Why not shock a trauma code?

snaps10

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This "discussion" has been going around the office lately. To shock, or not to shock a trauma code. Protocols here dictate that we do not shock arrest as te result of trauma. How do we know the trauma wasn't caused by arrest?
What harm is there in placing an AED on a patient and seeing if there's shockable rhythm? I've searched google and can't find a reason for the protocols, only that it's there.
Opinions?
 

TheGodfather

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it wont do anything if you shock a traumatic arrest... there is nothing wrong with the heart (unless there was direct cardiac injury) and even in that case, electrical therapy is not what is needed. the problem is blood loss.

studies show there is almost a zero percent success rate in the traumatic arrest resuscitation in the prehospital setting (without blood products). i can find these studies if anyone feels the need to challenge it.

EDIT: if you suspect the arrest was not due to the traumatic insult itself, then yes - follow ACLS guidelines. IE; car runs into wall at 5mph, etc etc. this all comes down to good history taking and a good size up
 
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DrankTheKoolaid

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There are exceptions to the no shocking trauma rules. A direct blow to the chest comes to mind. Precordial thump is the principal behind this... If a blow to the chest has the possibility of converting someone out of a lethal rhythm, the opposite also rings true. So if a blow to the chest IE a sternal punch, softball, steering wheel causes the lethal insult then shocking it would be appropriate.
 

TheGodfather

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There are exceptions to the no shocking trauma rules. A direct blow to the chest comes to mind. Precordial thump is the principal behind this... If a blow to the chest has the possibility of converting someone out of a lethal rhythm, the opposite also rings true. So if a blow to the chest IE a sternal punch, softball, steering wheel causes the lethal insult then shocking it would be appropriate.
agreed!
 

JPINFV

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There are exceptions to the no shocking trauma rules. A direct blow to the chest comes to mind. Precordial thump is the principal behind this... If a blow to the chest has the possibility of converting someone out of a lethal rhythm, the opposite also rings true. So if a blow to the chest IE a sternal punch, softball, steering wheel causes the lethal insult then shocking it would be appropriate.

Commotio cordis.

http://emedicine.medscape.com/article/902504-overview
 

DrankTheKoolaid

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That would bed it, thanks!
 

DrankTheKoolaid

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Sigh. Be it i mean... Cant seem to edit with tapatalk.........
 

zmedic

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I think when most people talk about "trauma arrest" they are talking about big trauma. Car crash. Person fall off building. Hit by bus. If they person doesn't have a pulse it probably isn't because of R on T. I agree if someone had a "trauma" by being kicked in the chest or hit with a baseball you should put the pads on them. (Hopefully someone has been doing CPR while you were on the way because otherwise chances are slim of bringing them back.)

As to not putting the paddles on trauma arrests. I don't know about BLS protocols, but when I was on ALS if we were not going to work a code we put them on the monitor to document asystole. And that included traumatic arrests. So if we did that and saw vfib we would work it. From the BLS perspective I would say unless you are sure (decapitation, shot in the head with brain matter and no pulses, smooshed by bus and not much left) I would work it unless ALS got there. But that's a good question for your medical director.

Again I'd look at the patient. If crashed his car but not much damage and they are in arrest, I'd probably work it assuming the arrest caused the crash.

Interesting question though.
 

the_negro_puppy

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Most pulse-less trauma patients present as a PEA or asystole arrest. rather than the shockable rhythms of VF of pulseless VT.

If you look at the pathophysiology behind traumatic arrests usually from (hypovolemic shock, head injury, tension pneumothorax or pericardial tomponade) you can understand why resus attempts in the field are almost futile.
 

snaps10

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Most pulse-less trauma patients present as a PEA or asystole arrest. rather than the shockable rhythms of VF of pulseless VT.

If you look at the pathophysiology behind traumatic arrests usually from (hypovolemic shock, head injury, tension pneumothorax or pericardial tomponade) you can understand why resus attempts in the field are almost futile.
Almost is the key word. Am I going to get sued for attaching an aed (30 seconds max) and getting a "shock not advised" or possible get sued for attaching an aed getting a shockable rhythm and delivering a shock, potentially with a positive outcome. Why would the protocols say not to shok a trauma code? Is there some negative that could possibly come of it? I can't think of any.
 

JPINFV

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Almost is the key word. Am I going to get sued for attaching an aed (30 seconds max) and getting a "shock not advised" or possible get sued for attaching an aed getting a shockable rhythm and delivering a shock, potentially with a positive outcome. Why would the protocols say not to shok a trauma code? Is there some negative that could possibly come of it? I can't think of any.
Depends, is the next step anything besides "stop resuscitation" for a blunt trauma? If it's a penetrating trauma, then the downside is a loss of 30 seconds from potentially definitive interventions (e.g. chest tube, pericardiocentesis<->pericardectomy continuum, etc). Also, at what time do you consider resuscitation futile, given the totality of the circumstances?
 

systemet

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Almost is the key word. Am I going to get sued for attaching an aed (30 seconds max) and getting a "shock not advised" or possible get sued for attaching an aed getting a shockable rhythm and delivering a shock, potentially with a positive outcome.
Well, you can get sued for anything, including doing your job possibly. The question is whether you'd get successfully sued. If you're following the protocols written by your medical director or medical advisory committee, they're unlikely to find you culpable.

Why would the protocols say not to shok a trauma code? Is there some negative that could possibly come of it? I can't think of any.
If the cause of the arrest is hemorrhagic hypovolemia, and you haven't corrected this, the defibrillation isn't likely to fix the code.

Alternatively, if you've opened an obstructed airway, made a surgical airway, decompressed a pneumothorax, or done a pericardialcentesis, things might be different.

Are there negatives per se? I doubt that's been shown prehospitally. As pointed out by an earlier poster, the survival here is very low. There's discussion that defibrillation may cause cardiac injury, that was part of the impetus behind moving from monophasic to biphasic defibrillation (the higher first shock success being the more significant reason).

The stars have to line up for these sorts of patients to survive. You basically have to be transporting a patient with surgically correctable injuries to a real hospital that can open their chest in the ER and has access to blood products in a timely fashion, or you have to be very lucky and decompress a pneumo that caused the arrest. This isn't a reality for most rural providers.
 

tacitblue

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I can answer this question pretty narrowly by saying that in any arrest situation, use electrical therapy when you have a shockable rhythm per ECC guidelines.

That said, VF/VT is not usually associated with traumatic arrest; PEA and asystole are going to be your presenting rhythms. Therefor shocks are more than likely not indicated. If you do happen to be on a TC with minor MOI and have a patient in VF/VT, suspect medical eitology and start standard ACLS
 

HMartinho

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I can answer this question pretty narrowly by saying that in any arrest situation, use electrical therapy when you have a shockable rhythm per ECC guidelines.

That said, VF/VT is not usually associated with traumatic arrest; PEA and asystole are going to be your presenting rhythms. Therefor shocks are more than likely not indicated. If you do happen to be on a TC with minor MOI and have a patient in VF/VT, suspect medical eitology and start standard ACLS

Hypoxia in trauma patients can provoke V-fib. So in this cases, you should shock him/her.
 

Veneficus

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I should charge for this stuff.

Defibrillation as the recommendation of therapy for VF/pulseless VT is from observation of patients suffering the most common side effect of an MI. (SCD from vfib secondary to MI is listed by multiple sources as near 70%)

This occlusion interrupts the delivery of oxygen to the heart resulting in anaerobic metabolism and eventually myocardial failure.

During this occlusion, the normal conduction mechanisms of the cells are disrupted in an easily correctable way.

There are also physiologic mechanisms for clot resolution allowing some level of delivery of o2.

In this case, the heart cannot be reperfused without specific medical or surgical intervention. In this case continued CPR is required to maintain central perfusion in the absense of a working pump.

This lack of delivery of o2 correction after a successful defibrillation is one of the main mechanisms of recurrent vfib. (basically since the heart cannot reperfuse itself to sufficent level, it falls victim to the exact same circumstance as before)

In the case of trauma, the most common mechanism for arrest is hypovolemia. There is just no oxygen being delivered to the heart and it fails in a predictable way. (often with PEA, but occasionally the pulseless vtach-vfib-PEA-asystole path)

If you witness this v-fib in hypovolemia, and you shock it, even if a "normal" rhthym returns, there is still no delivery of o2 and the situation will repeat itself.

CPR becomes ineffective as there is nothing to circulate.

Without prompt surgical and intensive resuscitation, there is nothing that can be done to correct this.

Outside of this hypovolemia, there are specific instances when the injury disrupts this delivery of o2 in a correctable way. R on T phenomenon from a direct blow, cardiac tamponade, pneumothorax, hemothorax, etc.

In these cases it is treatment of the direct insulting pathology that is key. Only in the first one will defibrillation be the treatment. (and I will mention it is an extremely rare phenomenon and you will likely know it when you see it.)

There are even cases where no therapy will help, like massive cardiac contusion or gross aortic dissection. (most aortic dissections discovered in live trauma patients are subclinical and while they require surgical or vascular correction, are not always the priority injury for repair. Compensation lasting on average 48 hours)

Defibrillating V-fib in a traumatic cardiac arrest is playing extremely long odds that one specific rare pathology is present.

If you are truly believe the patient to be viable in some way, they need to be transported without delay to a place with people capable of intervention of the specific pathologies causing the arrest.

If you think the patient is not viable and you are expending resources on them (including time preventing them from reaching definitive intervention) then you are just playing with a corpse.

In order to save any arrest patient, you must be able to preserve vital function until pathology specific interventions can restore normal physiology.

In the traumatic arrest patient, it is extremely rare that field providers or non dedicated facilties have the tools or abilities to do this.

In the medical arrest patient, EMS probably has the ability to maintain central perfusion. (in the form of IV therapy, CPR, etc.)

In a class III (or iv) shock patient, with an ongoing hemorrhage or (self)hemostasis unless you have blood and surgical intervention, EMS is not able to support or correct these people in the field.

The help for them is at the hospital. Do not delay them.
 
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snaps10

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So I guess what it comes down to is that there is no real medical reason for protocols to say "Do not use an AED on a trauma patient"
 

Veneficus

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So I guess what it comes down to is that there is no real medical reason for protocols to say "Do not use an AED on a trauma patient"
Apparently the page I typed on it is lost time.
 

snaps10

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I'm sorry I came across that way. In no way was it my intention to disrespect your very well written and knowledgeable response. (no excuse, but I'm going on three long nights and an 8 day old daughter when I'm at home, sleepless week)
I guess where this all stemmed from was a conversation I had with a partner on the walk to the office the other day. After a white cloud week, which seemed to go by very, very slow, I mentioned that a good trauma call would sure make the time go by faster. He one upped me by saying a trauma code would as well. Next thing you know we've got 3 people saying they're putting an AED on a trauma code, and 2 (including one supervisor) saying no way, no how. Protocol says no AED for trauma. I'm new to the company, so I'm still feeling some of the people out and honestly am on the fence regarding what I feel the correct treatment would be and what my Supervisor the company wants us to do.
Again, I apologize for my quick, smart-assed reply. The protocols don't mention any different options, other than do nor use an AED on a trauma patient.
 
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