Traumatic Cardiac Arrests

[VFlutter]

How aggressive, or not, are you working Traumatic Cardiac Arrests? As we know Traumatic Arrests survival is minimal however should we still attempt to identify and treat reversible causes? With some trauma centers becoming more aggressive with ECMO and REBOA is transport a more viable option?

Personally, if I arrive on scene of a patient in a trauma arrest in PEA/VT/VF without obvious injuries incompatible with life I think its reasonable to bilateral decompress, ventilate, and do basic resuscitation. I also have no problem grounding to the nearest ER or flying in arrest if they appear viable with a fixable injury.

This is very situation and crew dependent. There really isn't a right or wrong answer.

 

[wanderingmedic]

Right now I’m basically not. I’m in a rural system so our transport times to even a minimally equipped facility is >30 minutes.

I did work one ejection where the patient was in his 20s and the cause of the arrest was likely a ventilatory problem (massive face trauma). But that’s about it. Everyone else gets pronounced.

 

[CANMAN]

Not....Will work with the ground crew and either pronounce on scene, or transport to local ED. I don't put people with on-going CPR into my aircraft for many reasons.

 

[E tank]

Are we distinguishing PEA and full arrest?

 

[EpiEMS]

There really isn't a right or wrong answer.

Curious if there's any research you guys are relying on to back your practice.

I've poked around, seems like there's a bit of TCA research specific to HEMS, but mainly out of Europe & focused on physician staffed systems (e.g. London)

 

[E tank]

Interesting poll data so far...traumatic arrest is a surgical problem...

 

[VFlutter]

Curious if there's any research you guys are relying on to back your practice.

I've poked around, seems like there's a bit of TCA research specific to HEMS, but mainly out of Europe & focused on physician staffed systems (e.g. London)

We actually do not have a specific policy for TCA, just a generic Cardiac Arrest protocol.

I would say that current data probably leans towards calling it in the field. However European HEMS data is interesting with field surgical procedures.

Anecdotally, I have had a few patients whom were pulseless on our arrival and got ROSC after needle decompression and survived to the ER. Probably one of the few etiologies that are fixable in the field. Also have had a few peri-arrest/arrest patients that got a REBOA immediately on arrival to the ER and were stable after.

We usually will not fly patients actively in cardiac arrest however do fly many whom are likely to arrest in flight.

traumatic arrest is a surgical problem...

Agreed. The question becomes which TCA patients actually benefit from transport for surgical intervention.

 

[E tank]

Agreed. The question becomes which TCA patients actually benefit from transport for surgical intervention.

I'd argue that those with PEA are higher on that list.

 

[TXmed]

Fly patients in active TCA. Intubation, Any trauma to torso region gets bilateral darts, and blood broducts x2. Tourniquets if needed. Ive gotten several back usually after intubation and blood products.

 

[StCEMT]

I opted to work the last one based off call notes and being within a fairly close distance of a level 1. They actually got ROSC, but he died in the OR. Typically it is a no from me unless there are some other factors to consider.

 

[Summit]

Blunt TCA arrested significantly PTA or unwitnessed, probably a field termination.

Otherwise

 

[DrParasite]

blunt traumas typically get pronounced on scene, penetrating might get flown to trauma center but more often will go by ground.

If you get ROSC, fly them. If they arrest as you are taking them to the chopper, go by ground.

 

[EpiEMS]

We actually do not have a specific policy for TCA, just a generic Cardiac Arrest protocol.

I would say that current data probably leans towards calling it in the field. However European HEMS data is interesting with field surgical procedures.

Anecdotally, I have had a few patients whom were pulseless on our arrival and got ROSC after needle decompression and survived to the ER. Probably one of the few etiologies that are fixable in the field. Also have had a few peri-arrest/arrest patients that got a REBOA immediately on arrival to the ER and were stable after.

We usually will not fly patients actively in cardiac arrest however do fly many whom are likely to arrest in flight.

It's definitely one of those things that I'm happy I have a protocol for. I would love *more* protocol, frankly, when it comes to this.

Certainly seems reasonable to transport if you think the cause is fixable. That said, I'd love to see data (somewhere, someday) that shows whether it is effective & cost-effective to transport TCA.

Do you use a Lucas or similar device in flight? Particularly pre-attaching for a peri-arrest patient?

 

[VFlutter]

Do you use a Lucas or similar device in flight? Particularly pre-attaching for a peri-arrest patient?

I have not but have heard a few stories of them being used in HEMS. The Lucas is too tall for most helicopters. The squeezer types may work better. But the questions always come up about FAA compliance.

Manual CPR is not feasible in most helicopters but I feel about as comfortable doing CPR in a BK as I do in an ambulance. I totally understand people who will not do CPR in flight and I know it is not optimal by any means.

 

[CANMAN]

I have not but have heard a few stories of them being used in HEMS. The Lucas is too tall for most helicopters. The squeezer types may work better. But the questions always come up about FAA compliance.

Manual CPR is not feasible in most helicopters but I feel about as comfortable doing CPR in a BK as I do in an ambulance. I totally understand people who will not do CPR in flight and I know it is not optimal by any means.

I have used a Lucas in a 135 before in my previous program. You just click it off to load through the tunnel, then bring it in the side door and click it back into place and resume. Same obviously has to be done for off loading which is just a pain. Patient still died. This and multiple other factors have sealed my views on transporting an active arrest. I will do CPR in the aircraft if a patient we are transporting arrests, but don't believe in putting ourselves into that position from the starting point of the mission. One of the few things I like about my current program is still rotating through the trauma bays for clinical shifts. Keeps you in touch with what is really salvageable and when it's time to exercise good judgement on not only a "save" but also the likelyhood of ROSC to discharge, and what that quality of life would look like. If they are arresting once we land, we work there to fix fixable things, and will work 10 mins and re-evaluate. At that point we will make a decision. When I worked at my previous program and carried blood products we also would not give our products to blunt trauma arrests.

 

[TXmed]

The lucas in a 145 is OK but usually ill go with manual compression's unless its a long flight.

TCA's from penetrating injury (not counting ones to the head) have a far better outcome then blunt.