Resuscitating Traumatic Arrest
Disclaimer: This is my opinion and does not reflect the view of any entity that I trade time for cash with. Everything is meant for educational food for thought and you should always “follow your protocols.”
Traumatic arrest has been on my mind ever since I recently experienced one on duty a month or so ago. We tend to write off traumatic arrest due to the survival rate being the lowest of the low, but why is that and what can we do to possibly change this?
First off, let's look at the processes occurring in a traumatic arrest. When I say traumatic arrest, I am almost exclusively referring to hypovolemic shock turned arrest. In these cases the heart is not the cause of the situation, more so a lack of blood volume circulating. This causes hypoxia, known as hypemic hypoxia, as there is no hemoglobin to deliver oxygen. Kind of like a bus route with no buses. You can have all the oxygen in the world, but that isn't going to improve their status.
So now what can we do about it? The key to traumatic arrest is fixing the problem and restoring the volume. Here comes the uncomfortable part... CPR is secondary to fixing the volume. CPR in a traumatic arrest is futile if you can't stop the bleeding. You are just furthering the hypovolemia and harming the patient. This is going in line as well with vasopressors like Epi. You increase pressures on a potential clot forming and bust said clot with the increased pressures furthering hypovolemia. Since we do not have life-saving whole blood, we need to then judiciously resuscitate the arrest. Relative hypovolemia is in play here as we restore just enough perfusion yet, not over-pressurize the system.
Blood products, unfortunately, if the only thing that can turn the tide of blood loss. Fortunately, there are other types of trauma that can be corrected. Tension pneumothorax is something we can correct in the field. This is again before CPR, which I know feels wrong, but we need to have the heart working on all cylinders before we start circulating volume if we don't have bleeding going on.
Next is correcting arrhythmias as VF can occur in traumatic arrest. PEA could be just be cardiac activity that we just can’t feel.
Lastly, depending on downtime, consider hypoxia as well as breathing that may have been obstructed after the trauma.
So with all these moving parts, let's put it into a scenario. You arrive on the scene of a traffic accident that recently occurred. You find a 54 y/o male in the driver's seat of a vehicle with moderate left side damage. You observe no breathing and adjust the airway with no change. This would be considered a Black Tag under normal circumstances. This particular time though, he is your only patient and you rapidly extricate to attempt resuscitation. You do not start chest compressions….yet but provide ventilation, start I.V. access, and assess a rhythm and lung sounds. Let's say you find him in PEA. So, we know there is a small chance at ROSC. You give 500cc bolus of saline and perform bilateral needle decompression. Now, we have corrected all the possible issues that we are able to correct, now start CPR. After a couple of minutes with or without performing CPR you obtain ROSC and now you are transporting to the trauma center where they can get blood products and hopefully have an improved outcome.
Here is a sample algorithm from Dr. Bryan Bledsoe what illustrates what I am talking about.
Original illustration by Dr. Bryan Bledsoe
What is the takeaway here? Don't treat all traumatic arrests with a wide brush. I am all for not resuscitating the ones that are not viable, but some of these patients could have good outcomes if we assess and make the effort. Things like blood volume lost, injury patterns, rhythm, and downtime can factor into your decision whether to resuscitate or not.
Disclaimer: AHA has not officially come out advocating to delay performing CPR at all in these cases and even though some research calls for this, I suggest if you are going to resuscitate that you follow your protocols unless you are able to justify it appropriately. Or just start CPR to begin with and hope they survive before you pump all the blood out of their system. The some protocols state to initiate CPR, but it technically does not say when to do so.
There are a few spicy takes in this blog, as stated before, please don't take my word for it and research it for yourself. There are a couple of good studies on outcomes with/without CPR in addition to the Saline vs. Whole blood debate.
That is all for this post. Next up should be some thoughts on the new protocols that came out. I am curious to compare NASEMSO and current national ideology.
