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Complex Situations (SLO7)
This was previously featured in an exam
This was previously featured in an exam
Question 64 of 148
You are involved in a trauma case with multiple casualties following a major road traffic collision. You are leading cardiopulmonary resuscitation on a patient with blunt abdominal trauma who was estimated to have lost cardiac output 45 minutes ago. The surgical registrar requests that you prepare to perform resuscitative thoracotomy. Your consultant is currently tied up intubating a young child from the same incident and cannot be disturbed for advice. What is the most appropriate course of action?
Answer:
- Consider resuscitative thoracotomy for patients with penetrating torso trauma and less than 15 min of CPR and patients with blunt trauma with less than 10 min of CPR. Thoracotomy will enable evacuation of pericardial blood to relieve cardiac tamponade and repair of simple cardiac wounds.
- Patients with no pulse after penetrating chest or cardiac injuries, who arrive at hospital after a short on-scene and transport time with witnessed signs of life or ECG activity, are candidates for emergency department resuscitative thoracotomy.
- In this case, resuscitative thoracotomy is not indicated.
Traumatic Cardiac Arrest
Resuscitation / Trauma
Last Updated: 4th August 2021
Traumatic cardiac arrest has a very high mortality, but when ROSC is achieved, neurological outcome in survivors appears to be much better than in other causes of cardiac arrest. The response to traumatic cardiac arrest is time-critical and success depends on rapidly identifying and treating the reversible causes.
The history and scene assessment may provide clues to the cause of cardiac arrest. Cardiac arrest from a primary medical problem (e.g. cardiac arrhythmia, hypoglycaemia, seizure) may cause a secondary traumatic event (e.g. fall, road traffic accident). In these cases, standard advanced life support is appropriate.
Causes of cardiac arrest in trauma patients includes:
- Severe traumatic brain injury
- Hypovolaemia from massive haemorrhage
- Hypoxia from respiratory arrest
- Direct injury to vital organs and major vessels
- Tension pneumothorax
- Cardiac tamponade
Treatment of cardiac arrest:
- Survival from traumatic cardiac arrest is correlated with duration of CPR and pre-hospital time. Factors that are associated with survival include the presence of reactive pupils, an organised ECG rhythm and respiratory activity.
- Prolonged CPR is associated with a poor outcome; if there is no response after 20 minutes of advanced life support, stop further resuscitation efforts.
- Chest compressions are still the standard of care in patients with cardiac arrest, irrespective of cause. In cardiac arrest caused by hypovolaemia, cardiac tamponade or tension pneumothorax, chest compressions are unlikely to be as effective as in normovolaemic cardiac arrest. Thus, chest compression have a lower priority than the immediate treatment of reversible causes (e.g. thoracotomy, controlling haemorrhage etc.).
- Focused ultrasound can help diagnose haemoperitoneum, haemopneumothorax, tension pneumothorax and cardiac tamponade. This requires a trained operator and should not delay treatment. In more stable patients who are not in cardiac arrest, early whole-body CT scanning as part of the primary survey will help identify injuries and guide treatment.
Hypovolaemia
- Uncontrolled haemorrhage is the cause of traumatic cardiac arrest in 48% of cases, so early haemorrhage control is essential.
- Treat compressible external haemorrhage with elevation and direct pressure (with or without a dressing), use tourniquets if needed and/or apply topical haemostatic agents.
- Non-compressible haemorrhage is more difficult; use splints, blood products, IV fluids and tranexamic acid while moving the patient to surgical/radiological haemorrhage control.
- In the presence of uncontrolled bleeding, excessive fluid will increase the bleeding; the NICE recommendations include giving 250 ml boluses of crystalloid solution until radial pulse is achieved and not delaying rapid transport of trauma victims for fluid infusion.
- Use IO access when IV access is not initially feasible.
- The early use of blood products as a primary resuscitation fluid may improve outcomes and prevent trauma-induced coagulopathy.
- Aiming for a systolic blood pressure of 80-90 mmHg until definitive bleeding control may help prevent further blood loss but may be harmful in patients with a traumatic brain injury, where a higher blood pressure can be beneficial to the injured brain.
Hypoxia
- Effective airway management is essential to maintain oxygenation of the severely compromised trauma patient. Early tracheal intubation can be beneficial. Use basic airway management manoeuvres and alternative airways to maintain oxygenation if tracheal intubation cannot be accomplished immediately. If these measures fail, a surgical airway is indicated.
- In low cardiac output conditions, positive pressure ventilation causes further circulatory depression, or even cardiac arrest, by impeding venous return to the heart. Monitor ventilation with continuous waveform capnography. This may enable slow respiratory rates and low tidal volumes and the corresponding decrease in transpulmonary pressure may increase venous return and cardiac output.
- During CPR, use 100% oxygen. In peri-arrest or post-ROSC patients, titrate oxygen to achieve a SpO2 of 94 - 98%.
Tension pneumothorax
- To decompress the chest in traumatic cardiac arrest, perform bilateral thoracostomies in the 5th intercostal space, extending to a clamshell thoracotomy if required. In the presence of positive pressure ventilation, thoracostomies are likely to be more effective than needle thoracocentesis and quicker than inserting a chest tube.
- A significant proportion of patients have a chest wall that is too thick to be decompressed with a standard length 14-gauge cannula. Cannulae are also prone to kinking and blockage so this is a very temporary measure. Any attempt at needle thoracocentesis should be followed by insertion of a chest tube. The needle can be placed in the 2nd intercostal space in the midclavicular line or in the 5th intercostal space in the midaxillary line.
Cardiac tamponade
- Cardiac tamponade occurs when the pericardial sac is filled with fluid under pressure, which leads to compromise of cardiac function and ultimately cardiac arrest.
- It most commonly occurs after penetrating trauma and cardiac surgery. Mortality is high and immediate decompression of the pericardium is required to give any chance of survival.
- In traumatic cardiac arrest with penetrating trauma to the chest or epigastrium, immediate resuscitative thoracotomy with a clamshell incision can be life-saving.
- Needle aspiration of tamponade, with or without ultrasound guidance, is unreliable because the pericardium is commonly full of clotted blood.
Resuscitative thoracotomy
- Consider resuscitative thoracotomy for patients with penetrating torso trauma and less than 15 min of CPR and patients with blunt trauma with less than 10 min of CPR. Thoracotomy will enable evacuation of pericardial blood to relieve cardiac tamponade and repair of simple cardiac wounds.
- Patients with no pulse after penetrating chest or cardiac injuries, who arrive at hospital after a short on-scene and transport time with witnessed signs of life or ECG activity, are candidates for emergency department resuscitative thoracotomy.
- The chances of success are much lower when cardiac arrest results from blunt trauma.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
