Cardiac arrest month: What do you know about traumatic arrests?

Side of RRV with lozenge

So what do you know about traumatic cardiac arrest (TCA)?

It’s vitally important to recognise the differences in approach to medical cardiac arrest management. Resuscitation Council (UK) 2015 guidelines now acknowledge TCA as a special circumstance and the evidence obtained by the council recognises that, whilst it’s uncommon, there are reported survival rates of six to seven per cent..

Emphasis in TCA is placed upon recognising and treating the pertinent reversible causes otherwise known as airway obstruction, hypoxaemia/ hypoventilation and tension pneumothorax. A TCA is confirmed by the presence of agonal breathing or apnoea and the absence of central pulses in the context of a traumatic insult, injury or incident. Confirming TCA should, like medical arrests, be rapid and normally take less than 10 seconds.

It is important to ensure the critical care desk (CCD) or EOC is aware that you have a patient in TCA so that assistance can be sought in the form of critical care. Resuscitation must be started for all patients in TCA (unless the patient has conditions unequivocally associated with death) – after all, prior to the traumatic insult they were alive and well. This may involve ‘snatch rescue’ from their current position e.g. maybe they’re inside a vehicle or down a ditch. Once the arrest is confirmed, and if staffing levels allow, initiate CPR and if a medical cause is unlikely i.e. a true traumatic cardiac arrest, efforts should be made to rapidly treat the reversible causes (the four Hs and four Ts) as a matter of priority.

It is important to recognise that some reversible causes are more prevalent when associated with the TCA patient:

  • Hypoxia: basic/advanced airway management; give oxygen
  • Tension pneumothorax: bilateral needle thoracocentesis (or thoracostomy if trained)
  • Hypovolaemia: control external bleeding, splint pelvis and fractures, and IV or IO fluid resuscitation
  • Tamponade (cardiac): consider thoracotomy.

Managing a TCA needs quick decisive action with at times complex decision making. Remember what help is available to you – either CCD or the Clinical Advice Line (CAL). Patients who have been aggressively resuscitated for TCA and who have had reversible causes addressed and considered can have resuscitation stopped at the scene. 

A caution though - for penetrating trauma to the thorax/abdomen, patients should be transported rapidly to hospital (in the event of an enhanced care team not being on scene). This is due to the fact that one of the main reversible causes cannot be addressed (cardiac tamponade). Again, CAL or CCD can provide support and guidance.

So the nitty gritty:

  • Airway management must be decisive and aggressive - before attempting endotracheal intubation pause and think; ‘am I proficient at this, am I prepared, is this a difficult airway?’ There is nothing wrong with utilising a supra-glottic airway (SGA) device
  • Endtidal CO2 (ECO2) must be used for all advanced airways (supraglottic airway device or endotracheal tube); it will provide an indication of ventilation and perfusion/quality of arrest management and act as a prognostic indicator of both ROSC and in ROLE decisions
  • Bilateral needle thoracocentesis (NTC) should be performed (or thoracostomies) to decompress any tension pneumathoracies. Remember that in the context of NTC, patients can re-tension so you may need to repeat this procedure - please continue to assess. You should also consider your anatomical landmarking for NTC
  • IV/IO access should be sought early with aggressive fluid resuscitation (up-to two litres)
  • ‘Pulling limbs to length’, splinting pelvis and longbones will assist in haemorrhage control and will assist in gaining ROSC in the bleeding patient
  • CPR in TCA is still recommended, though not at the expense of addressing the key reversible causes.

Ash Richardson, Area Clinical Lead

Have any questions on traumatic arrest? Contact our area clinical leads, or Trauma Lead Chris Martin.

Want to practice your cardiac arrest management skills? There are still places left for our ‘cardiac arrest bootcamp’ on 30th November at Newmarket training centre. Open to clinicians of all levels, the bootcamp will include interactive lectures, workshops and real-life scenarios. More details available here on Need to Know.

Published 10th November, 2016

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