Traumatic cardiac arrest
Abstract
Introduction
Methods
Basic life support
Cause | Treatment | Intervention |
---|---|---|
Hypoxia | Oxygenate | Give high flow oxygen |
Tension pneumothorax | Decompress chest | Perform thoracostomy |
Cardiac tamponade | Decompress tamponade | Perform thoracotomy |
Hypovolaemia | Rapid infusion of blood and blood products; damage control resuscitation (including damage control surgery) | Large bore intravenous access (central or peripheral) and transfusion of blood/blood products via rapid infusion device |
The role of chest compressions
Use of adrenaline
Management of reversible causes
Tension pneumothorax
Rapid fluid resuscitation
The role of thoracotomy
Ultrasound
Use of a traumatic cardiac arrest standard operating procedure (SOP)
Exclude: |
• underlying medical cause for cardiac arrest (ALS algorithm applies) |
• clinically unsurvivable head injuries |
• long downtime without pulse |
For all others (usually with PEA as initial rhythm) apply resuscitation bundle: |
• no external chest compressions |
• no vasopressors |
• oxygenate |
• bilateral thoracostomies (unless certain of no tension pneumothorax; caution – can be bilateral) |
• rapid infusion of warmed blood and products via large catheter and infusion device |
• ultrasound the heart |
• ultrasound the abdomen |
• X-ray chest and pelvis |
Summary points
• The management of patients with traumatic cardiac arrest is not always futile |
• Reversible causes such as hypoxia, tension pneumothorax, cardiac tamponade and hypovolaemia should be actively sought and excluded or treated |
• A SOP for the management of these patients is provided |
• Standard Advanced Life Support algorithms should not be used for patients in traumatic cardiac arrest. |
• Ongoing research is described in Box 2. |
• Research is ongoing into the utility of chest compressions in patients in traumatic cardiac arrest. |
• Novel therapeutic options such as the use of Resuscitative Endovascular Balloon Occlusion of the Aorta and thoracic aortic compression in patients with hypovolaemic traumatic cardiac arrest are currently being investigated. |
• Research is ongoing into emergency preservation resuscitation (formerly known as suspended animation) whereby profound hypothermia to around 10°C is induced rapidly to slow the metabolic rate of all tissues in order to extend the time window to undertake haemostatic surgery. This may be of particular use in patients bleeding from multiple sites. |
• The appropriateness of the use of the principles outlined in this paper when dealing with children in traumatic cardiac arrest is currently being explored. |
A patient’s story (1)
He now lives with his wife and children in Cornwall, where he works as a part-time tree surgeon.I have no recollection of the incident or the treatment I received in the field hospital. I was in the ICU [intensive care unit] in Birmingham for about a week in an induced coma. After another week I had to walk the length of the ward in order to prove I could be moved, then after a few more days had to prove I was able to climb stairs before going home.At home I needed help to get out of bed and shower, and this would totally wear me out. I spent my time split between the Defence Rehabilitation Centre at Headley Court and home. I would spend my afternoons asleep after exercising and would still sleep at night. I went through a long period of physiotherapy and fitness training, but after approximately 18 months I completed a half marathon and since have trekked to Everest base camp twice. I do still have periods of fatigue but have learnt to manage it. I was discharged from the Royal Marines in 2013.
A patient’s story (2)
He suffered a hypovolaemic traumatic cardiac arrest en route to hospital, and after arrival underwent massive transfusion of blood and blood products, followed by vascular surgery to repair the blood supply to the injured limb.I was hit by my own car and my leg was crushed between the car and the garage wall. The paramedics arrived and gave me oxygen. That was the last thing I remember before waking up while being moved from the Intensive Care Unit (ICU) to an isolation room.
He has now been able to return to a near-normal life, enjoying overseas holidays, and he recently spent a spring day fixing his septic tank.I returned home after about 8 weeks in hospital. I was able to walk unaided, but it was difficult, and I had a lot of pain at the start. I underwent 10 sessions of physiotherapy over about 10 weeks. My limit is about a quarter of a mile, even after 15 months.
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