EMCrit Podcast 36 – Traumatic Arrest

Thanks to a suggestion from Melanie, this week I am discussing the management of traumatic arrest. Many things to do in these patients, but two things you definitely should not be doing are closed-chest CPR or giving ACLS medications. We discuss who gets a thoracotomy, what to do if a thoracotomy is not indicated, and when to stop.

Here is a great review article:

Hunt PA, Greaves I, Owens WA.  Emergency thoracotomy in thoracic trauma-a review. Injury. 2006 Jan;37(1):1-19.

This is one of the figures from the text. I think it is a great algorithm to determine who gets a thoracotomy:

From Hunt et al. Injury 2006;37:1

Update: This article lends further support that all patients should have tension pneumo excluded (Resus 2007;75:276)

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Comments

  1. Amazing Lecture. Thanks so much!

  2. Mark Albert says:

    No such thing as a silly question from a pharmacist, right? pre-hospital Trauma Cardiac Arrest still ACLS??? among other things obviously you can not do for tamponade in that setting? i guess PHTLS courses cover these. Tension Pnemorthorax yes a medic can do something, anyhow learn so much, although i will never do it but hope one day to work in settings were i can respond on Trauma and help prepare meds to free up the nurses, etc

  3. Scott Weingart, M.D. composes cutting edge Podcasts in Emergency Critical Care. A must listen for all those in the field.

  4. Paul Dupuis says:

    Scott
    love the show…FULL of pearls.i was wondering what your thoughts are on the necessity of the “finger sweep” with the finger thoracostomy. You won’t be placing a chest tube through any adherent lung (if that came about due to resus. success, then sure). A nice wide spread with the Kelley’s should decompress…….what and no risk of self injury. What are your thoughts??

    • if blood pours out or this is a burst of air, sure you’re done. If not, I don’t conclude that chest is clean unless i have my gloved finger in there with a rib touching the top of my finger and a rib touching the bottom of my finger and the tip of my finger touching lung. Been burned too many times by what residents stated was negative and when I stuck my finger in, I poked through the parietal pleura and blood came spurting. Sometimes the parietal pleura gets pushed in rather than lacerated when jammed with the kelly.

  5. Kristina says:

    Very well written. Great lecture! =) Keep them coming.

  6. Jason Cillo says:

    Good topic. I’ve seen various approaches to this problem. Trying to access the article, is the link broken?

  7. Thanks for the shout out mate
    Brilliant podcast as ever, keep up the fantastic work

  8. Dr. Weingart,

    I have a question from the EMS side. If we were to transport a patient with blunt/penetrating trauma who initially has vital signs, and proceeds to lose them en route, is it realistic to not do closed chest compressions and just call the code? Thanks for any info you can provide.

    • Excellent question. In the bus, unless you are doing prehospital thoracotomies : ), you do what you can. So closed-chest CPR and a dose of epi is fine. Give them some volume and have a low threshold for empiric needle decompression of the involved chest sides.

  9. Ram Reddy says:

    Scott,

    Great stuff as usual. Don’t know what it’s like in New York, but I”m buried in snow up here. Hopefully you’ve dug yourselves out or have not been hit as hard.

    Okay, Thoracotomy. I have thought a lot about this and i think there needs to be a paradigm shift in thinking about this procedure and utility of it. Personlly I think as an ER doctor this is ONLY worth doing if 1) there is a penetrating injury to the HEART causing tamponade and loss of vitals en route or in front of you. 2) you have the ability to go on pump (CPB) relatively soon, within 30 minutes. Doing it for anything else i believe is useless. Also doing it in a remote location without CVT backup is questionable. Forget X clamping the aorta distal to the head vessel take offs. Forget clamping the hila. It’s all wasted energy. The only save you will get is opening a pericardium and putting a finger in a hole somewhere in the heart and having a CVT surgeon get to them relatively fast.
    Secondly if one believes my axiom, then a left anterolateral thoracotomy(LAT) is the incorrect approach and one should be doing a median sternotomy. This sounds radical but I don’t think it is as crazy as one thinks. splitting the sternum is the only real way to access all areas of the heart once the pericardium is open. If the hole is in the RA or near LA (or pulmonary veins) it will be extremely difficult to access those areas from the left, so even if you get the pericardium opened and relieve the tamponade, the patient will still exanguinate. both pleura can also be opened from the medial side to access each of the lungs. the LAT approach, in addition to providing inadequate exposure, destroys the LITA in the process, which may be recquired if a coronary is bagged. This approch also invites injury to the phrenic as you slice the pericardium.

    So you have opened the pericardium and relieved the tamponade. Now what.? you have your finger there. Well the patient needs to go to the OR and essentially go on bypass. The heart needs to be arrested and inspected. The penetrating wound needs to be closed while the heart is not moving and also the coronaries, aorta and lungs need to be inspected as well as the possbility of any valvular injury needs to be ruled out with TEE in the OR. So trying to do this procedure in bumblefuck nowhere is questionable.

    I think this idea of putting a stich in a beating heart is retarded as you can easily occlude or lacerate a coronary. and if the hole is in the atria, you will rip the atria to shreds by attempting to sew it while it is moving and kill the patient faster. digital pressure is enough.

    Just my two cents but i would love to hear any comments regarding my thoughts.

    Ram

    • Hopefully you can hear my response through your headphones. I have asked Ram to come on the podcast so we can discuss the above and more.

  10. Jonathan Burns says:

    Fantastic lecture Scott,

    I’m really looking forward to the procedure based podcast/videocast.

    I think Ram brings up some great comments, though. In my community shop with only gen surg back up, and the nearest facility with bypass 45 minutes away, the only indication for me to open someone up is a stab wound with risk of tamponade. So I agree, although a well placed Foley may buy some time for penetrating cardiac trauma.

    I still say a LAT is the easiest and FASTEST way to get in, though. The phrenic is usually well visualized, and if there were a need for further visualization, converting a LAT to a clamshell is much easier than starting with a median sternotomy (althought that would be pretty cool. . .). My $0.02.

  11. ram reddy says:

    couple modifications to the points above. putting a purse string suture for hemostasis is not retarded, if you are a surgeon. If you aren’t then i believe a finger will have to suffice. Once in the OR CPB would likely not be the initial step. Hemostasis can be accomplished with the heart moving. Once that is achieved TEE would be necessary for Valvular assesment . IF injury then CPB would have to be initiated. Similarly if there is Coronary Artery injury, CPB would likely be necessary. CPB is not essential to achive hemostasis but needs to be available if further injury. If there are multiple gunshots all over the place that would preclude heparinzation for CPB then an incompetent valve might have to exist until later, if hemodynamics permit.

  12. Dr Weingart, great podcast!

    Across the pond, the first thoracotomy I saw was a LAT, the first one I did was a clamshell. I have to admit the LAT was very difficult to visualize and/or do anything with, whereas the clamshell provided a fantastic view, chest was open relatively quickly (two operators, one on either side meeting in the middle), pericardium was quickly opened, and the injury was apparent right away. Should the LAT be replaced by clamshell as procedure of choice in the appropriate situation and is there a trend towards this in North America?

    • My friend, we will cover this very question in an upcoming podcast in the next few weeks. stay tuned.

      scott

  13. Scott Gallagher says:

    Dr Weingart,
    Thanks for your blog and website. Really helpful stuff.

    Our medics wanted me to ask about using electricity in refractory VFIB following blunt trauma arrest, ie., skier vs. tree. Do you think that it is reasonable for them to try en route for the possibility of commotio cordis?

    Thanks,
    SG

    • defib for v-fib is a good idea any time. The commotio cordis case example is a great one for when electricity may still be helpful to these folks.

      • Scott Gallagher says:

        And would you still abhore ACLS medications in the setting of refractory VIFB following blunt trauma arrest?

  14. That is a great question and I am not sure what the correct answer is, b/c even in medicine codes, it is very questionable whether the anti-dysrhythmics have any outcome benefit. I think i probably would try some amio in the setting of v-fib refractory to shock, with no evidence to back that up. thanks for making me think!

  15. Scott Gallagher says:

    Thnanks Scott for all your thought and work on this website.

    With regard to blunt trauma, we see a fair number of skier vs tree (vs another skier, pole, etc), some of whom are found in a ventricular arrest ryhthm. Once found in these rhythms, the EMS guys tend to get focused on ACLS thinking. I certainly steer them away from this thinking in a PEA scenario of sinus tach without a palpable blood pressure or pulse. However unlike PEA, when they find a patient in Vfib or Vtach, the concept of an arrhythmia induced by commotio cordis or cardiac contusion, makes me hesitant to completely steer their thinking away from electricity, and perhaps amiodarone.

    The March 11 2010 NEJM has a review article on commotio cordis which claims 25% of reported cases in the Minneapolis registry receiving CPR or defibrillation resulted in survival.

    Thanks again for your time and contribution to continued learning for all of us!

  16. Dr. Weingart, thanks for all the valuable resources on your site(s). I was reviewing some ultrasound videos on hqmeded and found this one that fits almost perfectly with your take on CPR in traumatic arrest. It features a 25 yo pt after blunt trauma upon whom multiple physicians could not feel a pulse, however bedside echo at that moment demonstrated that hypovolemia was the root cause, not a lack of heart contraction. This, of course, led to a disagreement over whether CPR was necessary, and although it was ultimately performed, it didn’t address the true problem and probably caused more distraction and chaos than perfusion. Just wanted to share with you some more support for your lecture. Thanks again for raising the bar for emergency medical education.

    http://vimeo.com/17362408

  17. Soren Rudolph MD says:

    Hi Scott – great stuff as usual. One question/comment: If you’re doing an US to rule out tamponade why not go further and rule out pneumo- and hemothorax by US and omitting the finger thoracostomy?
    Soren – Copenhagen, Denmark

  18. Soren,
    Great question. You could, but for me slap the probe over the heart–if you have a good view you are done. pneumo/hemo uts is a little fussier, especially the pneumo scan with a ventilated patient. alternative to a echo for tamponade is a pericardial window or thoracotomy–big, big procedures. alternative to lung uts is finger thoracostomy–takes a few seconds and is easy. i certainly do lung uts for non-arrest trauma patients.

  19. Instead of thoracotomy, is peridcardiocentisis not an option of you see tamponade on ultrasound?

    • Good question. The ‘mantra’ is you don’t use a needle to try to suck out blood as you end up with a ‘clot’ on both sides of the needle.

      However, i know of 2 patients with traumatic effusions that were severely compromised that were radically improved by needle pericardiocentesis. In some cases/centres/situations maybe there is a role.

      The question i have is, is it worth any blood products/filling in blunt arrest? Has anyone ever survived with good neuro outcome?

      • If you are not capable of performing thoracotomy, then pericardiocentesis is worth trying. If you are capable, but scared, and try pericardiocentesis first, that is not good care. You will definitely get lucky in rare cases when the bleed has stopped, but there is tamponade physiology. If youg et even a little of the fluid portion of the blood out, you may get increase in vitals and the blood won’t reaccumulate.

        I had an aortic dissection cases with back-bleeding pericardial tamponade, removal of 3 cc of blood via pericardiocentesis changed the patient from crashing to stable for transfer.

  20. Kirsty Challen says:

    Hey Scott

    I’ve just directed my anaesthetist husband to this page…..he provides medical support at a car/motorbike racing track with probably a 30min run time to the nearest level 2 trauma unit and 45min or more to a full trauma centre. It’s been suggested that if a driver suffers a cardiac arrest post-crash at that site they should call it as nothing effective can be offered…. thoughts?

    PS they don’t have prehospital ultrasound!

  21. Kirsty Challen says:

    Agreed! I still wonder if they should think about detamponading the pericardium but that might be a bit much of an ask. BTW, I loved the ED thoracotomy videocast – if I ever see someone in need of one (much less penetrating trauma in the UK fortunately), you have probably saved my and their butt!

  22. Charlie says:

    Great review, I have been wondering whether closed compression for a brief period of time would provide benefit to a small group of trauma patients. I had a patient that was dropped off as a GSW to the lower extremity, bled out and was pulseless. CPR was initiated while we worked on obtaining access. After getting fluid boluses going and he had return of circulation and had a good outcome with no neurologic sequelae. Does it make sense to provide CPR when you know the cause is hypovolemia from volume loss that can be controlled with direct pressure and you are just trying to bridge the patient’s PEA arrest until you can get access and fluids/blood products running. I see it as the equivalent of your PEA hypovolemic arrest that you are treating. Anyone have any thoughts? Perhaps the patient would have done fine without compressions, but then again maybe he would have fell off the cliff. I understand that external compression does provide little benefit for perfusion, but it seemed like a thoracotomy was a little premature.

Trackbacks

  1. […] listen to one of the best podcast on emergency thoracotomy check out emcrit and listen to the master of podcast’s Scott […]

  2. […] compared to the recommendations of Hunt et al (2005) — as featured in EMCrit Podcast 36: Traumatic Arrest — longer CPR times are allowed (10 and 15 minutes, rather than 5 and 10 minutes for blunt and […]

  3. […] Weingart tipped us off to this chart, which displays the indications pretty […]

  4. […] pneumothorax when compared to needle thoracostomy. For more on finger thoracostomy, see EmCrit on traumatic arrest and […]

  5. […] CPR in traumatic arrests, but instead ED thoracotomy as Scott Weingart of emcrit describes in his podast 36 – Traumatic Arrest. But just wait until you here Dave’s Best Case […]

  6. […] compared to the recommendations of Hunt et al (2005) — as featured in EMCrit Podcast 36: Traumatic Arrest — longer CPR times are allowed (10 and 15 minutes, rather than 5 and 10 minutes for blunt and […]

  7. […] LITFL team highly recommends listening to this podacst by Scott Weingart: EMCrit Podcast 36 — Traumatic Arrest. Also, for an update on when to perform emergency thoracotomy, check this case-based Q&A: […]

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