Trauma Codes; To Work or Not.

WildlandEMT89

Forum Lieutenant
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We would of worked it until we had clearance to terminate given the circumstances you provided.

Field Termination of Resuscitation GuidelinesRevised and Approved by AEMS Board of Governors – July 19, 2006

Purpose: The purpose of this document is to provide a guideline for on-line medical control physicians to aid in the process of termination of resuscitation in the pre-hospital setting. In order to stop or withhold resuscitation efforts, an order from an on-line medical control physician is required. This document is not meant to establish a standard of care or mandate a specific action in individual cases of cardiac arrest.

Medical Indications:
1. Cardiac arrest is not associated with a condition that would easily respond to in-hospital treatment.
2. Airway has been managed appropriately.
3. ACLS measures have been followed during the resuscitation effort, including 3doses of appropriate medications.
4. The patient is in asystole or an agonal rhythm at the time the order is given tostop resuscitation.
Documentation of this event should be complete and include rhythm strips. Family or medical power of attorney requests for continued resuscitation efforts should be honored.

Trauma Indications:
1. Blunt trauma patient who is found to be apneic, pulseless, and in asystole.
2. Penetrating trauma patient who is found to be apneic, pulseless and in asystoleand without other signs of life such as pupillary reflexes or spontaneousmovement.
3. Resuscitation efforts may be withheld if a trauma patient meets the criteria in theabove #1 & #2.
On-line medical direction should be established as soon aspossible to confirm the decision to withhold resuscitation efforts.
In multiple patient situations, there may be inadequate resources to devote care to the resuscitation of pulseless patients. In such cases, the highest trained provider on the scene should confirm that the patient is pulseless and direct care to more viable patients. In addition, if the patient is pulseless and extrication is necessary before CPR can be provided, the patient should be triaged as deceased.

Obvious Death Criteria:
1. Decapitation/Decomposition
2. Dependent Lividity/Rigor Mortis
If the patient meets any of the criteria above, no resuscitative efforts are required. On- line medical direction is NOT required.
Other Considerations: It is recommended that termination of resuscitation be done on scene. If it is done during transport, the body may not be accepted at any hospital. Contact the police dept. or sheriff’s office for disposition of the body. Consider on-scene grief support for family members. A “Prehospital Medical Care Directive” (orange DNR form) can be accepted as a “Do Not Resuscitate” order if it is complete.

It's also of note that we utilize CCR before getting into ACLS
 
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Carlos Danger

Forum Deputy Chief
Premium Member
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In the absence of injuries obviously incompatible with life, whether or not to work a trauma code can be a tough call.

On one hand, we all know the statistics. Chances of survival from any traumatic arrest are very slim......practically zero depending on exact mechanism and co-mordities. Even if initial resuscitation is successful, long-term prognosis is still grim. We expend a lot of very expensive resources on people who ultimately end up not surviving.

On the other hand, we all know of anecdotes where someone who "shouldn't have made it".....does. It's easy to dismiss these as anomalies, until you remember that these are people who lived. There can be factors at play that lead us to believe that THIS patient has a higher chance of survival than average. Either way, we all want to give everyone the best chance possible, even if the odds are against them.

Point is, I generally don't begrudge anyone for wanting to work a "sensible" traumatic arrest. It might be justifiable in some cases, even if the odds remain poor. Penetrating trauma with close proximity to a trauma center, availability of blood, the presence of immediately reversible causes of death, etc.
 

jrm818

Forum Captain
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OP,

You almost certainly did well. It sounds like you are beating yourself up about this, and understandably given how close to home it was. Don't worry about if you performed perfectly, or followed your protocol exactly. Calls like this are almost universally not-quite-by-the-book, given the chaos. Even moreso if you know the patient. I'm very grateful that I've never experienced that, but it would be rough for anyone.

You gave your time and effort to try to help, and you did your best to take care of someone in a horrible situation. Often in EMS the "taking care of" someone is the most important part. There is always room for improvement, but that doesn't make every effort prior to improvement bad. Even if the medicine was imperfect (and it often is, from all of us), you should only take away from this that you did good.
 

k9Dog

Forum Crew Member
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Vfib yes because of her age. But in this situation, you saw asystole--this person is dead. There is structural damage to her organs, not a blood clot like in many medical arrests. This person is dead. The probability of survival is probably in the neighborhood of 1%
 
OP
OP
AustinSofa

AustinSofa

Forum Ride Along
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Thank all of y'all for the support, and your opinions on whether it should have been worked. Her funeral was Saturday and that's tr reason it's been so long I've commented back.
 

COmedic17

Forum Asst. Chief
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Since she had injuries not compatible with life, but had some degree of cardiac activity - I would of directed my partner to begin compressions while I called medical control and requested to terminate resuscitation. When in doubt- call medical control. This also takes the blame off of you if family becomes upset with the decision to pronounce.


A lot of "emotionally compromised" medics might try to run this as a full arrest and transport- especially if family/friends were on scene. As traumatizing as it would be for them to see their family member/friend pronounced on scene, how traumatizing would it be for them to see their friend being "worked" (tubed, drilled, whatever they might see) and get that false hope just to have the doctor say the patient had no chance of survival? At this point the bystanders are the patients. Get the body out of visual sight, and comfort bystanders.


To answer the question, if I knew the patient, I would still pronounce. With injuries as you explained- I know that survival is slim to none, and if the patient somehow did miraculous survive, quality of life would be poor at best. It would be hard to do, but at that point I think it's more inhumane to work it as opposed to calling it.
 
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