# Traumatic Arrest stop CPR?



## sneauxpod (Nov 13, 2012)

So this didnt happen to me, but a friend from work was telling me about this run they went on the other day. Mid-30s Male was struck by a vehicle going 40+ in a residential area. When they got on scene there was already a large crowd gathered and police on scene. They get to the patient and he has severe head, facial and chest trauma and deformity amongst other things. CPR had been administered prior to arrival, pulse had returned and then after another check had stopped so CPR was re-initiated. The PT is severely bleeding and with every compression blood is coming out of his mouth. Additional help is coming hot but they are about 15mins away. There arent enough trained hands on scene to move the patient so everything is being done on scene. Once the second crew arrives the PT is moved to the ALS rig and transported to the hospital. He is pronounced DOA at the hospital. I am not exactly sure what the protocol in my friends area is, but if I was on scene I would have contacted med control and seen if they wanted me to call on scene or continue. What Do you think? Should the PT have been called on scene or did my friend do the right thing?


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## STXmedic (Nov 13, 2012)

Just from the details there, I wouldn't have even had to call med control to call that patient. He would not have been transported.


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## Medic Tim (Nov 13, 2012)

sneauxpod said:


> So this didnt happen to me, but a friend from work was telling me about this run they went on the other day. Mid-30s Male was struck by a vehicle going 40+ in a residential area. When they got on scene there was already a large crowd gathered and police on scene. They get to the patient and he has severe head, facial and chest trauma and deformity amongst other things. CPR had been administered prior to arrival, pulse had returned and then after another check had stopped so CPR was re-initiated. The PT is severely bleeding and with every compression blood is coming out of his mouth. Additional help is coming hot but they are about 15mins away. There arent enough trained hands on scene to move the patient so everything is being done on scene. Once the second crew arrives the PT is moved to the ALS rig and transported to the hospital. He is pronounced DOA at the hospital. I am not exactly sure what the protocol in my friends area is, but if I was on scene I would have contacted med control and seen if they wanted me to call on scene or continue. What Do you think? Should the PT have been called on scene or did my friend do the right thing?


If you aren't going to load and go with this pt there is no need to ever start. Why couldnt the initial crew load and go? The only things that we can do for these pts are A. Call it or B. Get them to surgery ASAP. Acls will do nothing for this pt.

Was the pt in arrest one ems arrival or arrest in their presence? How far from a trauma center were they?

Blunt trauma arrest = injuries incompatible with life. 

I would have called it there...no olmc needed. 

If it was witnessed I have the option of load and go or bls code for 5 rounds and if no rosc call it. If we are less than 15 to trauma center.


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## sneauxpod (Nov 13, 2012)

> Was the pt in arrest one ems arrival or arrest in their presence? How far from a trauma center were they?



He was in arrest on arrival, but there was a confirmed pulse by 2 police officers a minute or two prior to arrival so im guessing either it stopped again or the officers are total idiots. so i guess technically it was witnessed.



> If it was witnessed I have the option of load and go or bls code for 5 rounds and if no rosc call it. If we are less than 15 to trauma center.



Im pretty sure the only als they did was dropped an ET in him. besides that it was all bls. and they were about 15 from lv 1 trauma, im not sure as to why they didnt just load and go though. but im with you, I would have just called on scene.


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## NYMedic828 (Nov 13, 2012)

exsanguinating blood loss is incompatible with life.

His injuries are incompatible with life.

His lack of a pulse is incompatible with life.


DOA.


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## TransportJockey (Nov 13, 2012)

Would have called it on scene. Blunt trauma arrests are statistically a crap shoot.


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## NYMedic828 (Nov 13, 2012)

TransportJockey said:


> Would have called it on scene. Blunt trauma arrests are statistically a crap shoot.



all trauma arrests are arguably a crapshoot.


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## TransportJockey (Nov 13, 2012)

NYMedic828 said:


> all trauma arrests are arguably a crapshoot.



Penetrating has a slightly higher percentage of saves, but yes, it's pretty much a crapshoot all around


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## sneauxpod (Nov 13, 2012)

I agree. Best case scenario for traumatic arrest, have it outside the entry doors to a lv 1 trauma ER.


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## Farmer2DO (Nov 14, 2012)

sneauxpod said:


> or the officers are total idiots.



I don't know how fair that is, though.  Police aren't paramedics.  I don't know all the laws, and how to do their jobs, and I don't expect them to know how to do mine.  This is more of an evolving attitude over the years from seeing good people do the best they know how to do.  Hell, there are EMTs that I don't trust to do a decent assessment.  When someone non-medical says the patient had a pulse after something like this, I take it with a grain of salt, and realize they probably didn't.



NYMedic828 said:


> all trauma arrests are arguably a crapshoot.



To be fair though, there are a small percentage that have reversible causes (tension pneumothorax, pericardial tamponade) and at least deserve a decent assessment, rather than walking up and saying "Oh, he's a trauma arrest?  He's dead. See ya.", like some of my co-workers are known to do.


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## sneauxpod (Nov 14, 2012)

> I don't know how fair that is, though.  Police aren't paramedics.  I don't know all the laws, and how to do their jobs, and I don't expect them to know how to do mine.  This is more of an evolving attitude over the years from seeing good people do the best they know how to do.  Hell, there are EMTs that I don't trust to do a decent assessment.  When someone non-medical says the patient had a pulse after something like this, I take it with a grain of salt, and realize they probably didn't.



Im not expecting them to do my job, as far as I am concerned, if you are a police officer, you have gone through a first aid class at some point in your career, or at least have figured out over the course of your life what a pulse is, a few places you can get one, and what it feels like. that really isnt asking too much of anyone. And quite frankly, I think it should be a requirement to get a CPR card in High School. whether or not you keep it up afterwards is your choice. just my opinion though.


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## STXmedic (Nov 14, 2012)

I seem to remember seeing an article about different types of providers and their ability- or rather inability- to distinguish between having a pulse and not. I believe it showed EMTs, paramedics, nurses, and lay people. The results, if I recall correctly, weren't that outstanding for any group. I'll see of I can find the article later, I failed to find it while on my phone. 

Regardless, if you have an excited police officer with little to no medical training looking for a pulse, I could see it going either way. Either he can't find one due to looking in the wrong area, or feels his own pulse and mistakes it for the patients.


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## sneauxpod (Nov 14, 2012)

I could buy if one did that, but for both to say they felt a pulse and be wrong seems to lean towards the realm of unlikelihood I think at least. I would actually like to read that article if you can find it though, because personally, the only pulse ive ever really had a hard time with is pedal pulses only because I never really got a chance to do them during school or working.


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## STXmedic (Nov 14, 2012)

sneauxpod said:


> I could buy if one did that, but for both to say they felt a pulse and be wrong seems to lean towards the realm of unlikelihood I think at least.


 Power of suggestion? I find it very likely if neither know what they're doing. Not fighting with you, more just playing devils advocate. 





> I would actually like to read that article if you can find it though, because personally, the only pulse ive ever really had a hard time with is pedal pulses only because I never really got a chance to do them during school or working.



I'm at a mass cas exercise today, but I'll certainly look for it when I get home


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## sneauxpod (Nov 14, 2012)

PoeticInjustice said:


> Power of suggestion? I find it very likely if neither know what they're doing. Not fighting with you, more just playing devils advocate.
> 
> I'm at a mass cas exercise today, but I'll certainly look for it when I get home



Oh no didnt take it like that at all lol. I play DA all the time so I can kind of sense when someone else does it haha. 

Sounds pretty interesting, let us know how that goes.


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## Anjel (Nov 14, 2012)

Nothing to do with protocol or anything. But the medics I work with would of taken that to the ER or pronouncement.

We don't work in a great area, and mist people don't think twice about pulling a gun, so when we have a huge crowd like that, we will transport, just to save the drama of leaving a dead person on the street.


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## sneauxpod (Nov 14, 2012)

Gotta love our mitten!


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## Bullets (Nov 20, 2012)

DOA, dont waste the time doing any work. 

Any chance one cop felt for a pulse while the other was doing compressions? Blunt trauma with a the visible deformities you describe are all reasons to not even start


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## Mad Russian (Nov 30, 2012)

Overall survival rate in traumatic arrest is 3% these people generally stay dead, I would have presumed him on scene.


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## Veneficus (Nov 30, 2012)

Mad Russian said:


> Overall survival rate in traumatic arrest is 3% these people generally stay dead, I would have presumed him on scene.



That is somewhat of a misleading number.

When you break it down into penetrating arrest, the local variance is between 6-8% usually.

The blunt arrest is <1% 

to call it an overall 3% I think is an oversimplification of a more complex statistic that does not reflect reality.


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## Ace 227 (Nov 30, 2012)

Had a traumatic arrest about 2 hours ago. Blunt trauma from an MVA. CPR started, pt was tubed and IO'd and had one round of epi. When he was still asystole we stopped.


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## bigbaldguy (Nov 30, 2012)

NYMedic828 said:


> all trauma arrests are arguably a crapshoot.



All arrests are a crap shoot  its like Vegas there are only enough winners to give the illusion it's worth playing the game.


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## bigbaldguy (Nov 30, 2012)

Veneficus said:


> That is somewhat of a misleading number.
> 
> When you break it down into penetrating arrest, the local variance is between 6-8% usually.
> 
> ...



That's what I said and everybody threw stuff at me 

I still think its ridiculous that we'll work an 80 year old in cardiac arrest from an MI but not an 18 year old in cardiac arrest from a GSW. Yes there's maybe a 5 percent greater chance of saving the 80 year old but we all know it's probably not going to end well. I still think its primarily a money issue.


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## Clare (Dec 1, 2012)

I wouldn't commence resuscitation on this patient nor would I expect anybody to.


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## AUSEMT (Dec 6, 2012)

bigbaldguy said:


> All arrests are a crap shoot  its like Vegas there are only enough winners to give the illusion it's worth playing the game.



agreed,
this guy had one chance and one chance only:
an ER doc (scott weingart) was walking past and did an open clamshell thoracotomy there and then as well as a surgical airway... even then his chances suck...

CPR is useless in traumatic arrest,
compressing a chest with shredded vessels/ shredded heart/ tamponade/heamopneumothorax is kicking a corpse...<_<

on the bright side, the 0.1% of times you do get ROSC is extremely rewarding


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## Farmer2DO (Dec 6, 2012)

bigbaldguy said:


> I still think its ridiculous that we'll work an 80 year old in cardiac arrest from an MI but not an 18 year old in cardiac arrest from a GSW. Yes there's maybe a 5 percent greater chance of saving the 80 year old but we all know it's probably not going to end well. I still think its primarily a money issue.



I don't think it's ridiculous at all.  CPR and ACLS are designed to work on patients that have a presumed cardiac (medical) etiology for their arrest, not for trauma.  Unless you can get the patient to someone that can open their chest within 5 minutes of arrest (and that's a stretch) all you're doing is wasting time, money, and effort, and beating on a corpse.  Pumping on the chest and pushing epi isn't going to do squat for a hole in the guy's ventricle.  IMHO, either work them all the way or don't do it at all.  Doing a few rounds of ACLS on a trauma patient and then calling them is just crappy medicine, again, IMHO.


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## Veneficus (Dec 6, 2012)

Farmer2DO said:


> I don't think it's ridiculous at all.  CPR and ACLS are designed to work on patients that have a presumed cardiac (medical) etiology for their arrest, not for trauma.  Unless you can get the patient to someone that can open their chest within 5 minutes of arrest (and that's a stretch) all you're doing is wasting time, money, and effort, and beating on a corpse.  Pumping on the chest and pushing epi isn't going to do squat for a hole in the guy's ventricle.  IMHO, either work them all the way or don't do it at all.  Doing a few rounds of ACLS on a trauma patient and then calling them is just crappy medicine, again, IMHO.



I agree.

I would add only that if you do not have the ability to actually use some sort of surgical intervention to restore delivery of o2, it is pointless to even begin resuscitation.


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## Clare (Dec 6, 2012)

bigbaldguy said:


> I still think its ridiculous that we'll work an 80 year old in cardiac arrest from an MI but not an 18 year old in cardiac arrest from a GSW. Yes there's maybe a 5 percent greater chance of saving the 80 year old but we all know it's probably not going to end well. I still think its primarily a money issue.



The aetiology of the two are very different.  A primary cardiac arrest from an underlying problem such as infarction or dysrhythmia has a much better prognosis than somebody who has had a cardiac arrest because their heart has no blood in it as it's all leaked out of a big hole from being stabbed or shot.

Unless you can treat a reversible cause of traumatic arrest (usually hypovolaemia or pneumothorax) fast then there is really no point in continuing resuscitation beyond a few (say 5-10) minutes; there is generally no blood in the heart so CPR is not really going to help.  

There may be a role for quickly transporting to hospital where somebody capable of opening the chest is standing in ED if there is an immediately identified and fixable problem such as haemopericardium or something but other than that I have no problems with quickly working then ceasing or flat out not working somebody who is in cardiac arrest because of trauma.


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