Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician staffed helicopter emergency medical service

PB Sherren, C Reid, K Habig, BJ Burns

Prehospital Emergency Medicine, Greater Sydney Area Helicopter Emergency Medical Services

Introduction Survival rates following traumatic cardiac arrest (TCA) are known to be poor but resuscitation is not universally futile [1]. There are distinct differences in the pathophysiology between medical cardiac arrests and TCA. The authors believe a separate algorithm is required for the management of out-of-hospital TCA attended to by a highly trained physician and paramedic team.

Methods

A suggested algorithm for TCA was developed based on the authors’ current standard operating procedures and available evidence.

Results In TCA priority should be given to catastrophic haemorrhage control (Tourniquets, direct pressure, haemostatic agents, pelvic and long bone splintage) and volume resuscitation. Given the importance of the haemostatic resuscitation, blood is the resuscitation fluid of choice if available, and tranexamic acid should be considered post return-of-spontaneous-circulation (ROSC).

Good airway management and the proactive exclusion of tension pneumothoraces with open thoracostomies are essential to ensuring good oxygenation in TCA. Commonly taught needle thoracostomy decompression can fail due to mechanical obstruction, kinking, iatrogenic injury, incorrect anatomical site, and chest wall thickness.

In TCA, the use of cardiac ultrasound to assist in the assessment of cardiac tamponade in blunt trauma, pulse presence and cardiac motion forms an integral part of the authors’ current practice. The presence of true mechanical cardiac standstill (versus low pressure state/'pseudo PEA'), electrical asystole and an ETCO2<1.3 kPa carries a grave prognosis in TCA.

Penetrating trauma to the chest or epigastrium associated with a TCA of less than 10 minutes should prompt an immediate thoracotomy.

Given the high incidence of hypovolaemia and obstructive shock prior to TCA, the role of adrenaline and external chest compressions may be limited.

Conclusions The suggested algorithm is designed for a highly trained physician-led prehospital team and aims to maximise the number of neurologically intact survivors in out-of-hospital TCA.

 References1.Lockey D et al. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med. 2006 Sep; 48(3): 240-4. Epub 2006 Apr 27.