Trauma Death?

[RedAirplane]

For traumatic cardiac arrest, our protocol says something like this:

.. Pronounce death without medical control if no signs of life and asystole

.. consult physician for pronouncement of blunt trauma after 15 minutes of unsuccessful working with initial rythym other than asystole

.. for penetrating trauma arrests not in aystole but no ROSC, if within 15 minutes of the trauma center, transport, otherwise, consult

I’m curious what the medical difference between the treatment of blunt and penetrating in this case is. Is there some magic that’s going to save someone with a penetrating injury after 15 minutes of arrest, that won’t save someone with a blunt injury?

 

[MSDeltaFlt]

Because for penetrating trauma, depending on the trauma, hot lights and cold steel can generally fix it: blood, oxygen, stop the bleeding.

Blunt trauma? Three leads and a sheet.

 

[VFlutter]

Unless it is a blunt arrest in VF there isn't much you can do. Penetrating trauma potentially has reversible causes that can be fixed at a trauma center.

On a side note I have seen more than a few traumatic arrests that had blatantly obvious tension pneumos but were not initially resuscitated because the mechanism was "blunt trauma" i.e. MVA ejection. Always decompress the chest in traumatic arrests

 

[Gurby]

On a side note I have seen more than a few traumatic arrests that had blatantly obvious tension pneumos but were not initially resuscitated because the mechanism was "blunt trauma" i.e. MVA ejection. Always decompress the chest in traumatic arrests

Yes! It feels to me like this is not as common of knowledge as it should be.

 

[RocketMedic]

Organ availability factors in too. Livers, skin, kidneys, potentially hearts and lungs. Lots of good tasty bits in there that someone else could potentially benefit from. I'm not a huge fan of leaving good organs at roadside.

 

[cprted]

Organ availability factors in too. Livers, skin, kidneys, potentially hearts and lungs. Lots of good tasty bits in there that someone else could potentially benefit from. I'm not a huge fan of leaving good organs at roadside.

Obviously guidelines vary by jurisdiction, but where I am, out of hospital cardiac arrest is a contraindication for organ harvesting. I'd have to check, but I believe if there is ROSC, they have to maintain a pulse for at least 24 hours before they can be considered a candidate again.

 

[NomadicMedic]

Usually not for bone, skin and connective tissue. We don't think about those harvests as much as hearts and kidneys, but still immensely valuable.

 

[Jim37F]

Because for penetrating trauma, depending on the trauma, hot lights and cold steel can generally fix it: blood, oxygen, stop the bleeding.

Blunt trauma? Three leads and a sheet.

Unless it is a blunt arrest in VF there isn't much you can do. Penetrating trauma potentially has reversible causes that can be fixed at a trauma center.

I suppose then the question boils down to WHY penetrating trauma arrests can (potentially) be fixed by a trauma surgeon, but blunt trauma arrests cannot? I.e. if the cause of cardiac arrest in traumas, regardless of blunt or penetrating, is exsanguation, what makes blunt trauma magically immune to the "cold steel and hot lights" that we expect to have a chance on penetraining trauma?

 

[Carlos Danger]

I suppose then the question boils down to WHY penetrating trauma arrests can (potentially) be fixed by a trauma surgeon, but blunt trauma arrests cannot? I.e. if the cause of cardiac arrest in traumas, regardless of blunt or penetrating, is exsanguation, what makes blunt trauma magically immune to the "cold steel and hot lights" that we expect to have a chance on penetraining trauma?

Good question.

Penetrating trauma is more likely to result in a rather isolated injury or injuries where the internal bleeding is more likely to be able to be relatively quickly controlled by a skilled surgeon. A splenic or vascular laceration than can be sewn up, for instance.

Blunt trauma sufficient to cause rapid death, on the other hand, is more indicative of a severe multi-organ injury that is very difficult or time-consuming to repair. Instead of a lung laceration and the associated hemo/pneumo, for instance, you might be looking at a massive tracheobrochial disruption or diaphragmatic rupture. Instead of a spleen or liver laceration, you might be looking at complete destruction of the spleen as well as a large portion of the liver, bowel, and important vasculature. The leading cause of death from blunt trauma is lethal CNS injury.

 

[VFlutter]

With REBOA becoming more common I think you can make an argument to transport some of these patients.

 

[MSDeltaFlt]

Good question.

Penetrating trauma is more likely to result in a rather isolated injury or injuries where the internal bleeding is more likely to be able to be relatively quickly controlled by a skilled surgeon. A splenic or vascular laceration than can be sewn up, for instance.

Blunt trauma sufficient to cause rapid death, on the other hand, is more indicative of a severe multi-organ injury that is very difficult or time-consuming to repair. Instead of a lung laceration and the associated hemo/pneumo, for instance, you might be looking at a massive tracheobrochial disruption or diaphragmatic rupture. Instead of a spleen or liver laceration, you might be looking at complete destruction of the spleen as well as a large portion of the liver, bowel, and important vasculature. The leading cause of death from blunt trauma is lethal CNS injury.

Exactly. Blunt trauma can cause more of a global injury encompassing the entire organ, organ systems, and even the entire body at the cellular level. Surgeons can't fix that.

 

[NPO]

We recently revisited our traumatic arrest protocol. We made several changes. Previously we either left them dead, or transported immediately. There was some confusion because on medical arrests we stay on scene and work using our CCR and pit crew model for at least 30 minutes.

Our new traumatic arrest protocol does not follow that. We do not do CCR, but traditional CPR, no epinephrine, and dopamine for PEA. We also work them on scene for 15 minutes before transport. No ROSC, no transport. This is because our nearest trauma center is 30-90 minutes away depending where in the county you are. We don't want to be transporting anyone without a pulse for that long.

Traumatic Cardiac Arrest
1. A traumatic arrest is defined as a patient that has blunt or penetrating trauma that is found
pulseless and apneic upon EMS arrival to the patient.
a. It is recommended by The National Association of EMS Physicians and the American
College of Surgeons Committee on Trauma to withhold resuscitation for patients with: (17)
i. Injuries that are obviously incompatible with life, such as;
1. Hemisection of torso
2. Decapitation
3. Catastrophic brain trauma
4. Pulseless and apneic in a MCI
5. Injuries that would prevent effective CPR
ii. Patients with evidence of a prolonged arrest, such as;
1. Rigor mortis
2. Dependent lividity
3. Known downtime of greater than 15 minutes
iii. On arrival of EMS, patient is pulseless, apneic and has no organized electrical
activity.
1. Asystole
2. PEA less than 40 bpm.
2. If the above conditions are not met, begin resuscitation efforts.
3. If the incident is within 10 minutes of a trauma center, load and go rapid transport and resuscitate
during transport. If not, remain on scene and resuscitate until ROSC is obtained or efforts
terminated.
4. Resuscitation of the traumatic arrest patient is not the same as a cardiac arrest patient. Do not
follow CCR protocols. Instead;
a. Begin CPR with 30:2 compressions to ventilations ratio with rhythm checks every 2
minutes. Defibrillate as needed.
b. Secure the airway with an advanced airway adjunct as soon as possible
c. Initiate large-bore IV/IO access and begin fluid resuscitation.
d. Consider Dopamine if the patient presents with a PEA rhythm. 10 mcg/kg/min IV drip.
e. If any injuries to the chest are noted, perform bilateral chest needle decompression
f. Continue resuscitation efforts until ROSC is obtained, or 15 minutes has passed.
i. If no ROSC after 15 minutes, contact medical control and terminate efforts. (18)
ii. If ROSC is obtained, begin rapid transport to a trauma center. Consider HEMS
transport if it is available and would not delay further care.
iii. Prior to transport, ensure that the Lucas device is in place if needed.
iv. If patient rearrests during transport, continue resuscitation and transport to the
nearest hospital.

 

[Bullets]

Do you still do CCR for medical arrests? If not, why did you get away from it?