# Trauma code question



## AnthonyTheEmt (Sep 13, 2012)

I just had a call today that was a traumatic arrest. We transported the guy under chp command to clear the road. I pushed epi and atropine on him cuz he was in asystole. Now I know trauma was the cause of his arrest and not a medical cause. Just wanted to get your thoughts on this. He was in asystole the whole time. We also bolused him with fluid while CPR was in progress as well ventilating with bvm + opa and suctioning to keep the airway as clear as possible. We did all we could though.


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## Veneficus (Sep 13, 2012)

AnthonyTheEmt said:


> I just had a call today that was a traumatic arrest. We transported the guy under chp command to clear the road. I pushed epi and atropine on him cuz he was in asystole. Now I know trauma was the cause of his arrest and not a medical cause. Just wanted to get your thoughts on this. He was in asystole the whole time. We also bolused him with fluid while CPR was in progress as well ventilating with bvm + opa and suctioning to keep the airway as clear as possible. We did all we could though.



You did what was available to you.

I don't think it made a difference one way or the other.


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## Handsome Robb (Sep 13, 2012)

Blunt or penetrating? You did all that you could. You still give atropine to asystole? 

How far from the Trauma Center were you? Call me an :censored::censored::censored::censored::censored::censored::censored: but my protocol says call for termination orders with a blunt traumatic arrest in pea/asystole, and I would've respectfully told CHP I have protocols/SOPs I have to follow. There's no reason to endanger yourself, your partner and everyone else on the road transporting a dead body just to open a road back up...


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## AnthonyTheEmt (Sep 13, 2012)

NVRob said:


> Blunt or penetrating? You did all that you could. You still give atropine to asystole?
> 
> How far from the Trauma Center were you? Call me an :censored::censored::censored::censored::censored::censored::censored: but my protocol says call for termination orders with a blunt traumatic arrest in pea/asystole, and I would've respectfully told CHP I have protocols/SOPs I have to follow. There's no reason to endanger yourself, your partner and everyone else on the road transporting a dead body just to open a road back up...



Blunt trauma. Guy ran on the freeway and I'm sure you can imagine what happened. We would have called, and he was in the criteria that allows us to but everyone on scene was helping ready him for transport so we transported him. We were 5 minutes at the most from the nearest trauma center.


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## Melclin (Sep 13, 2012)

With the limited info it seems the pt probably could have been "called" at the scene. The following is said assuming there were no special circumstances. 

In general, CPR on scene until ROSC or death is the best option. It lends itself to better quality CPR and reduces unnecessary L/S transports of corpses. This idea is magnified in traumatic arrests. 

Giving him the drugs and fluid in all likelihood did nothing to either help or harm him. He was probably already dead. In cases like this, I think there is both evidence and well reasoned arguments to support the idea of simply not starting. If they _are going to die_, a resus means wasted resources, added danger to yourselves/the community and in some cases false hope for families. This is especially true if you get ROSC with no hope of a good outcome and the pt ends up taking up the time of a chopper/flight crew, trauma team, surgeons, a theatre, blood products and an ICU bed/resources. These things don't grow on trees and if you are sure they'll die, why not offer these same limited resources to someone who might actually benefit. 

But shouldn't we give them the best chance possible? Would you exhume a corpse and administer adrenaline and CPR in order to give him/her the best chance? Of course not, that person is clearly dead and your efforts are a waste of time and resources, and infringes on the deceased's dignity. Your pt may not have been much different. There is some pretty good evidence to guide your decision to put pts like this in the corpse category.


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## Melclin (Sep 13, 2012)

AnthonyTheEmt said:


> We were 5 minutes at the most from the nearest trauma center.



I suppose this could change things somewhat depending on your opinion of resuscitative open thoracotomies. I think London HEMS have had a little success with opening the chest early. 

On the other side of the issue you could argue that an asystolic blunt trauma pt is just as dead 5 mins from a trauma centre as they would be 5 hrs away, perhaps even if they hypothetically received their injuries on the table in theatre with a surgeon ready to go. 

Perhaps this post is more about how you feel about the job. How are you feeling about it?


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## Veneficus (Sep 13, 2012)

Melclin said:


> I suppose this could change things somewhat depending on your opinion of resuscitative open thoracotomies. I think London HEMS have had a little success with opening the chest early.



In specifically what types of injuries? 



Melclin said:


> On the other side of the issue you could argue that an asystolic blunt trauma pt is just as dead 5 mins from a trauma centre as they would be 5 hrs away, perhaps even if they hypothetically received their injuries on the table in theatre with a surgeon ready to go.



I think this is the more reasonable argument. 

Cardiac and pulmonary contusions...DAI, Solid organ disruptions, which one do you plan to fix first?

...and how exactly?


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## Doczilla (Sep 13, 2012)

Ah, the pimp cane comes out.


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## Veneficus (Sep 13, 2012)

Veneficus said:


> In specifically what types of injuries?
> 
> 
> 
> ...



Sorry,

That is a collective "you" not directed specifically at Melclin.


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## Melclin (Sep 13, 2012)

Veneficus said:


> In specifically what types of injuries?
> 
> 
> 
> ...



Penetrating traumatic arrests. They've reported a case series, I think, where they successfully resuscitated a few penetrating trauma victims that we would probably have called on scene.

I come down on the side of trying in this case being pointless but I thought I'd tip the hat to what little evidence exists on the other side of the argument.


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## Veneficus (Sep 14, 2012)

Melclin said:


> Penetrating traumatic arrests..



That is what I thought.

I was specifically taught that cracking a chest on blunt trauma was not indecated.


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## Bieber (Sep 14, 2012)

Our current protocols for traumatic arrest (blunt and penetrating) call for basic resuscitative measures (open airway, ventilate via BVM), assess for/treat tension pneumothorax if present, and if no organized ECG activity or PEA rate <20 and no response to the above treatments we terminate on scene.


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## 7887firemedic (Oct 2, 2012)

One area I work protocol is full acls, transport to trauma center unless injuries incompatible with life. Every pt is transported emergent. :banghead: The other area is pronounce on scene if injuries are incompatible with life, (unless there is organized electrical activity on the monitor ie vfib, pulseless v tach, pea), or obvious signs of death. unless,


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## Anjel (Oct 2, 2012)

7887firemedic said:


> *One area I work protocol is full acls, transport to trauma center unless injuries incompatible with life. Every pt is transported emergent*. :banghead: The other area is pronounce on scene if injuries are incompatible with life, (unless there is organized electrical activity on the monitor ie vfib, pulseless v tach, pea), or obvious signs of death. unless,



Typical Michigan Fire Department. haha I kid I kid.


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## 7887firemedic (Oct 2, 2012)

Anjel1030 said:


> Typical Michigan Fire Department. haha I kid I kid.



Actually its the ohio agency with the cruddy protocols, my michigan protocols are great


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## VFlutter (Oct 2, 2012)

Dr. Weingart (Emcrit) has an interesting approach to blunt traumatic arrests in the ED. Basically secure airway, bilateral finger throacostomy, and then US the heart. If there is a tamponade then go for a thoracotomy*. If no tamponade then call it on the spot. He recommends no ACLS drugs and no closed chest compression. 

*He only recommends a thoracotomy if the patient loses their vitals on the table. If they lost their vitals in the field or even in the ambulance then no go.


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## medictmfl (Oct 2, 2012)

Statistically traumatic arrest pt's stay dead and should be left as such, protocols permitting.

Check this out if you have time/access: 
Journal of Trauma-Injury Infection & Critical Care:
October 2011 - Volume 71 - Issue 4 - pp 997-1002

Here is the abstract:


Background: The validity of current guidelines regarding resuscitation of patients in traumatic cardiopulmonary arrest (TCPA) and the ability of emergency medical services (EMS) to appropriately apply them have been called into question. The purpose of this study is to demonstrate the consequences of violating the current published guidelines and whether EMS personnel were able to accurately identify patients in TCPA.

Methods: We conducted a retrospective review of our Level I trauma center's database that identified 294 patients over an 8-year period (January 1, 2003, to December 31, 2010) who suffered prehospital TCPA and met criteria for the withholding or termination of resuscitation based on current guidelines. Patient demographics, prehospital/emergency department physiology, survival, neurologic outcome, and hospital charges were analyzed.

Results: One of 294 patients (0.3%) survived to reach hospital discharge with a Glasgow Coma Scale score of 6. The total costs incurred for these 294 patients meeting criteria for withholding or termination of resuscitation were $3,852,446.65. One hundred seventeen (39.8%) patients were evaluated by more than one EMS team. There was 100% agreement on the presence (15 of 15) or absence (102 of 102) of a pulse between the EMS teams.

Conclusions: Our data support the current guidelines regarding the withholding or termination of resuscitation of patients in prehospital TCPA and represent the largest series to date on this topic. EMS personnel were able to accurately determine traumatic cardiac arrest in the field in this series. Violation of the current guidelines resulted in six patients being resuscitated to a neurologically devastated state. No loss of neurologically intact survivors would have resulted had strict adherence to the guidelines been maintained.

Of course Mark Twain said there were three types of lies;lies, damn lies, and statistics... but he wasn't a trauma surgeon either.


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## JPINFV (Oct 2, 2012)

The correct action would be to ask where the police officer went to medical school, and follow up with asking why he is practicing medicine without a license.


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## Anonymous (Oct 3, 2012)

I thought atropine was removed from AHA guidlines for asystole?


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## arici (Oct 3, 2012)

Anonymous said:


> I thought atropine was removed from AHA guidlines for asystole?



It was. 
So how did you use atropine for the asystole then?
Is that allowed?


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## MediMike (Oct 3, 2012)

Guidelines are just that...guidelines.  Individual MPDs can keep it in their protocols if they want, heck they can put whatever they want in their protocols (within reason).  I know of several (anecdotally) who have kept it in their protocols simply because it hasn't been shown to do any harm so why drop it.


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## Aidey (Oct 3, 2012)

Maybe because it hasn't been proven to help? You could argue leeches aren't any more harmful than atropine, so why don't we use them too.


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## MediMike (Oct 3, 2012)

Take off all the drugs that haven't been proven to help and your arsenal is gonna be pretty damn slim.  I didn't say I wanted it in the protocols, I said MPDs are keeping them in there.


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## Commonsavage (Nov 1, 2012)

*Just wondering...*



AnthonyTheEmt said:


> We transported the guy under chp command to clear the road.



Why would you do this?  Is this SOP in your district...to act under CHP command?  I would have worked it just as any other trauma code, and called it after basic resuscitive efforts failed.  If LE requested body removal, and that is not within my SOP, I contact my MD and or supervisor.
It's a fatality. We wait for OMI to take possession of the body.  Traffic can wait, or be redirected, unless there is some sign of imminent danger to others.


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## Handsome Robb (Nov 1, 2012)

Commonsavage said:


> Why would you do this?  Is this SOP in your district...to act under CHP command?  I would have worked it just as any other trauma code, and called it after basic resuscitive efforts failed.  If LE requested body removal, and that is not within my SOP, I contact my MD and or supervisor.
> It's a fatality. We wait for OMI to take possession of the body.  Traffic can wait, or be redirected, unless there is some sign of imminent danger to others.



Agreed. I'd love to know the county coroner's take on disturbing a crime scene or transporting a deceased body "to keep the road open". 

Last time I checked most CHP officers aren't medics and even if they are, the ambulance or fire paramedic is the medical authority on scene. 

"Sir I'm sorry you have to close the road but I'm not risking mine, my partner's, a firefighter's and everyone else's lives on the road to transport a dead body code 3. Not to mention the financial burden placed on the deceased's family by us transporting them and having a trauma team activation."


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## JDallas (Dec 20, 2012)

NVRob said:


> Agreed. I'd love to know the county coroner's take on disturbing a crime scene or transporting a deceased body "to keep the road open".
> 
> Last time I checked most CHP officers aren't medics and even if they are, the ambulance or fire paramedic is the medical authority on scene.
> 
> "Sir I'm sorry you have to close the road but I'm not risking mine, my partner's, a firefighter's and everyone else's lives on the road to transport a dead body code 3. Not to mention the financial burden placed on the deceased's family by us transporting them and having a trauma team activation."



I concur wholeheartedly with the above quote


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