Prehospital traumatic cardiac arrest is relatively rare and highly complex event that will challenge even the most skilled providers and resuscitation teams. This is further complicated by a shortfall of clear consensus guidelines to help EMS providers rapidly identify, assess, prioritize and care for underlying life-threats as they simultaneously work to resuscitate the patient. What is the best bal-ance between simple algorithms that focus on core priorities versus critical think-ing recommendations that address issues more specifically? This session looks at the latest research and guidelines from key organizations such as the National Association of EMS Physicians, American College of Surgeons Committee on Trauma, and the American Heart Association as well as similar organizations from around the world to help us make the best decisions and take rapid action to give our patients the best hope of survival. Find more at www.RomDuck.com

1. Controversies in
Traumatic Cardiac Arrest
Capt. Rommie L. Duckworth Find me on @romduck

2. Rommie L. Duckworth, BS, LP
• Fire, rescue and EMS for 30 years
• Fire, hospital, commercial based EMS
• Rural, suburban, and urban Northeast
• Fire captain & paramedic coordinator
• Educator and author

5. Traumatic
Cardiac
Arrest

6. Should we even try?
NAEMSP/ACS COT
2013 Update on TCA
“It is appropriate to withhold
resuscitative efforts for
certain trauma patients for
whom death is the
predictable outcome.”
Initial data varies from <1%-3%
More current data shows 6.3% Evans, C. C., Petersen, A., Meier, E. N., Buick, J. E., Schreiber, M., Kannas, D., & Austin, M. A. (2016). Prehospital traumatic
cardiac arrest: Management and outcomes from the Resuscitation Outcomes Consortium Epistry-Trauma and PROPHET
registries. The Journal of Trauma and Acute Care Surgery, 81(2), 285–293. https://doi.org/10.1097/TA.0000000000001070

9. Trauma
Treatment
A
BC

11. The management of TCA patients remains
controversial and has shifted in the last
decade from withholding treatment on the
basis of futility to actively identifying and
treating the cause of the arrest.
The development of algorithms for the
management of TCA have focused on the
provision of interventions specifically aimed
at treating the underlying pathology,
reflecting the more common causes of TCA
including hypovolaemia, hypoxaemia, tension
pneumothorax and cardiac tamponade.

12. Should we CPR?
Do compressions…
-take manpower?
-cause thoracic trauma?
-dislodge clots?
-solve the key underlying
TCA problems of
hypovolemia or hypoxia?

13. The effectiveness of chest compressions in TCA has been debated and the
most recent guidelines from the European Resuscitation Council (ERC)
suggest that priority should be given to identifying and treating the cause of
cardiac arrest rather than the initiation of chest compressions which may or
may not be beneficial.
Faculty of Prehospital Care: The Royal College of Surgeons of Edinburgh. (2018). CONSENSUS STATEMENT 2018
MANAGEMENT OF TRAUMATIC CARDIAC ARREST. The Royal College of Surgeons of Edinburgh.
https://fphc.rcsed.ac.uk/media/2577/tca-submission-oct-2018.pdf

14. Should we Epi?
-Vasoconstrictor
-Increases O2 consumption
-Dysrythmic cathecholamine
-May worsen O2/CO2 exchange
-May stimulate platelet
activation reducing blood flow
to the cerebral cortex

16. Detect
Direct Pressure
Devices

17. “While tourniquets have been a focus of hemorrhage control
training, they are not the only intervention, which also includes
pressure bandages, wound packing, and hemostatic dressings, and
it is essential to recognize that in virtually all instances, all that is
needed to adequately control hemorrhage is … the application of
direct pressure; this is particularly true for extremity wounds, for
which tourniquets are recommended.”

18. Tourniquet
Clotting Gauze
Pressure Bandage
Pelvic Binder

19. E-FAST

21. Blood Products

22. However whilst the use of pre-hospital red blood cells have been
associated with an improvement in the rate of return of spontaneous
circulation following traumatic cardiac arrest, a survival benefit has not
been demonstrated and further studies are warranted.
Faculty of Prehospital Care: The Royal College of Surgeons of Edinburgh. (2018). CONSENSUS STATEMENT 2018 MANAGEMENT OF TRAUMATIC CARDIAC
ARREST. The Royal College of Surgeons of Edinburgh. https://fphc.rcsed.ac.uk/media/2577/tca-submission-oct-2018.pdf

24. OPA /NPA / Suction
SGA (iGel, King, etc.)
Endotracheal Intubation
Cricothyrotomy

32. • The rationale for wide and unspecific indications for pre-hospital intubation seems to lack
support in the literature, despite several publications involving a relatively large number
of patients.
• Pre-hospital intubation is a complex intervention where guidelines and research findings
should be approached cautiously.
• The association between pre-hospital intubation and a higher mortality rate does not
necessarily contradict the importance of the intervention, but it does call for a thorough
investigation by clinicians and researchers into possible causes for this finding.

35. Apneic
Oxygenation

36. Proper
Positioning

37. e

38. Eat your SALAD!

40. 5th Intercostal Space
Mid-axillary Line
3.5 cm
100%
2nd Intercostal Space
Mid-clavicular Line
4.5 cm
57.5%

43. Hypothermia
Hypocoagulability
H+ Acidosis
< 95 deg
pH <7.2
Lactate > 5

47. SUMMARY:
• Traumatic cardiac arrest is associated with a poor outcome but
improvements in the delivery of care both in the pre-hospital setting and
in-hospital are reflected in small improvements in survival rates.
• There are certain pathologies, which may precipitate traumatic cardiac
arrest and require rapid and effective treatment, which varies from
conventional treatments for other causes of cardiac arrest. Algorithms have
been developed to focus on the provision of simultaneous interventions,
which specifically target reversible causes.
• Termination of resuscitation efforts should be carefully considered as
survivors have been identified in groups of patients in whom termination
of resuscitation efforts were previously considered appropriate.

50. http://www.flickr.com/photos/22458831@N04/3676369069/