# Trauma Code/Order of Interventions



## jaksasquatch (Aug 27, 2013)

Hey all, 

   I'm a recent EMT graduate who recently became certified. I have a question for the vets that was not really addressed well in my EMT class. 2010 AHA guidelines state that we should be using CAB in pulseless, apneic patients. It was also stated in my EMT textbook that the AED is not indicated for a trauma cardiac arrest patient. When applied to a traumatic cardiac arrest due to let's say a amputation causing hypovolemia would I attempt to stop bleeding before compressions? Obviously this is a question of little worth as in the field I would have a partner to stop the bleeding while I work the pt (if protocols allow) Also is the AED really not indicated in traumatic cardiac arrest patients? I would think they could be in VT or VF due to medical causes and it could still shock.


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## brian328 (Aug 27, 2013)

http://www.emtlife.com/showthread.php?t=32750

There is a lot of good info in that thread

Edit: long story short, theres nothing you can do in the field. This pt would require surgery and unless this happens pretty much in the hospital parking lot, chances of survival are slim to none.


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## Rialaigh (Aug 27, 2013)

jaksasquatch said:


> Hey all,
> 
> I'm a recent EMT graduate who recently became certified. I have a question for the vets that was not really addressed well in my EMT class. 2010 AHA guidelines state that we should be using CAB in pulseless, apneic patients. It was also stated in my EMT textbook that the AED is not indicated for a trauma cardiac arrest patient. *When applied to a traumatic cardiac arrest due to let's say a amputation causing hypovolemia would I attempt to stop bleeding before compressions*? Obviously this is a question of little worth as in the field I would have a partner to stop the bleeding while I work the pt (if protocols allow) Also is the AED really not indicated in traumatic cardiac arrest patients? I would think they could be in VT or VF due to medical causes and it could still shock.



Basic order of events for BLS would be Control bleeding, load up, haul ***.

for ALS it would be Control bleeding, Fluid Bolus's (pressure bagged), and CPR.



As it has been pointed out though, this patient is dead unless you are really really close to a level 1 trauma center.


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## Bullets (Aug 27, 2013)

Amputation + Cardiac Arrest to hypovolemia = dead....i probably would even work that patient. Pronounce on scene


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## broken stretcher (Aug 29, 2013)

AED is not indicated at first because the reason people arrest form trauma is due to blood loss (hypovolemic shock). When the heart doesn't have enough blood volume it goes crazy and we get PEA (Pulseless electrical activity). The person could still be in a normal sinus rhythm but have no pulse due to loss of volume in the circulatory system. The AED won't shock unless its VT of VF. Eventually however, the hypovolemic shock will cause the heart to go in to VF or VT and then its AED time.


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## VFlutter (Aug 29, 2013)

Bullets said:


> Amputation + Cardiac Arrest to hypovolemia =  dead....i probably would even work that patient. Pronounce on  scene



There is a difference between a cardiac arrest related to trauma/hypovolemia and a blunt traumatic cardiac arrest. While both have a low survival rate I think some hypovolemic arrests should be worked unlike blunt arrests that should be pronounced on scene. 

In my opinion if a patient has a traumatic amputation and arrests due to hypovolemia there should be consideration for resuscitation, volume replacement, and hemorrhage control. Of course if they bled our their entire blood volume then there is no point but in some cases hypovolemic arrests bounce back after some volume resuscitation (Most importantly blood products). Distance to nearest trauma center is a major consideration as well.


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## Handsome Robb (Aug 29, 2013)

Amputation causing an arrest? 

Tourinquet, compressions, volume replacement, airway, monitor, diesel...if you're close to a hospital. Ill take any hospital at this point, as long as they have blood products.

For BLS everything except volume replacement and monitor but you need to replace that with your AED.


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## chaz90 (Aug 29, 2013)

In hypovolemic cardiac arrests, defibrillation (even when indicated) isn't going to do a heck of a lot. Even if a terminal rhythm is successfully converted, it will just go back to pumping nothing around again.


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## Bullets (Aug 29, 2013)

Chase said:


> In my opinion if a patient has a traumatic amputation and arrests due to hypovolemia there should be consideration for resuscitation, volume replacement, and hemorrhage control. Of course if they bled our their entire blood volume then there is no point but in some cases hypovolemic arrests bounce back after some volume resuscitation (Most importantly blood products). Distance to nearest trauma center is a major consideration as well.





Robb said:


> Amputation causing an arrest?
> 
> Tourinquet, compressions, volume replacement, airway, monitor, diesel...if you're close to a hospital. Ill take any hospital at this point, as long as they have blood products.
> 
> For BLS everything except volume replacement and monitor but you need to replace that with your AED.



What is ALS going to replace the lost blood with? NS and LR arent going to assist in moving oxygen to cells, which is the whole reason why i thought we got away from fluid in trauma

Closed blunt traumatic arrest is also reason to not attempt resuscitation, per the NAEMSP. 

Basically, traumatic arrests have little support for doing CPR, the Eagles dont support it, NAEMSP doesnt support it, why should we? I think as we do more research, this will only become more apparent

http://www.naemsp.org/MDC Reference...d Termination of traumatic cardiac arrest.pdf

http://www.jems.com/article/news/coding-penetrating-and-blunt-trauma-arre


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## STXmedic (Aug 29, 2013)

Bullets said:


> What is ALS going to replace the lost blood with? NS and LR arent going to assist in moving oxygen to cells, which is the whole reason why i thought we got away from fluid in trauma
> 
> Closed blunt traumatic arrest is also reason to not attempt resuscitation, per the NAEMSP.
> 
> ...



Until an effective oxygen-carrying fluid is developed (relatively cheaply), NaCl and LR are our only options. They obviously aren't the best options, but they will at least hopefully help keep a somewhat perfusing pressure.

The key with fluid replacement, or really any intervention in a significant trauma response, is to not waste time performing it. Surgical traumas are about the only time I will grab and go, and do everything en route.

Are people still actually performing CPR on traumatic arrests? Save BLS only units, or anybody in Cali 

Edit: Just to clarify, I was referring to fluids only helping to maintain a perfusing blood pressure, not bilateral 14s with as much fluid as we can make fit. That whole permissive hypotension thing and all


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## Handsome Robb (Aug 30, 2013)

Bullets said:


> What is ALS going to replace the lost blood with? NS and LR arent going to assist in moving oxygen to cells, which is the whole reason why i thought we got away from fluid in trauma
> 
> Closed blunt traumatic arrest is also reason to not attempt resuscitation, per the NAEMSP.
> 
> ...



There are ALS services out there with blood. Or if ground doesn't have it HEMS often does. 

Blunt traumatic arrests are done, nothing we can do. Penetrating trauma is a different story. While the survivability is low, they still are survivable. For what it's worth we only transport penetrating trauma if its within 10 minutes of the trauma center, otherwise we call for orders.

We didnt get away from fluid in trauma. We got away from the bilateral 14s and WFO normal saline in exchange for permissive hypotension.


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## Rialaigh (Aug 30, 2013)

Robb said:


> There are ALS services out there with blood. Or if ground doesn't have it HEMS often does.
> 
> Blunt traumatic arrests are done, nothing we can do. Penetrating trauma is a different story. While the survivability is low, they still are survivable. For what it's worth we only transport penetrating trauma if its within 10 minutes of the trauma center, otherwise we call for orders.
> 
> We didnt get away from fluid in trauma. We got away from the bilateral 14s and WFO normal saline in exchange for permissive hypotension.




I guess point being in a traumatic arrest (lets assume penetrating) Then bilateral 14's and WFO NS is all you got while you stop the bleeding, haul ***, and begin compressions.. Pressure bagging blood in at the hospital through a 14 is better than through a 20. 


If the patient has a pulse and a pressure then permissable hypotension is absolutely the way to go, if they just arrested in front of you do to volume loss then as much as you can put into them...


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## Handsome Robb (Aug 30, 2013)

Rialaigh said:


> I guess point being in a traumatic arrest (lets assume penetrating) Then bilateral 14's and WFO NS is all you got while you stop the bleeding, haul ***, and begin compressions.. Pressure bagging blood in at the hospital through a 14 is better than through a 20.
> 
> 
> If the patient has a pulse and a pressure then permissable hypotension is absolutely the way to go, if they just arrested in front of you do to volume loss then as much as you can put into them...



I think we're not understanding each other hah. From what it sounds like we're agreeing, I just didn't verbalized my thoughts well. 

In a serious trauma they're getting two large lines, and yes in a traumatic arrest they're going to be wide open but if we get pulses back and a BP I'm ok with they're getting dialed back really quickly. 

Another thing I'd consider is bilateral needle decompressions depending on the location and type of trauma, obviously.


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## Carlos Danger (Aug 30, 2013)

It really depends on the MOI, time down, medical hx (whatever you can get), and transport time to the hospital. 

There's a big difference between a 65 year old with CAD and DM who was crushed between a truck and loading dock and has been apneic for 30 minutes and is an hour away from the trauma center, and a 17 year old cross-country runner who was accidentally shot in the abdomen and HEMS is 5 minutes away with blood and can have him at the trauma center in 20.

I don't like protocols that say "traumatic arrests shall not be worked" or ones that say "traumatic arrest shall receive full resuscitation efforts and transport".

Traumatic arrests of any type have a very low chance of successful resuscitation, but there is a lot of grey area.


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## jaksasquatch (Aug 31, 2013)

Dang I didn't think there would be this many responses. It really helped me see that there is a gray area here. I should post on here more often ya'll really know your stuff. 

   If I have this straight. BLS is bleeding control, load, and work on the way. No time to play around on scene. Maybe don't work at all if trauma center is a far cry away. 


   BTW are there any videos or illustrations that would be helpful as I'm looking for an EMT  job and preparing for medic school in the future?


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## Bullets (Aug 31, 2013)

Im sure some of the Medics here will have my head, but Trauma is the BLS specialty. Above any other illness we encounter, 99% of traumas can be effectively managed by BLS. Only pnuemothorax needs ALS (in NJ) Controlling the bleeding and quick access to a surgical team are shown to be the keys in surviving traumatic injuries. Extended scene times are also shown to be bad for patient outcomes

Pressure, Tourniquet, and gas pedal


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## Rialaigh (Sep 1, 2013)

Robb said:


> I think we're not understanding each other hah. From what it sounds like we're agreeing, I just didn't verbalized my thoughts well.
> 
> In a serious trauma they're getting two large lines, and yes in a traumatic arrest they're going to be wide open but if we get pulses back and a BP I'm ok with they're getting dialed back really quickly.
> 
> Another thing I'd consider is bilateral needle decompressions depending on the location and type of trauma, obviously.





Absolutely 


I wish we could do needle decompression for suspected hemothorax. Per protocol we can only do it for pneumo's, I am sure we could pull a "I thought it was a pnuemo" card if it was that serious and we did the right thing. 

Some states allow needle decompression where you would put a chest tube, in that case I would think you could consider dropping 2 or 3 needles on the side you need (to attempt to begin to relieve a hemo). 





Halothane said:


> It really depends on the MOI, time down, medical hx (whatever you can get), and transport time to the hospital.



Considering there is not a level one trauma center my county (there is one close in the next county). The only traumatic arrest I could see working is one that occurs AFTER I get on scene or during transport. If they don't have a pulse when EMS gets there, they are dead. I could see working a penetrating trauma for 10-15 minutes until flight gets there if they arrested in front of me and I had a reasonable assumption I could limit bleeding somewhat and do some fluid replacement along with securing an airway.


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## Wayfaring Man (Sep 1, 2013)

jaksasquatch said:


> Dang I didn't think there would be this many responses. It really helped me see that there is a gray area here. I should post on here more often ya'll really know your stuff.
> 
> If I have this straight. BLS is bleeding control, load, and work on the way. No time to play around on scene. Maybe don't work at all if trauma center is a far cry away.



It really depends on what you're doing.

With the original scenario, we wouldn't even work that in MD.  Dude's DOA, and since July's protocol update we can now pronounce them in the field d/t injuries incompatible with life.

As for the load-and-go/stay-and-play debate, that's always an important early decision.  Usually if the patient is priority 1 or 2, it's a load-and-go.  If they're priority 3, we can stay and play.

Follow your ABCs, and based on that, if they are bleeding and it's a life threat that you need to address straight away, you need to fix that.  On the plus side, if they're spurting from an arterial bleed, they have a pulse so CPR averted for now.  If they're super dead and you do CPR and they're draining out, depends where from.  Can we realistically stop a horrible bleed out of a head wound that is dumping blood and brain every compression in the field?  Nope.  Dude is dead.

If he's super wounded but still alive, for a multi-trauma by MVA I'm going to actually decide to transport  by chopper because we have that luxury here.  You might need to transport by ground.  Regardless, in the case of a traumatic arrest, in MD, we can call it in the field if they are in asystole.  If they're in something other than asystole, we work them on site for 15 minutes and then consult for pronouncement.  So that's not a "load-and-go" for us because we do CPR in the field for 15 minutes before transport here.

We load-and-go for a penetrating trauma if we can get them to a trauma center in 15 minutes and they have something other than asystole, but I'm not entirely sure that's a plausible scenario for "found dude without his leg."

Dude's dead is a stay and play, unless you're in a state that requires definitive care to make a pronouncement.


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## Carlos Danger (Sep 1, 2013)

Rialaigh said:


> I wish we could do needle decompression for suspected hemothorax. Per protocol we can only do it for pneumo's, I am sure we could pull a "I thought it was a pnuemo" card if it was that serious and we did the right thing.
> 
> Some states allow needle decompression where you would put a chest tube, in that case I would think you could consider dropping 2 or 3 needles on the side you need (to attempt to begin to relieve a hemo).



The problem with relieving a hemo is that sometimes the blood you are draining is tamponading ongoing bleeding, and by relieving the pressure you can cause faster exsanguination. This is probably especially likely if the bleed was bad enough to make s/s of a hemo evident in the prehospital setting. If you don't have blood available or the means to autotransfuse, that can make for big problems.

I think that is a large part of the reason why chest tubes are not more commonly done in the field. Needles generally make a decent temporizing measure for a pneumo, and draining a hemo is a different animal altogether. Chest tubes can be pretty risky if you have no way of replacing blood volume.


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## Rialaigh (Sep 1, 2013)

Halothane said:


> The problem with relieving a hemo is that sometimes the blood you are draining is tamponading ongoing bleeding, and by relieving the pressure you can cause faster exsanguination. This is probably especially likely if the bleed was bad enough to make s/s of a hemo evident in the prehospital setting. If you don't have blood available or the means to autotransfuse, that can make for big problems.
> 
> I think that is a large part of the reason why chest tubes are not more commonly done in the field. Needles generally make a decent temporizing measure for a pneumo, and draining a hemo is a different animal altogether. Chest tubes can be pretty risky if you have no way of replacing blood volume.



True, but then you have to weigh the concern in the field of blood loss verse airway issue. If its a single stab wound through a lung (best as you can tell in the field) I would be tempted to place a couple needles if the patient was maintaining any blood pressure at all. Obviously needle decompression for a hemo in a traumatic arrest is...well..useless in the field.


At this point its really discussing technicalities on issues that arise 1 in a million calls, each traumatic arrest is going to be so different (penetrating that is) that whether you call it or work it and how savable the patient is is depandant on a million things.


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## MackTheKnife (Sep 1, 2013)

broken stretcher said:


> AED is not indicated at first because the reason people arrest form trauma is due to blood loss (hypovolemic shock). When the heart doesn't have enough blood volume it goes crazy and we get PEA (Pulseless electrical activity). The person could still be in a normal sinus rhythm but have no pulse due to loss of volume in the circulatory system. The AED won't shock unless its VT of VF. Eventually however, the hypovolemic shock will cause the heart to go in to VF or VT and then its AED time.



I remember when PEA was called EMD- ElectroMechanical Dissociation.


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## mycrofft (Sep 2, 2013)

second EMD.

Churchill said if you're going to kill a man it costs nothing to be polite.
Ditto AED.


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