as the resuts and poor effects in non-trauma patients too.

Most traumatic arrests are decleared dead upon arrival and no resuscitation is attempted for a reason, as most have learned it is a futile attempt.

I agree with you. There are reasons why we don't do some things. But now I have a question for you, and anyone else that wants to dig in....Everybody already knows that the chance of survival from trauma related injuries(severe) are extremely low...but my question is this:

Are the chances of survival for a multi systems trauma patient any higher or lower than that of a blunt force trauma patient?? Now this question is asked under the assumption that the trauma the patient suffered is what caused them to go into arrest in the first place.

[Doczilla]

We have to know what we're talking about here. "Trauma arrest" comes in many flavors, and whether or not you work it, and what interventions are applied, need to be decided based on a host of factors. Blunt or penetrating trauma? Is the bleeding controllable/controlled? Did the patient possibly arrest *before* they wrecked the car? What is the relative state of health of the victim? How far are we from someone that can do a thoracotomy? How long until extrication? When did they arrest? Prior to EMS arrival or after? Is there a potentially reversible cause like tension pneumothorax, airway compromise, or volume depletion that I can fix in the field?

I can't agree with the statement that putting ACLS drugs in them will just make them bleed faster. Like ERDoc said, I'll take the heart that is pumping blood (out) over the one that isn't pumping. We know how the latter one works out. ACLS is a lot about maintaining hemodynamic parameters such as preload and afterload, and so it has a role in trauma management.

I think there are many trauma arrests that should be worked, but obviously not all of them. I don't think a blanket answer of "yes" or "no" fits all traumas, as there are clearly ones that will benefit from care. The key thing is capturing those who will. We have some of those answers, but even the trauma physicians are trying to figure out which patients will benefit.

'zilla