Traumatic cardiac arrest by Dr Adam Holyoak
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This document discusses management of traumatic cardiac arrest and compares it to medical cardiac arrest. It notes that traumatic cardiac arrest may have better outcomes if caused by penetrating trauma, witnessed arrest, presenting in PEA rhythm, and receiving prehospital medical management. Interventions for traumatic cardiac arrest focus on treating reversible causes like tension pneumothorax, relieving pericardial tamponade through resuscitative thoracotomy, controlling hemorrhage, and replacing blood loss. The role of chest compressions is de-emphasized. Teamwork between emergency responders, aeromedical services, and trauma centers is important for expeditiously managing traumatic cardiac arrest.
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Traumatic cardiac arrest by Dr Adam Holyoak
- 2. Traumatic Cardiac Arrest Dr Adam Holyoak
- 5. • Some statistics, including who is likely to benefit from resuscitative efforts in traumatic cardiac arrest • What interventions are most meaningful in traumatic cardiac arrest • Are they different from medical cardiac arrest? • Where (and by who) should these interventions be carried out? • What makes traumatic cardiac arrest resuscitation different to medical cardiac arrest?
- 6. Who are we talking about? Avest et al. 2019 ANZCOR 2016 Harris et al. 2015 Deasy et al. 2012
- 7. All out of hospital cardiac arrestTraumatic cardiac arrest Survival from cardiac arrest Chen et al. 2019 Escutnaire et al. 2018 Evans et al. 2018 Lai et al. 2018 Prentice et al. 2018 ANZCOR 2016 Evans et al. 2016 Harris et al. 2015 Smith et al. 2015 Deasy et al. 2012 Zwingmann et al. 2012 Lockey et al. 2006
- 8. Survivor characteristics Blunt traumaPenetrating traumaPenetrating trauma + prehospital management Penetrating trauma + SOL on arrival Avest et al. 2019 Chen et al. 2019 Evans et al. 2016 Harris et al. 2015 Deasy et al. 2012 Zwingmann et al. 2012 Lockey et al. 2006
- 9. Survivor characteristics Without prehospital ROSCWith prehospital ROSCWith prehospital management Avest et al. 2019 Chen et al. 2019 Glasheen et al. 2018 Prentice et al. 2018 Evans et al. 2016 Harris et al. 2015 Smith et al. 2015
- 10. Presenting rhythm Presenting with VT/VF Presenting with PEA Harris et al. 2015; Deasy et al. 2012; Lai et al. 2018; Konesky et al. 2018
- 11. Presenting rhythm Survival with VT/VF Survival with PEA Harris et al. 2015; Deasy et al. 2012; Lai et al. 2018; Konesky et al. 2018
- 12. The ideal survivor?! • Traumatic cardiac arrest (possibly from penetrating trauma) • Witnessed arrest • PEA as presenting rhythm • Prehospital medical management
- 13. But neurologically intact survival? Blunt trauma Penetrating trauma ANZCOR 2016; Harris et al. 2015; Zwingmann et al. 2012; Konesky et al. 2018
- 14. Hypovolaemia (relative or haemorrhagic) Loss of airway Respiratory failure Tension pneumo/haemothorax Cardiac tamponade Severe CNS injury Severe cardiac damage Hypovolaemia (relative or haemorrhagic) Loss of airway Respiratory failure Tension pneumo/haemothorax Cardiac tamponade Severe CNS injury Severe cardiac damage Causes of traumatic cardiac arrest
- 15. Don’t forget medical causes of cardiac arrest
- 17. Treat reversible causes • Open, control and protect the airway • Provide appropriate oxygenation • Safe mechanical ventilation • Relieve tension pneumothorax – Finger vs tube thoracostomy • Relieve pericardial tamponade – Resuscitative thoracotomy (within 10 min blunt, 15 min penetrating) Avest et al. 2019 Chen et al. 2019 Dickson et al. 2018 Evans et al. 2018 Glasheen et al. 2018 Nevins et al. 2018 Prentice et al. 2018 Boddaert et al. 2017 Chinn et al. 2017 Evans et al. 2016 Moore et al. 2016 Smith et al. 2015 Harris et al. 2015 Lockey et al. 2013 Zwingmann et al. 2012
- 18. Find the bleeding, stop the bleeding
- 19. Replace haemorrhagic loss with blood • Minimise crystalloid use • Early blood use • Consider FFP (early) if available – PAMPER trial! • Visco-elastic testing guided product replacement – ?Better target trauma induced coagulopathy – Ongoing trials and research Avest et al. 2019 Watts et al. 2019 Evans et al. 2018 Howley et al. 2018 PAMPER 2018 Chinn et al. 2017 Mohamed et al. 2017 Saracoglu et al. 2017 Abdelfattah et al. 2016 ANZCOR 2016 Harris et al. 2015 PROPPRR 2015 Smith et al. 2015 Moore et al. 2013 PROMMTT 2013
- 20. De-emphasise the role of chest compressions Chen et al. 2019 Watts et al. 2019 Djarv et al. 2018 Evans et al. 2018 Nevins et al. 2018 Beck et al. 2017 Chinn et al. 2017 ANZCOR 2016 Harris et al. 2015 Smith et al. 2015 Lockey et al. 2013
- 21. Do vasopressors/inotropes have a role? • Controversy exists due to varying study outcomes – Overall worse outcomes if used • In arrest vs post arrest use – Once volume resuscitated – Neurogenic shock • PARAMEDIC-2 (all comers OOHCA) • VITRIS and AVERT results awaited Manley et al. 2019 Djarv et al. 2018 Evans et al. 2018 PARAMEDIC-2 2018 Chinn et al. 2017 Gupta et al. 2017 Hylands et al. 2017 ANZCOR 2016 Smith et al. 2015 Harris et al. 2015
- 22. So why is TCA different to MCA? • Usually in “well” individuals • PEA different to EMD – Early echocardiography • Speed of onset of “arrest” • Age may not be so predictive Chen et al. 2019 Escutnaire et al. 2018 Evans et al. 2018 Konesky et al. 2018 Beck et al 2017 Fernandez 2017 Chinn et al. 2017 Evans et al. 2016 Harris et al. 2015 Smith et al. 2015
- 23. Teamwork/Systems approaches • Stepwise approach to treatment of reversible causes • Role of trauma team – Skilled and experienced leadership – Massive haemorrhage protocol implementation – Expeditious transfer to operating theatre • Teamwork • Communication Chen et al. 2019 Prentice et al. 2018 Harris et al. 2015 Smith et al. 2015 Lockey et al. 2013
- 25. Primary responders role Chen et al. 2019; Chinn et al. 2017; Evans et al. 2016; Deasy et al. 2012
- 26. Aeromedical services: add or distract? Avest et al. 2019; Chen et al. 2019; Glasheen et al. 2018 Nevins et al. 2018; Prentice et al. 2018; Lockey et al. 2006
- 27. Receiving hospital:Trauma centre interplay Chen et al. 2019; Lai et al. 2018; Evans et al. 2016; Moore et al. 2013
Editor's Notes
- In the time we have to resuscitate someone in traumatic cardiac arrest, we will cover some statistics looking at who is most likely to benefit from resuscitation in TCA, what interventions make the most difference, who and where these should be undertaken, and the differences between medical and traumatic arrest resuscitation
- Medical causes of cardiac arrest comprise 84-99% of all cardiac arrests, with the average quoted at ~95%. So its this 5% that we are discussing today Medical cardiac arrest 84-99% with most commonly quoted at ~95% 5% TCA, so its this group we are talking about
- Survival from all cause cardiac arrest is 11% In the traumatic cardiac arrest population it is quoted at around 24%, with smaller studies reporting up to 75% This is clearly an important group to intervene in All OOHCA up to 11% TCA up to 24%
- What characteristics are associated with survival? Blunt trauma arrest ~8% survival Penetrating trauma increases to 16% If there is prehospital management of those with penetrating trauma, survival increases slightly further to 18% And if there are signs of life (prior to arrest) on arrival of medical care the post arrest survival doubles to 35% TCA with blunt trauma TCA with penetrating trauma TCA penetrating trauma and prehospital management TCA penetrating trauma and SOL on arrival
- If no ROSC is achieved prior to hospital arrival, survival is relatively poor at 7% If prehospital ROSC is achieved, survival quadruples to 26% However, regardless of ROSC if there is prehospital medical management, survival is 32% Survival without prehospital ROSC Survival with prehospital ROSC Survival with prehospital management
- Presenting rhythms for TCA are largely PEA (60% vs 8%) Presenting with VT/VF up to 7.9% Presenting with PEA up to 60%
- And PEA is associated with over double the number of survivors (35% vs 14%) Survival VT/VF up to 14.3% Survival PEA up to 34.5%
- Neurologically intact survival is identical in blunt and penetrating arrest at just under 7% of all TCAs Small studies again report up to 75% with GOS of 1-2 Almost identical Penetrating 1.9-6.6% Blunt 1-6.6%
- Common causes of TCA are listed here, and these 5 are potentially reversible
- Of course don’t forget medical causes, especially if picture not in keeping with cause of cardiac arrest eg. low velocity trauma
- The primary interventions are all aimed at treating the reversible causes of cardiac arrest Early intubation, oxygen administration and mechanical ventilation improve survival Aggressively seeking and treating obstructive shock early also improves outcomes Thoracotomy allows access to relieve tamponade, control bleeding and provide internal cardiac massage Zwingmann etal. 2012 Evans etal. 2016 Chen etal. 2019 -> aggressive attempts at reversible causes leads to increased ROSC (even if not in field) Glasheen etal. 2018 -> early intubation/reversible causes improves outcome Prentice etal. 2018 -> early addressing reversible causes Avest etal. 2019 -> early work on reversible causes improves outcome Dickson etal. 2018 -> finger thoracostomy is simple and effective Boddaert etal. 2017 -> tamponade, cardiac bleeding, internal cardiac massage, aortic clamping, lung injury control Chinn etal. 2017 -> thoracotomy timings ANZCOR 2016 <10 min if good outcome for TCA Lockey etal. 2013 -> reversible causes Moore etal. 2016 -> timing <15 min Nevins etal. 2018 -> thoracotomy and reversible causes Smith etal. 2015 -> reversible causes Harris etal. 2015 -> correct reversible causes Evans etal. 2018 -> reversible causes are priority
- Aggressively seek and treat haemorrhagic shock Use haemostatic dressings, torniquets, splinting long bones, pelvic binders, REBOA, resuscitative thoracotomy Early surgical intervention for damage control Torniquets Splints Haemostatic dressings Pelvic binder REBOA Open chest procedures Operating theatre ANZCOR 2016 Moore etal. 2016
- Large body of evidence supporting replacement of haemorrhage with blood products and avoiding crystalloids as this improves outcome FFP perhaps has a “magical” role (PAMPER trial) Debate for ratio based (certainly high ratio appears safe and superior to low ratio) vs visco-elastic guided replacement (however this does reduce blood product usage, may predict need for MHP, and early data may improve mortality Avest etal. 2019 -> blood products; independent predictor of ROSC Chinn etal. 2017 -> VET is useful in guiding transfusion ANZCOR 2016 -> 1:1 or 1:2 Watts etal. 2019 -> whole blood is better than saline Moore etal. 2013 -> role of plasma not just ratios – buffer fibrinolysis and metabolic derangements Mohamed etal. 2017 -> decreased blood use, ICU and hospital LOS Howley etal. 2018 -> reduced product use with increased survival Saracoglu etal. 2017 -> reduced blood products, mobidity and mortality (likely due to reduced reactions to blood products) Abdelfattah etal. 2016 -> reduced products, predict MHP need, better correct coagulopathy, mortality benefit PROMMTT 2013 -> decreased mortality with higher FFP and platelet ratios, mostly due to reduced bleeding in first 6 and 24hrs PROPPRR 2015 -> no mortality difference, but earlier haemostasis and less deaths at first 24hrs; no increase in adverse reactions PAMPER 2018 -> improved mortality (30 day) and improved INR; effect at 3hrs Smith etal. 2015 -> blood and blood products Harris etal. 2015 -> early blood products Evans etal. 2018 -> judicious crystalloid; whole blood or all components (balanced); TXA and other agents for coagulopathy
- Chest compressions appear to be associated with poorer survival, possibly as they distract from attention to treating reversible causes, but also compressions on empty heart not effective. May be of use if normovolaemic (so post blood resuscitation). If tamponade present, external compressions decrease MAP Chen etal. 2019 -> CPR alone not beneficial in reversing causes, so need a protocol to address reversible causes Djarv etal. 2018 -> early CPR beneficial Beck etal. 2017 -> CPR not correlated with outcome Chinn etal. 2017 -> may be of use to get to definitive care; but worse in tamponade, and focus should be on reversible interventions ANZCOR 2016 -> reversible causes have priority, not CPR Watts etal. 2019 -> chest compressions cause worse outcomes overall, unless done after blood resus Lockey etal. 2013 -> useful once normovolaemia returned Nevins etal. 2018 -> CPR unlikely effective if empty heart Smith etal. 2015 -> no evidence to support CPR Harris etal. 2015 -> internal better than external, in tamponade compressions reduce MAP; little use in hypovolaemia Evans etal. 2018 -> de-prioritise chest compressions in favour of fixing reversible causes; unless suspicious of MCA
- Highly controversial, but overall outcomes appear worse if vasopressors or inotropes are used during resuscitation (note PARAMEDIC-2) May be beneficial post resuscitation if vasoplegia or myocardial depression May have a role in neurogenic shock Manley etal. 2019 -> adrenaline may increase survival to hospital??? Djarv etal. 2018 -> more survivors without adrenaline Chinn etal. 2017 -> no role for adrenaline; disputable in medical OOHCA -> PARAMEDIC-2; caution in use of vasopressors with inadequate volume ANZCOR 2016 -> 90mmHg for non head, 110mmHg for head injury -> once volume replaced; little evidence for adrenaline in TCA, worse outcomes in haemorrhagic shock; can use once all other reversible causes corrected, or post resus care Gupta etal. 2017 -> only after volume resus, for vasoplegia or inotropes for cardiac dysfunction Hylands etal. 2017 -> paucity of good evidence Smith etal. 2015 -> maximally catecholamined due to slow decline in BP; no evidence of benefit, some of harm; neurogenic shock is exception Harris etal. 2015 -> vasopressor/inotrope use associated with worse outcomes Evans etal. 2018 -> no use when hypovolaemic, can be used in neurogenic shock; or post volume replacement when ongoing vasoplegia or cardiac dysfunction
- Several differences – often well individuals, arrest not due to comorbidities; onset of arrest is gradual rather than immediate; PEA vs EMD (contracting heart vs no cardiac activity); older age reported to be associated with improved outcomes Evans etal. 2016 -> very very low pressure, not “true arrest” Chen etal. 2019 -> full vs empty circulating volume Escutnaire etal. 2018 -> younger and less comorbidities Fernandez 2017 -> young and MVA Beck etal 2017 -> VT/VF and PEA better than asystole; older age!! Konesky etal. 2018 -> PEA most common presenting rhythm; low flow cardiac state; younger; also survival better in older age!! Chinn etal. 2017 -> PEA is best rhythm for outcome, especially if HR >40; early USS – PTX, tamponade, hypovolaemia, cardiac standstill Smith etal. 2015 -> PEA most common rhythm in survivors; early USS useful in identifying cardiac activity Harris etal. 2015 -> PEA better prognosis Evans etal. 2018 -> very low flow vs no flow; early USS
- Having a stepwise/systematic approach to treating reversible causes helps rapid progression through treatment and helps interactions of multidisciplinary teams involved Trauma teams with appropriate skill and coordination with surgical teams and OT Ability to implement MHP and immediate transfer to OT Chen etal. 2019 -> well trained trauma team; systematic approach – improved outcomes Prentice etal. 2018 -> coordinated EMS, HEMS, hospital system Lockey etal. 2013 -> algorithmic approach to reversible causes Smith etal. 2015 -> use of SOP or protocol Harris etal. 2015 -> protocol improves multidisciplinary team work
- All reports in literature demonstrate that rapid transfer to medical care and short prehospital times improves outcomes -> largely due to early access to surgical interventions Deasy etal 2012 -> EMS lead responder Evans etal. 2016 -> unmeasured “factors”, as improved survival when EMS Chen etal. 2019 -> improved outcomes with shorter pre-hospital times Chinn etal. 2017 -> rapid transport, especially for surgical intervention
- This is where HEMS may have a role – MO and paramedic teams that can provide resuscitative efforts as earlier described in the field and then facilitate rapid transfer to trauma centre improve outcome Lockey etal. 2006 -> physician led teams may improve outcomes Chen etal. 2019 -> early transport to trauma centre improves survival; decreased pre-hospital times Glasheen etal. 2018 -> early MO attendance Prentice etal. 2018 -> MO for advanced skills improves outcome (RSI, blood, thoracostomy, thoracotomy) Avest etal. 2019 -> HEMS result in more ROSC, and more interventions early that improved outcome; MO and para Nevins etal. 2018 -> thoracotomy is time critical, so rapid deployment of medical teams may save more lives
- A well defined trauma system improves outcomes, but this appears to be linked more to service capability than to actual case load Positive association with number of ICU beds in facility transferred to Early transfer to level 1 trauma centre improves outcome Lai etal. 2018 -> outcome positively linked to ICU bed numbers Evans etal 2016 -> trauma system improves outcome Chen etal. 2019 -> early transport to trauma centre associated with improved survival Moore etal. 2013 -> tauma centre capability not volume important in outcome