Trauma arrest, should CPR be stopped in the field?

[Anjel]

What I meant was. In this case, where PD states there was a pulse. No blood any where. So probably no injuries incompatible with life. And the dude was "throwing up".

When you call for a pronouncement, and describe this. They will ask what rhythm they are in. For us there must be a systole in 3 leads.

The OP said no blood. So how do we even know it was traumatic. He could of went into a dysrythmia and a very minor crash.

 

[Anjel]

We went on a guy run over by a train, and didn't do a strip.

But for this. I call BS.

 

[NomadicMedic]

Cardiac arrest following a traumatic mechanism isn't a clear presentation?

There was no clear trauma presentation in the scenario. A dirtbike accident with a rider who "vomited beer". Doesn't sound like a clear presentation to me.


Are you saying that trauma must be external and visible for us to base our triage/treatment on it?

No, but there should be a clearly documented mechanism of trauma, i.e.: He was ejected from the motorcyle at high speed, landed on his head and was pulseless for the last 20 minutes. He doesn't need to have visible trauma, but there should be some information that would paint a clear picture that trauma was the cause of the arrest.


What is an asystole strip going to tell you that you can't see for yourself? Better question, what does electrical activity in the heart have to do with the viability of a patient in traumatic arrest? Do we have reason to believe that this is an electrical problem?

With the absence of any clear indications of trauma, do we have reason to NOT believe it? Who's to say this patient wasn't suffering an infarct, had a VF arrest and fell off his bike?


Don't think for yourself. Treat the protocol, not the patient. That may not be the message you meant to present, but that's what it sounds like. And it's that kind of mentality that's lead to us worrying more about protocol violations than providing clinically sound patient care.

Not putting a monitor on a patient to confirm asystole doesnt sound like a lapse in " clinically sound patient care". It sounds like the prudent thing to do.

I won't argue against getting more info, but the picture presented thus far paints a traumatic etiology. I'll disagree with you that the EMT should be disciplined for a protocol violation. That sends the message that EMS providers shouldn't be encouraged to think for themselves, and should instead blindly follow whatever the silly protocol says regardless of what their clinical judgment dictates.

This picture paints nothing more than a new EMT who's asking questions about an arrest that he felt was not handled appropriately. If what the OP claims about the protocols is true, then the EMT who handled that call should be disciplined. Maybe it’s okay to blow off protocols in your system, but they are there for a reason… and not following the standard procedures, whether you believe they fit your situation or not is not “critical thinking”, it’s called being a cowboy and that’s the kind of behavior that continues to expose EMS providers to ridicule and liability.

...

 

[Aidey]

We need to keep in mind that the OP wasn't actually on the call, so there may be some details missing.

 

[med109]

"This picture paints nothing more than a new EMT who's asking questions about an arrest that he felt was not handled appropriately. If what the OP claims about the protocols is true, then the EMT who handled that call should be disciplined. Maybe it’s okay to blow off protocols in your system, but they are there for a reason… and not following the standard procedures, whether you believe they fit your situation or not is not “critical thinking”, it’s called being a cowboy and that’s the kind of behavior that continues to expose EMS providers to ridicule and liability."

Im actually EMT-I, but am a new Intermediate. I was a basic for 11 years. Normally calls like this are not an issue, because we follow protocol. He didn't follow protocol, the medical director asked me about the call and why some things were ignored, and I heard the family is suing someone, so now I am wondering how things should have went. The only other events leading up to the trauma that I know were he went over the edge of a hill (not a cliff, just a normal dirtbike hill) and when the rest of his party went over the same hill shortly after, they found him laying next to his bike, and he was drinking.

 

[Aidey]

Why was your medical director asking you why protocol wasn't followed on a call you weren't on?

 

[bigbaldguy]

Patient has heart attack while riding dirt bike wrecks. No one works him? Patient gets loaded on drugs, wrecks bike, arrests between time he wrecks and police are on scene. No one works him?

Just playing devils advocate. I'd be interested to know exactly what his visible traumatic injuries were, how hard and what he hit, how fast he was going, was there a helmet ect.

Pulling a patient back out of ambo sounds like poor judgement. Maybe in a disaster situation or a MCI I could see it.

 

[DesertMedic66]

Would have been called DOA without calling the Doc. Blunt trauma arrest with continuous asystole or PEA at a rate of less then 10 and medics can call.

If it was an BLS rig in my system (they don't respond to 911 calls) we would have had to work him.

 

[Aidey]

Patient has heart attack while riding dirt bike wrecks. No one works him? Patient gets loaded on drugs, wrecks bike, arrests between time he wrecks and police are on scene. No one works him?

Just playing devils advocate. I'd be interested to know exactly what his visible traumatic injuries were, how hard and what he hit, how fast he was going, was there a helmet ect.

Pulling a patient back out of ambo sounds like poor judgement. Maybe in a disaster situation or a MCI I could see it.

It sounds like this may have been in a rural area. One of the things left out was down time prior to the amb getting on scene.

I also don't think the pt was loaded in the amb, it sounded like they put him in the back of a pick up truck to get him back to the road.

 

[Anjel]

Would have been called DOA without calling the Doc. Blunt trauma arrest with continuous asystole or PEA at a rate of less then 10 and medics can call.

If it was an BLS rig in my system (they don't respond to 911 calls) we would have had to work him.

But there was no monitor. How do you know? All you know is there is no pulse.

And you have no idea how he was hurt.

 

[DesertMedic66]

But there was no monitor. How do you know? All you know is there is no pulse.

And you have no idea how he was hurt.

The OP doesn't have all the information. It was a dirt bike accident. Normally dirt bike riders wear riding gear that you can tell if they just fell off the side or had a serious accident (scraped helmet vs mangled helmet. Mangled chest protector etc).

Also didn't say (that I read at least) if there were any other injuries (fractures etc) that would be a hint of a blunt trauma.

 

[bigbaldguy]

It sounds like this may have been in a rural area. One of the things left out was down time prior to the amb getting on scene.

I also don't think the pt was loaded in the amb, it sounded like they put him in the back of a pick up truck to get him back to the road.

Doh you're right I missed "officers truck" although seems like all the more reason not to move him after they called it.

I wonder if patient had an obviously broken neck? If there was no or little blood and they bothered backboarding him I would think there would have been some doubt as to his viability. Our protocols require at least a 1 lead unless it's just patently obvious it's not workable.

I will say that I've been researching the whole "don't work traumatic arrest" thing and while I am not convinced penetrating trauma arrests should never be worked from what I've found blunt trauma arrests are nearly always non viable.

Did officer have a monitor? Was it left in the ambo? The medic probably made the right choice but maybe didn't handle the PR part of it very well. Unfortunetly customer service skills seem to be something very few medics seem to be able to grasp. And yes I used the term customer service just because I knew it will make some of you hop up and down and shout profanities when you read it

 

[Sublime]

But there was no monitor. How do you know? All you know is there is no pulse.

And you have no idea how he was hurt.

It's easy to play armchair quarterback here and say what you would've done in this situation, but in reality there is not even remotely enough info to say how it should have been handled. The OP even stated much of the info was from bystanders, so the accuracy of what is provided is questionable at best.

There is really no way to know what that provider saw or what influenced his ultimate decision to call it DOA, but clearly it was good enough for med control.

However I will say I really don't see how any of you can say that you would of made the same decision based on the limited info provided. Like others have stated how do you know this was a traumatic arrest? How do you know it wasn't the arrest that caused him to crash?

And I know during CPR as air is forced into the stomach, those contents have a tendency to back come up, but in a full arrest it seems odd that he is still vomiting after being left alone. But that is just hear-say info also.. so who knows.

Just saying it seems like some of you guys are too quick to call a blunt trauma arrest without adequate information. For all you know he could be in a sinus rhythm with a very low BP that made the pulse difficult to palpate.

 

[med109]

Why was your medical director asking you why protocol wasn't followed on a call you weren't on?[/QUOTE

He mentioned concerns while I was dropping a patient on day. When I finally figured out what he was talking about I told him I wasn't on the call, and the conversation was dropped.

 

[NYMedic828]

This entire thread is pointless unless the OP states the presenting injuries leading to the assumption of traumatic arrest.

Otherwise it is a medical arrest until proven otherwise.

The question keeps behind danced around. Don't even entertain the question anymore until he answers it. Its fishy to me.

 

[Bieber]

There was no clear trauma presentation in the scenario. A dirtbike accident with a rider who "vomited beer". Doesn't sound like a clear presentation to me.

I wouldn't disagree with getting more info.

No, but there should be a clearly documented mechanism of trauma, i.e.: He was ejected from the motorcyle at high speed, landed on his head and was pulseless for the last 20 minutes. He doesn't need to have visible trauma, but there should be some information that would paint a clear picture that trauma was the cause of the arrest.

I don't disagree.

With the absence of any clear indications of trauma, do we have reason to NOT believe it? Who's to say this patient wasn't suffering an infarct, had a VF arrest and fell off his bike?

There's indications of trauma, more info would be helpful.

This picture paints nothing more than a new EMT who's asking questions about an arrest that he felt was not handled appropriately. If what the OP claims about the protocols is true, then the EMT who handled that call should be disciplined. Maybe it’s okay to blow off protocols in your system, but they are there for a reason… and not following the standard procedures, whether you believe they fit your situation or not is not “critical thinking”, it’s called being a cowboy and that’s the kind of behavior that continues to expose EMS providers to ridicule and liability.

There's a difference between "blowing off" protocols and recognizing when they do not fit the situation and it's time to do what's best for the patient based on the provider's knowledge, experience and assessment.

Btw, what is the reason for protocols again? Because if the answer is "to make sure people are doing the right thing for the patient", then why is actually doing the right thing for the patient something that merits disciplinary actions?

Also... yes, to the OP, we need more info.

 

[usalsfyre]

Lets be realistic. Your talking about taking multiple vehicles into a wilderness area to get to a patient with unknown downtime and a logistical nightmare to get back out. Is it worth working even a medical arrest? This was more of a rescue initially than a medical call. Don't forget, rescues often have "victims" as opposed to "patients"

 

[med109]

This entire thread is pointless unless the OP states the presenting injuries leading to the assumption of traumatic arrest.

Otherwise it is a medical arrest until proven otherwise.

The question keeps behind danced around. Don't even entertain the question anymore until he answers it. Its fishy to me.

As I have said, I wasn't on the call. Bystanders stated there were no obvious injuries, there was no blood. They stated he went over the crest of a hill and when they crested the same hill they found him laying by his dirtbike. The first officer found him unresponsive, checked for a pulse, didn't find one and started CPR, a second officer arrived checked pulse, found a pulse, CPR stopped. While waiting for EMS they checked pulse again, didn't find one and began CPR again. I have stated this a few times, I am not sure what you think I am dancing around. I am also not sure why this sounds fishy. Why would I be making a story like this up? I am female BTW

 

[AnthonyM83]

Some of these statements are real surprising.

It was specifically stated that a traumatic arrest counts injuries incompatible with life. Bull. if you're going that literally, VFib is technically a rhythm incompatible with life, so let's not work it up. In other words, there's misuse of the the term incompatible with life. That's usually reserved for decapitations, etc, etc.

To those who are okay with not even putting a monitor on him, you might be excluding some patients from getting potential lifesaving care.
Example Gratis:
-Commodio Cordis
-Dysrhythmia (aka a medical leading to trauma)
-Tension Pneumo
-Pericardial Tamponade

Sure, they're not common, but they're not what is meant by the phrase "injuries incompatible with life". And in the cost/benefit analysis, it's not costing you much to put some patches on him. All the above are cardiac arrest causes that we've had reversed in our system. I'm not saying work everyone up, but if you patch him up and "Oh, look a narrow complex non-brady PEA...or VFib", sure give him a chance.

Am I nuts here?
It's simply patching someone up!

Oh, and I wouldn't move that patient after determining him dead. At least in California, that's illegal.

 

[Pavehawk]

Had a trauma code last night. 15 yo male auto vs ped ( and perhaps bike hard to say) Our local ALS helo landed on scene before fire and EMS as they were on routine patrol in the area.

The young mans parents were on scene and the flight medic elected to run the code.(we generally do not run trauma codes in our county) He was intubated and an IO was placed. There were no obvious external injuries except for some head trauma. They loaded him on the ground ambulance (no real room for CPR on this aircraft) and took him to the closest facility.

On arrival good CPR was in progress (ETCO2 was 17 with compressions) he was in PEA and additional lines were started in the ER, Epi and NAHCO3 given. FAST scan showed a clear chest (no air or blood) and some free blood in the abdomen.

He went into V-vib and we shocked him and after another two minutes of CPR shocked him again and he got his 3rd epi. We achieved ROSC shortly there after. Portable chest showed no trauma and good tube placement.

Labs were drawn, foley inserted and blood was started and he was packaged for air transport to the Level 1 Pedi facility.

I don't think the prognosis will be anything other then grim for this young man, and his head injury (left occipital open skull FX) is pretty serious. The point of all this is the look of amazement on the EMS folks faces when we got ROSC and a decent pressure in the ER. The medics (all seasoned veterans) are not used to seeing trauma codes run, let alone resuscitated, in our area.

I am not an advocate of running most blunt trauma arrests in the field but this case is an example of why, sometimes, it makes sense to use your judgement rather then blindly follow a protocl or make blanket "black or white" statements. Medicine, as we all know, is almost always shades of grey.