The Peri-arrest or Arrested Trauma Patient
- To know how to build your resuscitation room to optimize success.
- To try to think of trauma resuscitation in 3 phases:
- Active assessment and treatment.
- To list the preventable causes of death in trauma and the initial treatment (HOTT).
- To know the indications for ED thoracotomy and when not to do it.
- To know when to stop resuscitation or not to start in the first place.
- To realize that CPR is useless in traumatic arrest…so don’t do it.
Building your trauma room and preparing for trauma resuscitation
- This and good preparation will go a long way towards a successful resuscitation.
- One needs to organize people, things (equipment) and to huddle to make a plan, assign roles and make sure everyone is on the same page.
- Trauma team typically consists of 2 or 3 physicians, 3 nurses, an RT, the health care aid, the unit clerk.
- Lab and Xray are important but don’t need to be in the initial huddle.
- Choose a leader and to know what the roles of each member of the team will play.
- For example one physician may do the primary survey and ultrasound and the other may do procedures. There may be a dedicated physician just for airway, but this depends on resources.
- Wear name tags and labels as to what role the person is doing can be very helpful.
- We use sticky tape name tags.
- Other people that may need to be notified would be CT, OR, the surgery service, the trauma service, Paeds or Ob/Gyn, etc.
- Equipment needs to be prepared in advance.
- Like rapid transfuser.
- Preloading the resuscitation bed with a binder in all blunt traumas.
- A checklist printed up and placed in the resuscitation room can be helpful here. Examples of an equipment list is in Appendix A.
- The huddle prior to the trauma arrival is very important. It clarifies an initial plan. It also clarifies what everyone’s roles will be.
- For example the leader may state that we are not going to do CPR as it is ineffective and will get in the way of resuscitation.
- Everyone involved will need to put on their Personal Protective Equipment.
The active assessment and treatment phase
- It is important to give the paramedics respectful silence to allow their detailed report.
- The assessment and treatment phase can then begin.
- The leader typically stands at the foot of the bed and provides clear direction.
- People are addressed by name and good closed loop communication occurs.
- Frequent summary statements and updates of the plan coming up are essential.
- The assessments and treatments often occur simultaneously.
- The leader should ask the team periodically if he/she is missing anything and if anyone else has any suggestions.
- During critical interventions like intubation, every effort at quiet should occur.
- Crowd control is important, as a loud trauma bay becomes inefficient.
The process of preparation, huddle, and active assessment and treatment should be practiced using simulation training. The principles of CRM (crisis resource management) are very important to reinforce as one of the commonest pitfalls of a resuscitation is a breakdown in communication and/or leadership.
The causes of preventable death are:
- Hemorrhage (60%).
- Tension pneumothorax (33%).
- Cardiac tamponade (10%).
- Hypoxia (7%).
- The number one causes of death overall are head injury and ruptured aorta.
Treatment in the arrested/periarrest trauma patient focuses on HOTTS
H: control Hemorrhage, give volume.
O: maximize Oxygenation.
T: Assess for Tension pneumothorax and treat.
T: Assess for cardiac Tamponade and treat.
S: Know when to Stop the resuscitation, or not start in the first place.
- Can be of two types:
- Compressable (like an extremity arterial bleed or neck bleed).
- Noncompressable (like bleeding within the torso (chest, abdomen, pelvis, retroperitoneum).
- Extremity bleeding or neck bleeding can usually be controlled by direct pressure.
- Tourniquets are great for extremity bleeds that aren’t controlled by direct pressure.
- In a mass casualty like a bombing one focuses mainly on stopping bleeding as this will save the most number of lives.
- For junctional bleeds sometimes a foley balloon can often tamponade the bleeding.
- 2 large bore peripheral IV’s are enough. Not all big traumas need a central line.
- If you can’t get a line initially go with bilateral IO’s.
- The humeral head will give the best flow.
- In the preparation phase the massive transfuser would need to be primed and 4 units of blood to be in the resuscitation bay ready for use.
- All unstable trauma patients will get one liter of crystalloid (it doesn’t matter which of NS, RL or plasmalyte). After that whole blood is best.
- This is not available for most centers so go with 1:1:1 ratio of packed RBC’s, FFP and platelets.
- A pitfall is giving more than one liter of crystalloid as this increases morbidity post resuscitation.
- In my opinion the best central line would be a subclavian cordis (7F). Don’t use a triple lumen as it doesn’t transport volume as fast as a cordis.
- The ultrasound is key to detect intraperitoneal or thoracic hemorrhage. If the hemorrhage is of the noncompressible type (like a ruptured spleen) then early OR is critical.
- Don’t transport a pulseless patient to the OR.
- Don’t transport an unstable patient to CT either.
- For open book pelvic fractures bind them early. Preloading the resuscitation bed with a binder in all blunt traumas is a good idea.
- TXA does save lives do don’t forget this.
- REBOA (resuscitative endovascular balloon occlusion of the aorta) is an option in some centers but most don’t have this option.
The emphasis recently has been CAB (not ABC)
- So try to maximize the BP /circulatory volume prior to intubation. The Shock index is a clue that the patient will crash with intubation.
- Shock index is Systolic BP/P.
- Shock index less than one this is bad and predictive of hypotension post intubation.
- Adrenaline in arrest does improve ROSC but has never been shown to improve mortality.
- I recommend giving adrenaline in arrest. Similarly push dose pressors have never been shown to decrease mortality but I recommend phenyepinephrine prior to intubation if there is a poor shock index (and volume of course).
Hypoxia (poor Oxygenation) is another reversible cause of periarrest or arrest in the trauma patient.
- The airway if not patent must be addressed. An oral airway /jaw thrust or bilateral nasal trumpets usually serves to open the airway. If the airway is blocked, one has to act immediately to open it.
- This may require a surgical airway if passing an endotracheal tube is not an option. Sometimes an early King tube can buy you some time and allow ventilation and oxygenation. You can use the king tube as a bridge to definitive airway.
- Head injuries and chest trauma both may impair ventilation.
- Lung contusions, flail chest, pneumothorax, open pneumothorax are the main thoracic causes of impaired ventilation.
- An open pneumothorax must be covered and a chest tube placed. There will be almost no lung ventilation if the open pneumothorax is greater than 2/3 the diameter of the trachea (air will preferentially go in and out or the chest wall not the trachea).
- The main cause of refractory hypoxia after the airway is opened is bilateral lung contusions.
- PEEP may help, but in severe cases the patient should be transferred to an ECMO center for ECMO.
- Intubation in the periarrest trauma patient can be tricky and may cause cardiovascular collapse if volume resuscitation is not done first. However as mentioned above, the airway must be opened and so intubation may have to be done right away if temporizing maneuvers don’t work.
- It is recommended that for every intubation the intubating person verbalizes 3 different options for securing the airway.
- For example one might say: “I will try with the glidescope, then direct laryngoscopy with a bougie, then a king airway”.
- For the difficult airway it is wise to have the surgical airway equipment handy and open.
- Always undo the C collar and have a provider do inline stabilization.
- Use ½ dose ketamine (0.5 to 0.75mg/kg) as in periarrest trauma patients ketamine may have a further hypotensive effect.
- Use 2mg/kg of rocuronium (higher than the usual 1.5mg/kg) because the circulatory time may be prolonged due to shock.
T is for rule out Tension Pneumothorax.
- In the crashing trauma patient who is periarrest, consider going directly to bilateral finger thoracostomies. Then follow with chest tubes when time permits.
- The other option is ultrasound to look for lung sliding, but it if often faster to go straight to the finger thoracostomies. It should only take a few seconds per side. No anaesthesia is required in such patients if they are periarrest.
- Bilateral needle thoracentesis is just not good enough. Studies show that there is a significant rate in which the needle doesn’t enter the pleural space.
The other T is assess for Cardiac Tamponade
- In a stab to the cardiac box with periarrest it is entirely reasonable to go straight to a left lateral thoracotomy.
- Any other situation, the heart should be assessed first with ultrasound. Especially in blunt trauma ultrasound should be done and DO NOT do a thoracotomy unless you see pericardial fluid.
- Pericardiocentesis is not adequate for stab hearts and the safer and more efficacious approach is a thoracotomy.
- Thoracotomy’s main goal is to first open the pericardium to relieve the pressure, and the second goal is to stop bleeding from the heart.
- Sometimes a clamshell thoracotomy is necessary if the bleeding is thought to be coming from the left side of the heart or lung.
- Bleeding from a stab heart usually stops with direct pressure.
- An alternative is to stick a foley in the heart through the wound, blow up the balloon and pull back to stop the bleeding.
S if for when to STOP a resuscitation or even not to start it
- Obviously lethal injuries (like decapitation),
- No signs of life after 10 minutes of resuscitation.
- No cardiac activity on ultrasound or no cardiac activity on thoracotomy are reasons to stop.
- Although some studies show up to 3% survival after traumatic asystole, most would not start a resuscitation in the asystolic patient.
So what are considered signs of life?
- An organized rhythm on the monitor,
- A pulse, or
- Spontaneous breathing or motor activity or
- Reactive pupils.
- There can be pulselessness but a tachycardia on the monitor and this is still considered a sign of life.
Investigations and monitoring
- Early phlebotomy to get off labs is important. One may need to do femoral stab to get this.
- Ultrasound is hugely important to assess for hemoperitoneum, for pneumothorax and for Tamponade. It also can help guide the resuscitation and confirm ETT placement.
- ROTEM or TEG are both used in some trauma centers to assess coagulopathy, but are not available in most smaller centers and have not yet been shown to change mortality.
- An early femoral art line is great to monitor BP, to draw blood every 30 min. And one can rewire the fem line to place a REBOA (if you have it, another device that has not yet been proven to decrease mortality, but probably will in my opinion).
- Most blunt trauma periarrest patients should get a CxR and a pelvic xray.
- CT is not an option in this patient population, only take a more stable patient to the CT suite.
CPR has never been proven as useful or efficacious in trauma.
- The idea is that if the heart is empty then CPR will not be able to move the blood.
- It also gets in the way of therapeutic treatments like central lines, chest tubes, intubation etc.
- Never do CPR in trauma…unless the cause of the arrest is not trauma but something else.
Epinephrine has not been shown to change mortality. But it does increase ROSC in the arrested trauma patient. So if the patient is in arrest I still give it.
ECMO is only useful in trauma for refractory hypoxia, or hypothermia.
In summary in the periarrest trauma patient
- Make sure you prepare your team and equipment ahead of time. Have the roles of each team member clarified.
- The leader should stay at the head of the bed and give frequent summary statements and what the next goals in the resuscitation should be. The team should be invited to give feedback. Principles of CRM should be used.
- Work your way through HOTTS.
- Don’t do CPR.
- The crash protocol is:
- Bilateral chest tubes.
- 4 units of blood with TXA.
- Ultrasound to rule out tamponade (or straight to thoracotomy if stab or gsw in cardiac box).
- When the resuscitation is over and the patient is either dead, or gone to OR or ICU a debrief is essential. It allows emotional catharsis and just as importantly can serve as a quality improvement tool.
- If things went wrong they can be identified and then corrected prior to the next big trauma.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Nov 29, 2021
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