# Penetrating traumatic arrest, work or not?



## LACoGurneyjockey (Jun 12, 2016)

You have a mid 30s male with multiple gsw's to the chest. Pulseless and apneic, showing a wide complex PEA at a rate of 30 on the monitor, fixed pupils. Call time was 15 minutes ago but bystanders can't advise any details on pt condition prior to arrival. Who out there would work it, who would pronounce? What are the protocols for everyone's system? For the sake of the scenario, you're 5-10 minutes from a small ER with no specialties, and 40 minutes from a trauma center.


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## TransportJockey (Jun 12, 2016)

Ugh the pea is what would force us to work it. Work it on scene and then call it. There is zero point in transporting it.


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## chaz90 (Jun 12, 2016)

I'd be stuck working it, and an attempt at pronouncement would likely be denied since A. There's no GSW to the head and B. The patient still exhibits some cardiac activity.

If I start working it and he becomes asystolic, the rhythm is trending towards agonal, and/or the EtCO2 output is terrible, medical control might be more likely to grant me termination orders. This is going to be very doc dependent too. 


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## STXmedic (Jun 12, 2016)

We'd likely pronounce. Our PEA rate for being required to work a traumatic arrest is >40 (and unofficially a narrow complex >40). Along with the rate qualifier, there is also Presence of VF/VT, or Arrest in front you (of course) or any first responder.


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## SandpitMedic (Jun 12, 2016)

Our protocol is 2 minutes of high quality CPR with BLS airway, NRB mask at 15lpm, and bilateral decompression if suspected pneumo. Then call it if nothing improves.


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## Carlos Danger (Jun 12, 2016)

No palpable pulse with exsanguination as the apparent cause of death? Call it.


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## NomadicMedic (Jun 12, 2016)

I'd call that.


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## Summit (Jun 12, 2016)

SandpitMedic said:


> Our protocol is 2 minutes of high quality CPR with BLS airway, NRB mask at 15lpm, and bilateral decompression if suspected pneumo. Then call it if nothing improves.


I like this... corrects the unlikely but correctable. Avoid working the unsalvagable.


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## Gurby (Jun 12, 2016)

Remi said:


> No palpable pulse with exsanguination as the apparent cause of death? Call it.



OP doesn't say anything about bleeding.  I mean, that's obviously a pretty likely guess...

Dispatched 15 minutes ago but it sounds like don't have a very reliable story.  For all we know he was alive until just before we pulled up on scene.

With so little information, young patient, penetrating trauma, 5 minutes from an ED who can at least give him blood... Maybe it's my inexperience, but I don't see how you can justify not working this at least for a few minutes before calling.  I probably end up throwing him in the truck and transporting, it'll be less hassle to just let the hospital call it, and we can do interventions away from prying media eyes.


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## Carlos Danger (Jun 12, 2016)

Gurby said:


> OP doesn't say anything about bleeding.  I mean, that's obviously a pretty likely guess...


Yeah, but with multiple GSW's to the chest, exsanguination is the most reliable assumption. If you had US you could take a look at how well the ventricles were filling and whether the lungs were compressed.



Gurby said:


> Dispatched 15 minutes ago but it sounds like don't have a very reliable story.  For all we know he was alive until just before we pulled up on scene.
> 
> With so little information, young patient, penetrating trauma, 5 minutes from an ED who can at least give him blood... Maybe it's my inexperience, but I don't see how you can justify not working this at least for a few minutes before calling.



I actually think that's a really reasonable approach. I think if you wanted to go with a strictly EBM approach, you would not transport this guy. But OTOH, young healthy people surprise you sometimes and the long shots are sometimes worth it. With a five minute transport, I don't see much harm in transporting a patient like this.

Hopefully @ERDoc and the other EM guys will weigh in.


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## JDub (Jun 13, 2016)

Our protocol is that if we arrive on scene to find a pulseless and apneic patient with traumatic injuries that is in Asystole or PEA at a rate of <40 then it we immediately call it on scene. If the PEA is greater than 40, shockable rhythm or other signs of life such as agonal breathing are present then we would transport it. If we start resuscitation on a traumatic arrest we must transport and you can not call it in the field like a medical code.



Gurby said:


> OP doesn't say anything about bleeding.  I mean, that's obviously a pretty likely guess...
> 
> Dispatched 15 minutes ago but it sounds like don't have a very reliable story.  For all we know he was alive until just before we pulled up on scene.
> 
> With so little information, young patient, penetrating trauma, 5 minutes from an ED who can at least give him blood... Maybe it's my inexperience, but I don't see how you can justify not working this at least for a few minutes before calling.  I probably end up throwing him in the truck and transporting, it'll be less hassle to just let the hospital call it, and we can do interventions away from prying media eyes.



The patient in case though is not simply hypovolemic, which could be corrected with blood or fuids, but clearly has exsanguinating trauma which is causing him to bleed out rapidly. Even if EMS was capable of administering blood products he would be immediately bleeding out internally again and it would not matter. The only thing that might possibly save the patient is an operating room with an on duty trauma surgeon. Taking this patient to the small ER would not benefit him.


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## vf116 (Jun 13, 2016)

I'd call it as well. 

PEA greater than 30 or v-tach/fib gets worked with transport to closest unless trauma center is no more than 15 out. (Closest is a level 3 trauma, next is a community ER 30 mins away)

Wide complex PEA 30 or less, pt shall be determined to be dead. 


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## ParamedicStudent (Jun 13, 2016)

From my knowledge we dont work traumatic arrests because they have a hole somewhere that we can't fix.

However, pediatrics we always work them up and transport. Anyone know the reasoning for this?


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## TransportJockey (Jun 13, 2016)

ParamedicStudent said:


> From my knowledge we dont work traumatic arrests because they have a hole somewhere that we can't fix.
> 
> However, pediatrics we always work them up and transport. Anyone know the reasoning for this?


Outdated thinking. People work peds when they shouldn't to 'prove to the parents that everything was done' when in reality that provides a false hope for them.


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## ERDoc (Jun 13, 2016)

The problem could be a damaged blood vessel, pneumo or both.  The likelihood of survival in this case in minimal, neurological recovery is even less likely.  As for where to take him, there is no good answer.  He may or may not get a thoracotomy and chest tubes in the ER, it just depends on who the doc is.


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## Gurby (Jun 13, 2016)

TransportJockey said:


> Outdated thinking. People work peds when they shouldn't to 'prove to the parents that everything was done' when in reality that provides a false hope for them.



I don't see a problem with this. If it helps the family cope, why not?

I just can't imagine how this goes down in real life.  You walk in, Mom and Dad are hysterical, you look at the kid and say "he dead, sorry" and leave?  Really?


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## Flying (Jun 13, 2016)

Gurby said:


> If it helps the family cope, why not?


Does it though? I think breaking the news honestly would be easier on them.

Once you start pumping on the body in front of a family member, the family will make some sort of emotional investment. We can't forget that the act of resus has probably been played up to these families.


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## chaz90 (Jun 13, 2016)

Gurby said:


> I just can't imagine how this goes down in real life.  You walk in, Mom and Dad are hysterical, you look at the kid and say "he dead, sorry" and leave?  Really?



It never, ever happens remotely like this. I've done only one pediatric DOA, but everyone else I know has done the human thing and broken the news (that the parents likely already know) as gently but directly as they can. 

I spent over an hour on my scene talking to the family as well. We did our paperwork like on any DOA, waited for LE to respond, called a pastor and friend at the family's request, did some cleaning in the patient's room, then made a pot of coffee and sat with them as they told us about vacations they had taken and struggles with the decedent's illness. Emotionally draining, but worthwhile.


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## Handsome Robb (Jun 14, 2016)

Lack of a pulse and organized respiratory activity upon my arrival and then lack of organized respiratory effort after basic airway maneuvers we'd call for termination. With that said I probably wouldn't even start working him to begin with and cite an injury incompatible with life as my reasoning.

If we did work him it would be extremely basic.We'd do compressions, basic airway maneuvers and the monitor then if they remained pulseless and apneic we'd call for TOR orders. Only advanced thing we might down would be a three hole punch but it would be under OLMC and since it's wide complex PEA it's not really indicated. Narrow complex PEA would be a different story. 

If I witnessed him lose pulses I can do a three hole punch on standing orders then go from there. 

For those of you who don't know a three hole punch is bilateral needle decompressions and a pericardiocentesis.

Generally a traumatic arrest with a wide complex PEA indicates structural damage to the myocardium which is virtually unsurvivable. Narrow complex PEA indicates an obstructive cause like a tamponade or tension pneumo.


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## ParamedicStudent (Jun 14, 2016)

TransportJockey said:


> Outdated thinking. People work peds when they shouldn't to 'prove to the parents that everything was done' when in reality that provides a false hope for them.



It's also protocol based, like in my county. Whether or not its outdated thinking, we still gotta do everything right, just a matter of agreeing with it or not.


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## Ensihoitaja (Jun 14, 2016)

My typical scenario is a bit different, in that we have short response times and we're never very far from a Level I trauma center. That said, as a general rule, we'll transport a penetrating trauma arrest and pronounce a blunt trauma arrest. 

Our resuscitation efforts for trauma are limited- CPR, IV access, airway management, needle thoracostomy if indicated. We won't defibrillate and we won't use any ACLS drugs.

We actually had a patient a couple years ago who was in cardiac arrest from multiple gunshot wounds to the chest. He had a total of about 45 minutes without a pulse (response+scene time+transport+ED time) and survived with a good neurological outcome.


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## gotbeerz001 (Jun 14, 2016)

Call it.


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## CANMAN (Jun 14, 2016)

TransportJockey said:


> Ugh the pea is what would force us to work it. Work it on scene and then call it. There is zero point in transporting it.



This... only because of the PEA per protocol, and if that deteriorates I am calling it.


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## medicsb (Jun 15, 2016)

LACoGurneyjockey said:


> You have a mid 30s male with multiple gsw's to the chest. Pulseless and apneic, showing a wide complex PEA at a rate of 30 on the monitor, fixed pupils. Call time was 15 minutes ago but bystanders can't advise any details on pt condition prior to arrival. Who out there would work it, who would pronounce? What are the protocols for everyone's system? For the sake of the scenario, you're 5-10 minutes from a small ER with no specialties, and 40 minutes from a trauma center.



Small ER with no specialty back up?  Does it even have an EM trained physician working?  Would that EM trained physician even think of cracking the chest?  Without known time of arrest, I think it would be reasonable to load and go - do needle decompressions, CPR, and intubate if possible (all en route).  ED may not do much more than bilateral chest tubes.  But I think if you are at all going to work it, you need to transport.  Pronouncing on scene immediately is not unreasonable either.


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## LACoGurneyjockey (Jun 16, 2016)

ER is hit and miss with EM trained physicians. Sometimes it's a family practice physician, sometimes it's a doc with over a decade of level 1 trauma center experience. This night it happened to be the former.


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## FiremanMike (Jun 20, 2016)

I wouldn't have hooked the monitor up...

The only caveat to this scenario is how public the scene was.  If we have a big crowd, we are supposed to work it.


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## NomadicMedic (Jun 20, 2016)

FiremanMike said:


> I wouldn't have hooked the monitor up...
> 
> The only caveat to this scenario is how public the scene was.  If we have a big crowd, we are supposed to work it.



What? Is that a written policy?


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## FiremanMike (Jun 20, 2016)

DEmedic said:


> What? Is that a written policy?



I'm paraphrasing slightly, but we are not to terminate resuscitation in public places and there are times where, unless there is obvious death that can be identified by a layperson from a distance, resuscitation attempts may be "safer" for the crew so as to avoid upheaval.

I don't work in a nice area, if that context helps..


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## Summit (Jun 20, 2016)

FiremanMike said:


> I'm paraphrasing slightly, but we are not to terminate resuscitation in public places and there are times where, unless there is obvious death that can be identified by a layperson from a distance, resuscitation attempts may be "safer" for the crew so as to avoid upheaval.
> 
> I don't work in a nice area, if that context helps..


Translating, they think if you don't work futile codes, someone is gonna shoot you?


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## chaz90 (Jun 20, 2016)

I'd rather those "violent crowd" scenarios be handled as the situation merits on an individual basis, but I understand the thinking. I'm grateful I don't work in that kind of area. 


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## ThePants (Jun 20, 2016)

Our local protocol is that if it's not obvious 5-step CPR, and the body is still warm, you work it.


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## Ensihoitaja (Jun 20, 2016)

What's 5-step CPR?


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## ThePants (Jun 20, 2016)

Ensihoitaja said:


> What's 5-step CPR?


It's when a vital part of the body, like a head, is detached from the body.  Five footsteps from the chest to the head.  

In other words, an MOI that is incompatible with life.


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## ERDoc (Jun 20, 2016)

I would imagine 2 steps would be enough, but I guess you can never be too sure.


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## ThePants (Jun 20, 2016)

ERDoc said:


> I would imagine 2 steps would be enough, but I guess you can never be too sure.



Aye, doc.


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## Ensihoitaja (Jun 21, 2016)

ThePants said:


> It's when a vital part of the body, like a head, is detached from the body.  Five footsteps from the chest to the head.
> 
> In other words, an MOI that is incompatible with life.



Huh, never heard that before.


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## FiremanMike (Jun 21, 2016)

Summit said:


> Translating, they think if you don't work futile codes, someone is gonna shoot you?



There is certainly the risk of immediate violence on scene, emotions beget yelling and screaming which can and does escalate into distraction of property and life.

There's also the risk of people running their mouths to the media about what we should have or could have done.  If the current climate is any indication of what type of society we're currently in, this event could be career ending and potentially lead to criminal charges thanks to the court of public opinion...


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## STXmedic (Jun 21, 2016)

Do you live in Flint? Because I work in a pretty nasty area with high rates of violence and homicide, and I've never felt in danger for calling an arrest. They're usually just grateful we tried, even if emotions are high.


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## FiremanMike (Jun 21, 2016)

Nope not Flint, just a populated urban area in a lower socioeconomic strata


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## STXmedic (Jun 21, 2016)

Same here. Inner city of a very large metropolitan city. Never felt personally threatened though, even on scenes where tensions are high.


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## Carlos Danger (Jun 21, 2016)

My first job as a paramedic was in a pretty violent inner-city area. In my few years there, there were a handful of times that we would load & go when it wasn't clinically indicated, or transport a patient who we otherwise wouldn't have transported, because we didn't feel the scene was a safe place for us otherwise.


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## ParamedicStudent (Jun 22, 2016)

Hi guys, just the protocols I have in my county that I'm learning from states: 

Trauma arrest - Adults
Blunt arrest/ penetrating arrest/ prolonged extrication.

That's all they stated on trauma arrest. Just to clarify, that mean's NO intervention right?


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## MonkeyArrow (Jun 22, 2016)

ParamedicStudent said:


> Hi guys, just the protocols I have in my county that I'm learning from states:
> 
> Trauma arrest - Adults
> Blunt arrest/ penetrating arrest/ prolonged extrication.
> ...


That sentence means absolutely nothing alone out of context.


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## aquabear (Jul 17, 2016)

I know this is a late reply, but if the PT has been without pulses for less than 5 minutes we would do a "3 hole punch," which consists of bilateral needle Ts and performing a pericardiocentesis. If we don't get any change, we call it. Anything longer than 5 minutes without pulses we call too.


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