Lockey et al recently published an algorithm for traumatic cardiac arrest in Resuscitation. It suggests incorporating resuscitative on-scene thoracotomy into our algorithms for traumatic cardiac arrest. It is a consequence of the very same group’s previously published data on prehospital clamshell thoracotomies in patients with cardiac arrest due to penetrating chest injuries. The algorithm comes out of prehospital thinking but is just as relevant in the ED.
Resuscitating on scene traumatic cardiac arrests (TCA) was up until not that long ago considered a hopeless prospect. The available literature suggested outcomes ranged from futile to, at best, 2% survival with poor neurological outcome. Then during the last five years or so several studies provided a more positive outlook with TCA survival rates comparable to out-of-hospital cardiac arrests (OHCA) as a whole and in sub-groups.
Of note is the London HEMS retrospective study published in 2011, also by Lockey and Davies, that demonstrated how on-scene TCAs with penetrating trauma to the chest who had an emergency thoracotomy seemed to have resulted in 18 out of the 71 patients surviving to discharge.
Key was the on-scene thoracotomy these patients had with the primary intention of relieving cardiac tamponade but also indirectly pneumothorax and hemothorax. All the survivors had right ventricle penetrating injury and cardiac tamponade and these are the patients that benefited from the thoracotomy.
The technique is called a clamshell thoracotomy, they have more than 15 years worth of experience performing it, and there is even a ‘for dummies‘ instruction available.
The algorithm in Resuscitation looks like many other TCA algorithms with an important exception. Immediately after confirming traumatic arrest/peri-arrest, but before even starting ALS/BLS one must decide if there is penetrating injury to the chest or epigastrium. If so, then one immediately proceeds with the thoracotomy. No lines, no intubating, no transportation, no chest compressions…we go directly for the thoracotomy.
Some other highlights from the article…
Diagnosis of TCA should be lightning fast. Abnormal or absent respiration and the absence of a central pulse over a 10 s period should prompt entry into the algorithm. No mucking about…
Peri-arrest is imminent cardiac arrest in these patients. These patient should too be entered into the algorithm for targeted interventions. Often after intubation.
Compressions are likely to be ineffective in hemorhagic cardiac arrest. Bleeding control and volume replacement is priority. However, diagnosing hypovolaemia is often difficult and we end up doing compressions anyway.
Standard ALS/BLS without intervention against reversible threats is not acceptable. Think H.O.T…hypotension, oxygenation and tension pneumothorax.
Don´t forget bleeding control. In the ED we all to often see trauma patients being handed over with blood seeping through bandages. Compress bleedings properly, a bandage is often not enough. It often takes 10 minutes for a clot to form. Reposition fractures. Use a tourniquet.
This is required reading. Paper lives here:
Resuscitation. 2013 Jun;84(6):738-42. doi: 10.1016/j.resuscitation.2012.12.003. Epub 2012 Dec 7. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Lockey DJ, Lyon RM, Davies GE.