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:
Update: This article lends further support that all patients should have tension pneumo excluded (Resus 2007;75:276)
Additional New Information
More on EMCrit
EMCrit 287 – Thoracotomy Masterclass with Dennis Kim(Opens in a new browser tab)
EMCrit 83 – Crack to Cure – ED Thoracotomy(Opens in a new browser tab)
The Abbreviated ED Thoracotomy Tray(Opens in a new browser tab)
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Amazing Lecture. Thanks so much!
Thanks, Dax!
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
Scott Weingart, M.D. composes cutting edge Podcasts in Emergency Critical Care. A must listen for all those in the field.
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.
Very well written. Great lecture! =) Keep them coming.
Good topic. I’ve seen various approaches to this problem. Trying to access the article, is the link broken?
now fixed, thanks!!!
Thanks for the shout out mate
Brilliant podcast as ever, keep up the fantastic work
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.
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… Read more »
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.
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… Read more »
great comments. look out for the thoracotomy podcast with Ram after the new year.
s
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… Read more »
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
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.
And would you still abhore ACLS medications in the setting of refractory VIFB following blunt trauma arrest?
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!
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… Read more »
love it! i’m going to add an addendum on this on the next podcast.
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… Read more »
Vince, That is a perfect case example! Great find.
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
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.
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.
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!
At the very least, bilateral throacostomies should be performed as tension pneumo is an easy fix as a cause of traumatic arrest.
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!
Thanks Kirsty
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… Read more »
Hi Scott,
I love your site.
I was hoping you could provide me with a reference for your statement that all thoracotomy patients should get a right sided chest tube. A surgeon recently was telling me that is incorrect. Thanks!
thank you, scott
Thank you, how about your polytrauma patient arrest because of a neurogenic shock? To my polytrauma patients, I still give adrenaline (specially the motorcycle riders). Thank you for the podcast, it is great.