Many patients die because of inappropriate interventions in the prehospital or ED phase, because of delay in performing thoracotomy, and due to poor peri-operative management.
ACLS algorithms DO NOT APPLY to traumatic arrest.The primary causes of traumatic arrest are HOTT: Hypovolemia/Hemorrhage, hypOxia, Tension pneumothorax, and cardiac Tamponade. Hypoxic arrests respond rapidly to intubation and ventilation. Hypovolemia, tension pneumothorax and cardiac tamponade are all characterized by loss of venous return to the heart. External chest compressions in trauma controversial and not well-studied, in theory they may cause blunt cardiac injury and obstruct access for performing definitive maneuvers (i.e. thoracotomy and aortic cross clamping, relief of tamponade, repair of myocardial laceration; needle decompression; MTP).
The administration of inotropes and vasopressors such as epinephrine to the hypovolemic patient (who is already maximally vasoconstricted) causes profound myocardial hypoxia and dysfunction.
Management of Traumatic Arrest
Treat the cause of the traumatic arrest.
Endotracheal intubation is mandatory and should be secured immediately. Ventilation with 100% oxygen should rapidly reverse hypoxic traumatic arrest without the need for further interventions. This is especially true of pediatric head injuries.
If pt awake, use ketamine and/or fentanyl induction agents for RSI; even etomidate can worsen hypotension significantly.
Relief of tension pneumothorax should be accomplised rapidly either by needle chest decompression or preferably bilateral thoracostomies. Bilateral tension pneumothoraces may exist and the classic signs of a tension (tracheal deviation, unilateral hyperresonance) may not be present. Tension pneumothoraces should therefore be presumed and bilateral decompression undertaken in ALL cases of traumatic arrest.
Performing bilateral thoracostomies has the advantage of identifying major hemorrhage and which side of the chest the major injury is on. This will determine the side of the chest incision for the thoracotomy.????????
The treatment of massive thoracic hemorrhage is control of hemorrhage, not intravenous fluid therapy. Fluid therapy prior to hemorrhage control worsens outcome in penetrating thoracic trauma (and perhaps all penetrating trauma patients). If there is no response to a small (500ml) fluid challenge, fluid administration should be halted until hemorrhage control is achieved.
The classic signs of distended neck veins and muffled heart sounds are almost universally absent in traumatic cardiac tamponade. Needle pericardiocentesis may also fail as a diagnostic measure due to blood in the pericardial sac being clotted. FAST ultrasound scan, if available, will indicate the presence of pericaridal fluid. The pericardium may be felt through the left thoracostomy to assess for the presence of tamponade.
Patients will be cold and profoundly coagulopathic. Blood and component therapy should be warmed and administered rapidly AFTER hemorrhage is controlled. ????The use of epi (or other pressors) is contraindicated in the presence of hypovolemia. Inotropes may be required AFTER control of hemorrhage and cardiac repair. Direct myocardial injury, ischemic myocardial injury, acute cardiac dilatation, pulmonary hypertension and mediator release due to global tissue ischemia can all lead to cardiogenic shock which may require inotropic support.
Lethal Triad of Trauma
= acidosis, coagulopathy, hypothermia
-etiology is massive hemorrhage: 1st 1-2 units uncrossmatched fridge, remaining crossmatched
-use MTP to permissive hypotension to prevent clot destabilization
-PENETRATING trauma: arrest in ED or within 15 min? prior to arrival
-to look for and relieve cardiac tamponade (cannot see it, so always cut the pericardium)
-to look for aortic rupture and cross-clamp proximally
-to look for exsanguination into lung and repair lacerated vasculature and myocardium
Signs of life (per East trauma guidelines) = pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, or cardiac electrical activity.
West trauma guidelines
-repair heart with 3-0 nonabsorbable running suture
-NEVER assume the pt only has the injuries you can see. Assume there are more.