0. International Trauma Life Support, 7e
Cardiopulmonary Arrest in the Trauma Patient 21
Key Lecture Points
Briefly 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.

1. Cardiopulmonary Arrest
© Pearson

2. Overview Traumatic cardiac arrest Treatable causes
Proper evaluation and management
Guidelines 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.

4. Unsalvageable Patient
Resuscitation attempt and transport expose EMS and public to risks
Do not attempt unless chance of patient survival
NOTE: The next several slides discuss what is meant by “chance of survival.”
Attempting to resuscitate patient in traumatic cardiac arrest can put you and public in danger.
Rapid transport has potential for MVC.
Possible exposure to bloodborne pathogens.
Work-related injury, etc.
Do not attempt resuscitation unless there is some chance of survival.
One review: 195 trauma patients presented unconscious, without palpable pulse or spontaneous respiration.
Patients with sinus rhythm and nondilated (<4 mm) reactive pupils had a good chance of survival.
Those with asystole, agonal rhythm, ventricular fibrillation, or ventricular tachycardia did not survive. (Cera, S., G. Mostafa, R. Sing, et al., Physiologic predictors of survival in post-traumatic arrest. The American Surgeon, 69: 140–44.)
© Alexander Sayganov

5. Unsalvageable Patient
Prehospital Trauma Arrest Guidelines
Joint Position Statement
National Association of EMS Physicians
American College of Surgeons Committee on Trauma
Guideline categories:
Resuscitation withheld
Resuscitation initiated
Resuscitation terminated
NOTE: 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 activity
Blunt trauma arrest on EMS arrival
Penetrating trauma arrest
No pupillary reflexes or spontaneous movement
Injuries incompatible with life
Evidence of significant time since pulselessness
Dependent 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 identify
Prolonged hypoxemia is most common
Airway problems
Breathing problems
Circulation problems
NOTE: 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 problems
Foreign body
Tongue prolapsed
Swelling
Tracheal damage
Hemorrhage into airway
Misplaced advanced airway
NOTE: 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 problems
Tension pneumothorax
Sucking chest wound
Flail chest
Diaphragmatic injury
High spinal-cord injury
Carbon monoxide inhalation
Smoke inhalation
Aspiration
Near-drowning
CNS depression from drugs/alcohol
Apnea secondary to electric shock or lightning strike
NOTE: 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 problems
Hemorrhagic shock
Tension pneumothorax
Pericardial tamponade
Myocardial contusion
Acute myocardial infarction
Cardiac arrest secondary to electric shock
NOTE: 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
Young
No preexisting cardiac disease
Scene Size-up is essential
Carefully record observations
Different from medical cardiac arrest
2–4 liters normal saline rapid infusion
Aggressive 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 field
Massive blunt injury
Resuscitation withheld if found asystolic
Children
Aggressively attempt resuscitation
Follow PALS guidelines
Isolated 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 same
Drug dosages are same
Fluid volume needed increases
4 liters normal saline rapid infusion during transport
Treatment 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
Airway
Optimal airway unclear
ETI
Prolonged periods of hypoxia
Risk of aspiration
Survival the same ETI or SAD
NOTE: 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
Ventilation
Positive pressure ventilation reduces venous return
Avoid over-ventilation
8 per minute with 750 cc tidal volume (adult)
Capnography
Low CO2 indicates O2 in cells is low
Rising CO2 indicates improving circulation
Establish correct ventilatory rate
Capnography 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 patients
Identify and treat underlying cause:
ITLS Primary Survey
Aggressive airway management
Aggressive breathing management
Aggressive circulatory management
Trauma 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.)