The document discusses the management of traumatic cardiac arrest. Key points include: - Traumatic cardiac arrest has a very poor prognosis, usually caused by penetrating or blunt chest injuries. - For blunt trauma patients, emergency thoracotomy is only recommended if they had witnessed cardiac arrest or hypotension on arrival. - For penetrating chest injuries, emergency thoracotomy within 20 minutes of injury may be considered if signs of life were witnessed or if ECG activity is present. - Initial management involves bilateral thoracostomies to relieve tamponade, control bleeding, and provide fluids and medications. Emergency thoracotomy may be attempted in select cases but survival rates are extremely low.

2.  4am on Saturday morning, bat phone
rings….
 29 year old male with bread knife lateral
to left sternum
 Initially had recordable vitals, then lost
output – CPR in progress
 ETA 2 minutes
 What would you do?

3.  Epidemiology
 Causes
 Blunt
 Penetrating
 Management
 Emergency Thoracotomy

4.  Cardiac arrest caused by trauma,
usually penetrating or blunt thoracic
injury
 Can also include abdominal and head
injury, as well as drowning, asphyxiation,
electrocution

5.  Patients usually young and healthy
 Usually not primary cardiac event

6.  Various papers with differing
mechanisms and standards
 1990s survival to hospital discharge 2.5%
 2000s 4-8%
 Poor survival persists

7. Hypoxia
 airway obstruction – vomit, foreign body,
facial fractures
 tracheobronchial injury
 CNS depression
 open/tension pneumothorax

8.  Hypoperfusion
 Haemorrhage  hypovolaemia
 Cardiac tamponade

9.  EMS Physicians and the American College
of Surgeons Committee on Trauma (COT)
guidelines 2003:
 WITHOLD RESUS…
 Blunt trauma patient who is found apnoeic,
pulseless, and without organized ECG
activity upon the arrival of EMS at the scene
 Penetrating trauma found apnoeic and
pulseless by EMS, without signs of life
 injuries obviously incompatible with life
 Rigor mortis

10.  15-20 minutes of unsuccessful CPR
 Transport to trauma centre >15 minutes

11.  Paediatrics
 Pregnant women – perimortem
caesarean
 “Medical” arrest
 Hypothermia

12.  London air ambulance retrospective
over 10 years
 Almost 1000 patients included -
 740 dead at scene
 7.5% survived to hospital d/c
 Up to 64% breached guidelines

14.  Airway
 Bilateral open thoracostomies
 Haemorrhage control
 Blood/ fluid
 Defib as necessary
 USS

15.  No venous return in TCA patients
 Delay procedures
 May cause further thoracic damage

16.  Needle approach conventionally 2nd IC
space, midclavicular line
 Danger of going too medial and hitting
vessels
 Can kink, cause pneumothorax or not
reach
 Suggestion to go laterally or do finger
thoracostomies

20.  ABCs as with blunt injury
 Chest compressions not warranted
 Bilateral open thoracostomies
 Emergency thoractomy

21. "The surgeon who should attempt to suture a wound of the heart would
lose the respect of his surgical colleagues" - Theodore Bilroth, 1882

22.  Blunt trauma: limited to those with vital signs
on arrival and witnessed cardiac arrest or
unresponsive hypotension (BP < 70mmHg)
 Or Rapid exsanguination from chest tube
(>1500ml)
 Penetrating cardiac injuries who arrive at
the trauma centre within 20minutes with
witnessed signs of life or ECG activity
 Exsanguinating abdominal vascular injury

23.  Primary aims:
 Release of cardiac tamponade
 Control of haemorrhage – direct finger
pressure
 internal cardiac massage
 Secondary aims:
 cross-clamping of the descending
thoracic aorta

24.  supine anterolateral thoracotomy
 rapid skin preparation
 Incision 5th intercostal space; sternum to
mid-axillary line
 Incise through subcutaneous tissues to
reach intercostal musculature
 Enter chest bluntly with a finger through
intercostal muscles
 Extend opening with heavy scissors and
blunt dissection
 Insert the rib spreaders between the ribs
and open

26.  Massive head trauma
 prehospital CPR performed for >15 minutes
after penetrating chest injury without
response
 prehospital CPR performed for >10 minutes
after blunt chest injury without response
 asystole is the presenting rhythm, and there
is no pericardial tamponade
 no hope of providing definitive surgical
interventions following the procedure.

27.  Risk to provider – needle stick, scalpel –
broken ribs in blunt trauma
 Resuscitation of a patient without likely
neurological outcome
 Resource consumption – OT without
benefit, costs
 Risks of further injury to patient

29.  Get blood/ trauma pack
 Get access – IO/IV
 Permissive hypotension
 Look for sources of bleeding and close
 ?head – scalp wound
 ?FAST exam
 Pelvic binder
 Traction on long bones
 Call surgeons

30.  Signs of life
 Previous documented vital signs
 USS showing cardiac activity
 Age
 Rhythm
 Isolated penetrating cardiac injury
 Stab wounds vs gunshot

31.  PREPARE
 Major trauma call
 Staff - Call in consultant and
cardiothoracics…..GOWN UP!
 Trauma bay
 Equipment - thoracotomy kit, USS
 Call for trauma pack
 Know limitations of yourself and
colleagues

32.  Traumatic cardiac arrest has grim
survival rates
 Should be carried out in correct setting
and with appropriate surgical backup
 Emergency thoracotomy for penetrating
wounds, otherwise bilateral
thoracostomies
 DON’T use closed CPR or vasopressors

33.  http://emcrit.org/podcasts/traumatic-arrest/
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3672499/

 http://www.trauma.org/index.php/main/article/361/

 http://www.alabmed.com/uploadfile/2014/0515/20140515
070229503.pdf
 http://www.biomedcentral.com/content/pdf/cc10558.pd
f
 http://resuscitation-
guidelines.articleinmotion.com/article/S0300-
9572(10)00441-7/aim/8i-traumatic-cardiorespiratory-arrest