Presentation on theme: "Cardiopulmonary Arrest"— Presentation transcript:
0 International Trauma Life Support, 7e Cardiopulmonary Arrest in the Trauma Patient21Key Lecture PointsBriefly review the causes of cardiopulmonary arrest in the trauma situation.Review the position statement (National Association of EMS Physicians and the American College of Surgeons Committee on Trauma) on withholding or terminating resuscitation of prehospital cardiopulmonary arrest. Discuss any local protocols that impact this decision.Review the general management of the trauma arrest.Compare and contrast the management of the trauma arrest to general advanced cardiac resuscitation guidelines.Remind the students always to think of hemorrhagic shock, tension pneumothorax, and pericardial tamponade when evaluating the trauma arrest patient.Stress rapid transport of the trauma arrest patient.NOTE: This chapter will discuss guidelines for when to attempt resuscitation and when it would be futile. You also will review the causes of the traumatic cardiac arrest and the best plan of action to rapidly identify the cause and match your response to that cause.
2 Overview Traumatic cardiac arrest Treatable causes Proper evaluation and managementGuidelines for withholding resuscitation
3 Unsalvageable Patient Traumatic cardiopulmonary arrest survival is rare but some causes are correctable with prompt recognition and intervention.While CPR in pulseless arrest is considered futile, there are several causes of traumatic cardiac arrest that are correctable, and prompt recognition and intervention could be lifesaving.Trauma patients who are found pulseless or apneic on-scene or who “crash” and develop those signs while under your care rarely survive; however, it is possible in certain cases.Discuss survival numbers from traumatic arrest.
5 Unsalvageable Patient Prehospital Trauma Arrest GuidelinesJoint Position StatementNational Association of EMS PhysiciansAmerican College of Surgeons Committee on TraumaGuideline categories:Resuscitation withheldResuscitation initiatedResuscitation terminatedNOTE: Refer to Table 21-1: Guidelines for Withholding or Termination of Resuscitation.Guidelines for Withholding or Termination of Resuscitation of Prehospital Traumatic Cardiopulmonary Arrest developed based on trauma survival research.Jointly developed by National Association of EMS Physicians and American College of Surgeons Committee on Trauma.In trauma, arrest is usually not due to primary cardiac disease.Direct treatment by identifying underlying cause of arrest, or will almost never be successful in resuscitation.Use ITLS Primary Survey to identify cause of arrest and those patients for whom you should attempt resuscitation.
6 Resuscitation Withheld No breathing, no pulse, no organized cardiac activityBlunt trauma arrest on EMS arrivalPenetrating trauma arrestNo pupillary reflexes or spontaneous movementInjuries incompatible with lifeEvidence of significant time since pulselessnessDependent lividity, rigor mortis, etc.NOTE: Refer to Table 21-1: Guidelines for Withholding or Termination of Resuscitation.NOTE: Emphasize these are all trauma arrest patients.Resuscitation should be withheld in cases of:Blunt trauma with no breathing, pulse, or organized rhythm on EKG on EMS arrival at scene.Penetrating trauma with no breathing, pulse, pupillary reflexes, spontaneous movement, or organized EKG activity.Pupils dilated and nonreactive.Any trauma with injuries obviously incompatible with life (e.g., decapitation).Any trauma with evidence of significant time lapse since pulselessness, including dependent lividity, rigor mortis, etc.
7 Guidelines for Withholding or Terminating Resuscitation IMAGE: Table 21-1 Guidelines for Withholding or Terminating Resuscitation of Prehospital TCPA.NOTE: Emphasize these are all trauma arrest patients.
8 Causes and Treatment of Traumatic Cardiopulmonary Arrest (TCPA)
9 Trauma Arrest Treat underlying cause Use ITLS Primary Survey to identifyProlonged hypoxemia is most commonAirway problemsBreathing problemsCirculation problemsNOTE: See Table 21-2 Causes of Cardiac Arrest in Trauma Situation.NOTE: Each of these categories discussed on following slides.Hypoxemia is most common cause of traumatic cardiopulmonary arrest.Acute airway obstruction or ineffective breathing will be clinically manifested as hypoxemia.Prolonged hypoxia causes such severe acidosis that patient will not respond to attempted resuscitation.
10 Causes of Trauma Arrest Airway problemsForeign bodyTongue prolapsedSwellingTracheal damageHemorrhage into airwayMisplaced advanced airwayNOTE: See Table 21-2 Causes of Cardiac Arrest in Trauma Situation.Drugs and alcohol, often in conjunction with minor head trauma, can result in airway obstruction by the tongue as well as by respiratory depression.The same is true of the patient who is unconscious from a head injury.You may use a blind insertion supraglottic airway device (King Airway, LMA, and others) if tolerated by the patient.The role of endotracheal intubation (ETI) in the major trauma patient is an area of wide debate and study.Theoretically, management of the airway should be simpler with ETI, but studies have questioned its benefit and any role in improving survival. In any case, the provider should use all efforts available to prevent aspiration, including having an effective suction device readily available.Courtesy of Bonnie Meneely, EMT-P
11 Causes of Trauma Arrest Breathing problemsTension pneumothoraxSucking chest woundFlail chestDiaphragmatic injuryHigh spinal-cord injuryCarbon monoxide inhalationSmoke inhalationAspirationNear-drowningCNS depression from drugs/alcoholApnea secondary to electric shock or lightning strikeNOTE: See Table 21-2 Causes of Cardiac Arrest in Trauma Situation.Patients with hypoxia secondary to a breathing problem have an adequate airway, but are unable to oxygenate their blood because they cannot get oxygen and blood together at alveolar capillary membrane of lungs.Aggressive airway management and ventilation with high-flow oxygen!Carefully monitor airway and breathing.Many of these patients will respond quickly if they have not been anoxic for too long.Significant number of near-drowning patients who appear lifeless in field will eventually have a complete recovery (one study showed 19%).
12 Causes of Trauma Arrest Circulatory problemsHemorrhagic shockTension pneumothoraxPericardial tamponadeMyocardial contusionAcute myocardial infarctionCardiac arrest secondary to electric shockNOTE: See Table 21-2 Causes of Cardiac Arrest in Trauma Situation.Cause hypoxemia through inadequate blood return to heart, resulting in inadequate oxygenation of tissues.Inadequate blood return to heart caused by:Increased pressure in chest, causing increased resistance to venous return to heart.Tension pneumothorax or pericardial tamponade.Inadequate blood volume from hemorrhage.Inadequate pumping of heart caused by:Rhythm disturbances:Myocardial contusion, acute myocardial infarction, or electrical shock.Arrest from an electric shock usually presents as ventricular fibrillation, which responds readily to ACLS protocols if you arrive in time.Acute heart failure with pulmonary edema:Large myocardial contusion or acute myocardial infarction.Hemorrhagic shock (hypovolemic or empty heart syndrome) is most common circulatory cause of trauma cardiopulmonary arrest.
13 Trauma Cardiac Arrest Most victims: Scene Size-up is essential YoungNo preexisting cardiac diseaseScene Size-up is essentialCarefully record observationsDifferent from medical cardiac arrest2–4 liters normal saline rapid infusionAggressive airway and breathing management should be performed as in all patients, paying particular attention to underlying cause of arrest.Once airway and breathing have been managed, if there is no improvement, circulation should be treated with rapid volume infusion.As with all patients, do not delay transport for volume infusion; this can be done during transport.
14 Trauma Cardiac Arrest Special groups Isolated head injury Extent of injury not determined in fieldMassive blunt injuryResuscitation withheld if found asystolicChildrenAggressively attempt resuscitationFollow PALS guidelinesIsolated head injury:Usually do not survive, but should be aggressively resuscitated.Extent of injury cannot always be determined in field.Also potential organ donors.Massive blunt trauma found in asystole are dead; resuscitation should be withheld.Children: be especially aggressive in attempting to resuscitate children with no palpable pulse.Some reports show dismal results for resuscitation of children in cardiac arrest.One study showed 25% of children who received CPR in field survived to discharge (out of 700 cases).This may be in part because sometimes pulse is difficult to find in a child, but is still present.
15 Pregnant Patients Pregnant trauma arrest Treatment priorities are same Defibrillation settings are sameDrug dosages are sameFluid volume needed increases4 liters normal saline rapid infusion during transportTreatment is same as for other patients, except for fluid resuscitation.Fluid resuscitation during transport, same as for other patients.Receiving facility should be notified as early as possible to give them time to mobilize resources.Remember: Survival of fetus is dependent on survival of mother.
16 Considerations in Management AirwayOptimal airway unclearETIProlonged periods of hypoxiaRisk of aspirationSurvival the same ETI or SADNOTE: SAD – Supraglottic Airway Device.It is unclear what the optimal airway is for the patient in TCPA.Prolonged periods of hypoxia have been demonstrated for patients on whom ETI is attempted in the prehospital phase of care (Davis, et al.).Excessive manipulation of the airway during ETI has been associated with increased risk of aspiration (Wang, et al.).A recent study has revealed no difference in survival to hospital discharge in cardiac arrest patients when comparing the use of ETI to Combitube placement in the prehospital phase of care.
17 Considerations in Management VentilationPositive pressure ventilation reduces venous returnAvoid over-ventilation8 per minute with 750 cc tidal volume (adult)CapnographyLow CO2 indicates O2 in cells is lowRising CO2 indicates improving circulationEstablish correct ventilatory rateCapnography provides a glimpse of the actual metabolism of the body, and the normal level measured at the airway is approximately 40 mmHg during exhalation.A low measured level of CO2 at the airway in TCPA patients is an indication that O2 supply to the cells is low.Rising CO2 levels during resuscitation of TCPA patients is an indication of improving circulation.Over-ventilation of the TCPA patient can reduce cardiac output. This lowers O2 delivery to the tissues, reducing CO2 production and measured capnography.Adjust the ventilation rates downward if capnography measures under 10 mmHg.Specific guidelines to ventilation rate and capnography measurements should come from your local medical direction.
18 Summary Traumatic arrest survival is rare Prehospital Trauma Arrest Guidelines:Do not resuscitate unsalvageable patientsIdentify and treat underlying cause:ITLS Primary SurveyAggressive airway managementAggressive breathing managementAggressive circulatory managementTrauma patient in cardiopulmonary arrest is usually suffering from a breathing or circulatory problem. If you are to save this patient, you must identify cause of arrest with ITLS Primary Survey and then rapidly transport patient while performing those procedures that specifically address cause of arrest.If you resuscitate:Limit spinal motion.Establish airway.Ventilate.Start CPR.Transport.Use Rapid Trauma Survey to identify and treat causes en route. (Treat suspected hypovolemia with fluid resuscitation.)