# 41 YOM - Traumatic Arrest - Obvious Death or Begin Resuscitation?



## NYMedic828 (Jan 12, 2012)

had this call about a week ago now and its been bugging me.

*Story:
*
41 y/o male, found supine on ground post gunshot to left chest. Patient was working under his car when someone walked up and shot him at close range. Called in by a bystander no further info could be obtained on-scene.

When my partner and I arrived, the BLS unit had already begun CPR and c-spine. 

*Assessment:*

-Pulseleness Apneic.
-Single GSW to left chest, roughly one inch inferior and medial to the the left nipple.
-No exit wound
-Absolutely no blood from the wound or anywhere for that matter.
-Possible non-tension hemo-pnuemothorax to left side.
-Idioventricular PEA on the monitor at a rate of <20 complexes per min.


Since CPR was already started, in the NYC 911 system, you must continue until a physician takes over either via telemetry or hospital and takes responsibility for pronouncement. 

We ran it as a PEA arrest,

EJ to the left jugular, giving vasopressin followed by Q5 epi.

Tubed the patient no problem, frothy pink secretions in tube (hence hemo-pnuemo)

CPR throughout.

We gave a notification to the trauma hospital and upon arrival they took over CPR for about 3 minutes until the trauma surgeon walked in gave the "We're done here" look once he saw where the wound was and they called it.

My question is, would you have arrived on-scene and began CPR, or would you call it an obvious death and write up a pronouncement on-scene, leaving the crime-scene in tact as well.

The shirt had burn marks on it, the wound had no bleeding leading me to believe immediate cessation of blood flow. The bullet was directly in the anatomical location of the left ventricle and probably went through to the left lung.

What would you have done if you were first on-scene?


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## Aidey (Jan 12, 2012)

[YOUTUBE]http://www.youtube.com/watch?v=KrZHPOeOxQQ[/YOUTUBE]


*ahem*  

Sorry, couldn't resist. 

I would have worked him, but not transported. Given the location of the wound and the PEA it is very likely that there massive damage to the heart. Since I don't have an ultrasound on scene I can't prove that, but if we don't get anywhere after 3 rounds we're done. 

And c-spine????


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## Smash (Jan 12, 2012)

He's dead where he lays, it's not appropriate to attempt resus.

And I'll second the "huh?" when it comes to c-spine.


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## Medic Tim (Jan 12, 2012)

DId you take c spine because it was a gsw?

Where I work we would call it right there.


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## NYMedic828 (Jan 12, 2012)

In NYC C-spine is a requirement for any penetrating trauma to the thorax. Its really annoying to be honest.

I wanted to get on the horn to pronounce but my partner said it didn't qualify for obvious death... I thought it was pretty obvious lol.


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## RocketMedic (Jan 12, 2012)

In my system, barring size/distance/time challenges, we need asystole to halt resuscitation.


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## SanDiegoEmt7 (Jan 12, 2012)

No c-spine,

For us ALS gets to re-evaluate the indications for CPR regardless of first responder actions.

For us that wouldn't qualify as injuries incompatible with life (decapitation, brain matter showing, entire body charred etc.) 

PEA less than 20 gets transported only if we are within 10 minutes of a hospital.  (asystole gets 1 min of CPR if its still asystole after that its terminated, all other rhythms are transported)


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## Smash (Jan 12, 2012)

NYMedic828 said:


> In NYC C-spine is a requirement for any penetrating trauma to the thorax. Its really annoying to be honest.



That is annoying.



> I wanted to get on the horn to pronounce but my partner said it didn't qualify for obvious death... I thought it was pretty obvious lol.



What, the fact that he is dead doesn't qualify as obvious death?  :rofl:

EDIT:

I thought I should throw in some references, just because I haven't for a while.  C-Spine for penetrating trauma is not just dumb, it is probably harmful.  For this case, it is probably a moot point, however it is still bad:  _"The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66"_

Pretty poor numbers there.

Spine Immobilization in Penetrating Trauma: More Harm Than Good? Haut et al, Johns Hopkins. J Trauma 68(1): 115-121, 2010.

Transporting traumatic arrests is also bad:  The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients.  Molberg et al,  J Trauma, 2011


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## usalsfyre (Jan 13, 2012)

SanDiegoEmt7 said:


> For us that wouldn't qualify as injuries incompatible with life (decapitation, brain matter showing, entire body charred etc.)


While in most systems that's the case, a bullet that sounds like it fairly neatly transacted the LV is pretty much incompatible with life.

I think a pretty good case could be made for at least phoning a doc.


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## DrParasite (Jan 13, 2012)

NYMedic828 said:


> *Assessment:*
> 
> -Pulseleness Apneic.
> -Single GSW to left chest, roughly one inch inferior and medial to the the left nipple.
> ...


doesn't scream obvious death to me.  really bad,  yeah, likely to die, probably, should I call a priest for him for last rights, I would think so.  

brain matter showing, decapitation, rigor mortis, asystole in 3 leads with pupils fixed and dilated pupils are those signs of obvious death.  This guy, although he sounds really messed up, probably wouldn't qualify (although as the trauma surgeon said, even in a trauma center was beyond care), but that's the doctor's call as they have more flexibility than a medic in what they can do.


NYMedic828 said:


> The shirt had burn marks on it, the wound had no bleeding leading me to believe immediate cessation of blood flow. The bullet was directly in the anatomical location of the left ventricle and probably went through to the left lung.


PEA is pulseless electrical activity.  so the heart isn't pumping (hence the CPR), but it is still sending signals to try to get it to pump.  that could have explained the cessation of blood flow, because the heart wasn't pumping.





NYMedic828 said:


> In NYC C-spine is a requirement for any penetrating trauma to the thorax. Its really annoying to be honest.


I was taught the same thing back in the 90s.  the latest edition of PHTLS says it's no longer needed, but I still see many many experienced EMTs and paramedics still doing it.  But I would have still put him on a board to aid in carrying him to the cot and transfer him to the ER bed, if we were going to transfer him.


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## Handsome Robb (Jan 13, 2012)

I'm with usalsfyre on this one. 

Call a doctor and get termination orders.


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## rmabrey (Jan 13, 2012)

NVRob said:


> I'm with usalsfyre on this one.
> 
> Call a doctor and get termination orders.



And hope they let you. My partner and I worked a GSW worse than this and the doc made us intubated and do a round of CPR. 

Long story short we got our butts chewed cause we didn't load and go. Only cause we were part of the crime scene for 3 hours. 

It was a catch 22. Load and go and disrupt a crime scene, work it and disrupt a crime scene. We really had no desire to do either. We wanted the call it option 



Sent from my Desire HD using Tapatalk


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## R99 (Jan 13, 2012)

No he is dead right there


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## NYMedic828 (Jan 13, 2012)

rmabrey said:


> And hope they let you. My partner and I worked a GSW worse than this and the doc made us intubated and do a round of CPR.
> 
> Long story short we got our butts chewed cause we didn't load and go. Only cause we were part of the crime scene for 3 hours.
> 
> ...



We load and go'd and did it all enroute mostly. But still, regardless of it not being the standard obvious death, and technically his EKG was still viable as his heart was giving off some form of conduction, we all know there is no hope for you if a bullet goes directly through your heart... 

Pretty messed up is surviving 5 GSWs around the body, FUBAR is a bullet directly through the heart.

ETCO2 was 10mmhg throughout by the way. So lungs were decently viable too.


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## Veneficus (Jan 13, 2012)

NYMedic828 said:


> In NYC C-spine is a requirement for any penetrating trauma to the thorax. Its really annoying to be honest.
> 
> I wanted to get on the horn to pronounce but my partner said it didn't qualify for obvious death... I thought it was pretty obvious lol.



A penetrating traumatic arrest without blood products and surgery?

C-spine was a waste of time, efforts. 

ACLS algorythm was a waste of time and materials.

I think you may have been brainwashed in with ACLS to the point of not understanding the obviousness of the truth.

If you have a big hole in a pump and pipe system, constricting the pipes doesn't help. Playing with the electrical machinery running the pump doesn't help, increasing the rate of the pump doesn't help.

Plugging the hole helps.

I have seen 1 patient salvaged with a 12g slug through the left ventrical.

The instructions from med command included: "put your finger in the hole and get here asap" (the squad was about a minute down the street from the level 1)

Upon arrival a left thoracotomy with extension was performed in the ED. With the trauma surgeon (the same one who I saw stop a carotid artery wound bleed with a foley catheter) sewing a heart flap around my finger while infusing 4 units of O negative prior to going to the OR.

You now see the problem with cookbook medicine.


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## HMartinho (Jan 13, 2012)

DrParasite said:


> doesn't scream obvious death to me.  really bad,  yeah, likely to die, probably, should I call a priest for him for last rights, I would think so.
> 
> brain matter showing, decapitation, rigor mortis, asystole in 3 leads with pupils fixed and dilated pupils are those signs of obvious death.  This guy, although he sounds really messed up, probably wouldn't qualify (although as the trauma surgeon said, even in a trauma center was beyond care), but that's the doctor's call as they have more flexibility than a medic in what they can do.
> PEA is pulseless electrical activity.  so the heart isn't pumping (hence the CPR), but it is still sending signals to try to get it to pump.  that could have explained the cessation of blood flow, because the heart wasn't pumping.I was taught the same thing back in the 90s.  the latest edition of PHTLS says it's no longer needed, but I still see many many experienced EMTs and paramedics still doing it.  But I would have still put him on a board to aid in carrying him to the cot and transfer him to the ER bed, if we were going to transfer him.




Congratulations for your excellent post. Lesions of this man, in my view, despite being highly critical, and the probability of survival is extremely low, does not mean that their injuries are incompatible with life.

I play at, this man has a probable injury hemopneumothorax, and/or cardiac tamponade. I know that the Portuguese system and American system are different, but the approach here would be: (I'm in a ILS unit - me and my partner(nurse)):
- CPR with endotracheal intubation
- Start an IV
- start a rapid infusion of saline
- give Epinephrine / vasopressin
- request an immediate backup of ALS rapid response unit/ALS helicopter for possible pericardiocentesis, thoracotomy or chest tube insertion .
- After a possible stabilization, transport immediately to a advanced trauma center, with advanced medical and surgical facilities.


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## DrankTheKoolaid (Jan 13, 2012)

In 99% of my response area I would have called him at scene after 20 minutes of effort including decompression of the left chest to rule it out.  If i had transported, patient would have been on a backboard but not for spinal precautions, but to make compressions more effective as CPR on a gurney matress is all but useless.


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## imadriver (Jan 13, 2012)

In my system we'd probably have to run him regardless. We aren't but tops 15 minutes from a hospital 95% of the time anyway. Trauma Alert / Trauma Code him, grab and go. Back board for compressions, C-Collar for airway.

In order to stop compressions we'd have to call a doc since they were started by a healthcare provider. The doc may call it because of the shots location, but remember especially with ribs, that bullet may of bounced off a rib, went down hitting a lung along towards the abdominal cavity. Could've coded from respiratory issues, not a bullet in the heart.

With my protocols and system, we would have ran it.


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## usalsfyre (Jan 14, 2012)

imadriver said:


> but remember especially with ribs, that bullet may of bounced off a rib, went down hitting a lung along towards the abdominal cavity. Could've coded from respiratory issues, not a bullet in the heart.


Speaking from both a medical and firearms stand point, it is extremely unlikely a contact distance gun shot of any decent cartridge wound would "bounce" off of anything in the body. The energy it carries at close distance is simply too great for a bone to divert.



imadriver said:


> With my protocols and system, we would have ran it.


In most systems this is going to be the case, right or wrong.


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## DrParasite (Jan 14, 2012)

see, this is an example of obvious death, where CPR should probably not be started:


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## Shishkabob (Jan 14, 2012)

Those who are picking up on the cspine... Do you not apply a collar to your intubated patients?


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## DrankTheKoolaid (Jan 14, 2012)

I personally always collar my intubations, but i dont consider it spinal precautions.  Patient would be on backboard but not secured with straps and c-collar and head would not be taped down. So though the equipment is in use, the patient would not be in full spinal precautions


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## usalsfyre (Jan 14, 2012)

Not often. A cuffed ET tube doesn't tend to get displaced in the unconscious patient by head movement, it gets pulled out.

Unless your patient is HIGHLY PEEP dependent, you should be disconnecting the BVM or circuit before you move.


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## SanDiegoEmt7 (Jan 14, 2012)

usalsfyre said:


> While in most systems that's the case, a bullet that sounds like it fairly neatly transacted the LV is pretty much incompatible with life.
> 
> I think a pretty good case could be made for at least phoning a doc.



I agree, and a cool minded medic would definitely get the orders here.  But when I read the call description I could imagine a great deal of our medics transporting because the way the protocol is written and they would be too caught up in everything to stop and think.


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## imadriver (Jan 15, 2012)

Not trying to get too far off subject but:



usalsfyre said:


> Speaking from both a medical and firearms stand point, it is extremely unlikely a contact distance gun shot of any decent cartridge wound would "bounce" off of anything in the body. The energy it carries at close distance is simply too great for a bone to divert.



- I would think so myself, but I have ran several gunshot wounds myself where the entry / exit wounds either don't match or the person must of been in some weird position. A particular one I remember running is a guy who got shot in the stomach, entry wound in the URQ, no exit wound anywhere. After a while of searching, they found the bullet still inside behind his knee. I talked to the doc a few days later and he said he still wasn't sure how it got there, but they did find a few fractures around, I think one in the lumbar, one hip, and a femur. I didn't think to ask what caliber or anything, but the entry looked only about a 22.


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## Veneficus (Jan 15, 2012)

imadriver said:


> Not trying to get too far off subject but:
> 
> 
> 
> - I would think so myself, but I have ran several gunshot wounds myself where the entry / exit wounds either don't match or the person must of been in some weird position. A particular one I remember running is a guy who got shot in the stomach, entry wound in the URQ, no exit wound anywhere. After a while of searching, they found the bullet still inside behind his knee. I talked to the doc a few days later and he said he still wasn't sure how it got there, but they did find a few fractures around, I think one in the lumbar, one hip, and a femur. I didn't think to ask what caliber or anything, but the entry looked only about a 22.



Bullet tracts are unpredictable. I have made a fool of myself more than once trying to SWAG how and why and where. (especially when sleep deprived)

But having said that, in this scenario, I agree the projectile probably caused catastrophic damage to the heart in this case as witnessed by PEA. 

It is entirely possible that there was a tamponade or a hemo/pneumothorax. But the blood would have to come from somewhere and without striking either the aorta or the actual myocardium, I am not entirely sure how that much blood would be lost that fast. The intermamilary or bronchial arteries are simply not big enough.

While I think with a highly skilled provider this was a workable call, and not a workable call with anyone else, many things would have had to go right to change the outcome.


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## NYMedic828 (Jan 15, 2012)

Since I'm sure some people are clearly interested, the bullet was found in the abdominal cavity.

Personally, the reason for my personal diagnosis of instant death and assumption of the left ventricle being completely transacted, is because there was no blood to be found in the airway aside from the small amount of pink frothy secretion in the tube. And more so because the wound itself had absolutely zero signs of bleeding which to me would indicate an immediate cessation of blood flow upon traumatic occurrence which means the pump shut down nearly instantaneously.

And someone posted on the second page that the injuries were possibly compatible with life as a reason to work him up, the last time I checked not having a bullet driven directly through your heart is considered incompatible with life...


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## Veneficus (Jan 15, 2012)

NYMedic828 said:


> Since I'm sure some people are clearly interested, the bullet was found in the abdominal cavity.
> 
> Personally, the reason for my personal diagnosis of instant death and assumption of the left ventricle being completely transacted, is because there was no blood to be found in the airway aside from the small amount of pink frothy secretion in the tube. And more so because the wound itself had absolutely zero signs of bleeding which to me would indicate an immediate cessation of blood flow upon traumatic occurrence which means the pump shut down nearly instantaneously.
> 
> And someone posted on the second page that the injuries were possibly compatible with life as a reason to work him up, the last time I checked not having a bullet driven directly through your heart is considered incompatible with life...



I posted in this thread I have personally been part of a resuscitation of somebody who had a 12 guage slug penetrate thier heart. It was the first open thoracotomy where I saw the patient actually survive. I even remember us laughing at the bedside nurse who was trying to put the transport EKG leads on the patient as we were wathing the heart beat in the open chest cavity on the way to the operating theatre. 

As I stated in that post, many things went right, from early EMS arrival, to being in a level 1 trauma center in less than 10 minutes, and finally on the night when an extremely aggresive and skilled trauma surgeon was working.

Having a bullet in the abdomen after being shot in the chest is not uncommon. 

Actually in one of my surgical textbooks it states specifically if there is any doubt if the bullet is in the abd or the thorax to open the abd first.

In medicine, experience and capability counts. Not all things are equal. It is not an "If:Then" statement.

Like I said, attempting to work this or any other patient, is dependant on the people and resources available. It also depends on your approach to resuscitation. If you were using an algorythm that is designed for 70% of the population who go into cardiac arrest secondary to an MI, for a patient with a bullet hole in his chest, nobody should be surprised when it doesn't work.


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## Fish (Jan 15, 2012)

NYMedic828 said:


> had this call about a week ago now and its been bugging me.
> 
> *Story:
> *
> ...



I would have phone the Doc while on scene, since CPR was in proocess.


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## RustyShackleford (Jan 15, 2012)

As with most responses in this thread your local protocols will most likely greatly differentiate on what you would do on scene.  Our personal protocol here is if there is known or suspected destruction of, brain, heart or lung tissue incompatible with life we can pronounce there.  Obviously you don't have an ultrasound in your glasses so it would be a rough call determining if the heart was damaged beyond repair from inspecting the pt, in that case we could just do a penetrating trauma termination with that PEA rhythm and no perfusion.


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## jjesusfreak01 (Jan 18, 2012)

Veneficus said:


> I have seen 1 patient salvaged with a 12g slug through the left ventrical.
> 
> The instructions from med command included: "put your finger in the hole and get here asap" (the squad was about a minute down the street from the level 1)
> 
> ...



I would buy the doc a beer for letting me be present for that level of badassness.


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## emtpjwc (Jan 24, 2012)

Where I'm at in Texas we would of worked the pt for 20 mins and if no changes on the monitor we terminate efforts. And treat as a crime scene to the cops get there.


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## beefaroni (Mar 13, 2012)

Dude im bls in brooklyn. You know how they are here, might as well cover your *** and txp or risk getting restricted.


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## medicjosh (Apr 7, 2012)

NYMedic828 said:


> In NYC C-spine is a requirement for any penetrating trauma to the thorax. Its really annoying to be honest.
> 
> I wanted to get on the horn to pronounce but my partner said it didn't qualify for obvious death... I thought it was pretty obvious lol.



as a fellow city medic, i'm going to have to disagree. just reviewed the BLS protocol for chest trauma and c-spine. neither indicate that you must immobilize c-spine in penetrating chest trauma.


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## Fox800 (Apr 7, 2012)

We would not have resuscitated this patient. He would have been pronounced on scene.


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