Authors: Chris Srinivasan / Editor: Charlotte Davies / Codes: CMP2, HMP2, CC4, RP3, SLO1 / Published: 21/06/2022
Imagine it’s 2am and the Red Phone rings…. “A 26-year-old male, fallen off motorcycle, in traumatic cardiac arrest”. Your heart races, you’re apprehensive, but you feel way out of your depth. You know there’s loads to prepare and often there isn’t much notice. What do you do?
You may be thinking this only applies to doctors working at major trauma centres, but you’re wrong, patients in cardiac arrest do not bypass trauma units, they are conveyed to the nearest ED.
The majority of traumatic cardiac arrests have recognition of life extinct (ROLE) at the scene, so if the crew are conveying the patient, it would be reasonable to assume that it’s a “workable” arrest. Trauma networks have policies for the management of traumatic cardiac arrest and in-situ simulation is the best way to drill and prepare your team for these circumstances.
The mainstay of management is to attempt to correct the reversible causes.
Activate your trauma team as early as possible (they need time to prepare), this may be your CODE RED TEAM (depending on your tiered setup). Expect a crowd, consider allocating someone to control the crowd. Your cognitive bandwidth will narrow and even the most experienced will lose situational awareness– using a checklist is a strength, not a weakness.
Trauma Team Leader- Usually an Emergency Medicine Consultant or HST, brief the team, make sure people know what to do, support the members, receive ideas from the team
Airway Doctor and Airway Assistant- Prepare to intubate the patient on arrival and ensure they have immediate access to Plans B, C and D for airway management.
Breathing Doctor- Ensure equipment is available to perform thoracostomies, cover chest wounds and assist with thoracotomy if clinically indicated.
Circulation Doctor (Big C and little C)- competent to rapidly apply military grade tourniquet, haemostatic agents, blast dressings, pelvic binder, IO access. Try and have a second senior critical care doctor able to site a subclavian line- wide bore and single lumen.
Damage Control Surgeon- A consultant grade surgeon who is able to make a rapid decision to take the patient to theatre if necessary. Perform thoracotomy in ED if required. Ensure that theatres are on standby.
Radiology- ensure that you’ve given a heads up to the radiology team and interventional radiologist.
Trauma wingman/woman- Another ED consultant, to support the team leader, provide a second pair of experienced eyes and undertake a peer review.
Trauma Nurses- you’re better to have a small number of highly trained nurses. Allocated one nurse to be your blood nurse (it’s a full time job for one person). Prepare a TXA infusion before arrival.
Activate the Massive Haemorrhage Protocol and send a runner to get packed red cells (don’t send your ED nurses, they’ll be busy preparing other things in ED!)
Turn the heat up in the room and prepare a forced air warmer
Run through your blood/fluid warmer- have it primed and ready. Consider spiking packed red cells to attach as the patient comes through the door.
If resuscitative thoracotomy is possible, get the trolley out, ensure the person doing it is trained and they have an assistant.
You won’t be able to do a hands-off handover this time! Transfer the patient across to your trolley. Allow the ambulance crew to remove their monitoring etc, before applying the ED monitoring. The monitoring should be self-adhesive pads and waveform capnography.
Set your C, A, B, C team to work whilst you take a focussed ATMIST (this should take less than 1 minute). These actions should be performed simultaneously…. Big C whilst doing A, whilst doing B and C…
Take a time-out when it’s safe to do so to update the team.
Bleeding you can hear is bad!! It needs to stop ASAP. For limbs apply direct pressure – if this doesn’t work quickly move the military grade tourniquets. Apply tourniquets just proximal to the bleeding site. If bleeding is still not controlled, site one at midshaft humerus or femur (single bone), tighten the strap tight, then the windlass until the bleeding stops, it needs to be “tight-tight”. Remember to check for bleeding if the patient’s perfusion improves. Central wounds should have packing and direct pressure, consider using haemostatic agents.
Apply a pelvic binder (better called a hip binder… that where they go) down to skin.
Anatomically splint mangled limbs straight. If you don’t have rapid access to femoral splints, then just pull everything straight.
Attach the packed red cells, make sure they are running and it’s given warm. Those packed red cells carry oxygen….. not much else…. But they are in an acidic, calcium depleted solution…… you also must support the clotting, by giving fresh frozen plasma, platelets and cryoprecipitate as per your MHP policy. Remember- packed red blood cells aren’t blood!
Intubate the patient, prepare for difficulty. Do everything to optimise first pass success; patient positioning, airway positioning, video laryngoscope. If the patient cannot be intubated, change something (e.g blade, position) … and use standard rescue techniques … remember that all flowcharts end with surgical front of neck access. If the patient has ROSC and needs drugs to facilitate intubation, ketamine will also dump the blood pressure so reduce the dose or consider a rocuronium only intubation.
If there are signs of chest trauma, perform bilateral finger thoracostomies, most injured side first. To perform this you need minimal equipment; sterile gloves, something to clean, scalpel and an instrument to bluntly dissect (e.g Spencer Wells Forceps). You do not routinely need to site a drain, unless there is considerable blood leakage or concerns that the thoracostomy will occlude. Trying to suture them in place during active resuscitation is a significant needle stick injury risk. If the patient has ROSC and spontaneously breathes, thoracostomies are essentially sucking chest wounds, so the patient requires either a carefully considered anaesthetic with positive pressure ventilation or chest drain insertion. For more details on this have a look at our video, or other SLO6 resources.
Recheck that catastrophic haemorrhage is under control. You need access. If you have a suitably trained person to site a right subclavian large single bore trauma line (8.5Fg), they will need to be scrubbed and ready to site the line. Traditional teaching would say two large IV lines in the ACFs… Good luck!! If you can’t get IV access, humeral head IO is your saviour. Just be careful abducting the arms (e.g for thoracostomies) as the needles impact on the acromium and bend or displace. Keep the shoulder internally rotated by ensuring the palm faces the floor.
Get the TXA running
Your first Major Haemorrhage Pack is normally 4 units of Red Cells, 4 units of FFP and 1 pool of Platelets depending on your trust protocol. Avoid the temptation to only give Red Cells, remember the straw coloured stuff is hidden in the patients blood, so it’s imperative to give FFP and platelets. Cryoprecipitate tends to come a little later.
Use FAST ultrasound to look for free fluid to help guide surgical control of haemorrhage in the event that the patient has ROSC.
Chest compressions– you’ll hear some people state that chest compressions are pointless in traumatic cardiac arrest. This is partially true but impact brain apnoea makes this statement false. Patients who have had an apnoeic episode that leads to cardiac arrest, will benefit from chest compressions. A pragmatic approach is to perform chest compressions unless it interferes with actions to correct pathology e.g thoracostomies, thoracotomy.
Resuscitative thoracotomy– indicated in penetrating trauma to the thorax/ upper abdomen and loss of signs of life within 15 minutes. Resuscitative thoracotomy should be performed by an “appropriately trained person”. Establishing the timeline can be challenging, ask the prehospital crew, look how long the monitor has been turned on… ask was the patient in cardiac arrest when you arrived? Most cases will be subject to internal or external review, if you go outside of standard operating policies, that’s fine but you need to be able to justify your decisions (the Trauma wingman/wingwoman provides a useful sense check).
Image created by Bagrat Lalabekyan – twitter @anaecritmed
Getting back an output
We often try and apply ALS style methods to our traumatic arrest, which don’t really work. LOST (low output state in trauma) and NOST (no output state in trauma) provide a good classification, however there are certainly grey areas.
Unfortunately the outcomes following traumatic cardiac arrest for patients are poor. If you get ROSC, and there is enough haemodynamic stability, CT is the preferred modality for imaging. You may need to transfer the patient straight to theatre.
For even the most experienced trauma clinicians, this will be a stressful experience. Remember your team will have a large breadth of experience and offer a hot debrief (better termed de-stress in these situations). A psychological stress reaction is entirely normal! Tell people this! On the whole the debrief needs to be positive and supportive. Don’t let any frustrations boil over and if there are any learning points, these should be owned by the team rather than focussing on individuals. Don’t forget yourself… look after yourself.
So what next….. drills are a great way of becoming very slick at tasks. Consider working with your nursing team taking 5 minutes to do a drill even something simple like Mock MHP activation… Setting up an airway kit dump… application of military grade tourniquet. Aim to improve lots of small elements by a bit (maybe 5-10%). Bring all this together with an in-situ simulation, multispecialty with the trauma team of the day.
In summary, you’re going to need a lot of carefully briefed people.