Trauma Arrest

When a trauma arrest rolls though the door, chaos often ensues. But it doesn’t have to be that way. Scott Weingart returns to ERcast to share his thoughts on how to run a rational blunt trauma arrest resuscitation when you are working by yourself or with limited personnel.


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Scott W’s recipe for blunt trauma arrest

Check for a pulse when the patient arrives. If they’re pulseless, they’re in arrest….

The fundamental philosophy: Do only those actions that will make a difference in your patient’s survival

Step 1. Airway

Control the airway. If your patient is already intubated, you’re done. If not, intubate or place a supraglottic device.

Step 2. Breathing

Perform bilateral finger thoracostomies. There are very few things in a blunt trauma arrest that you can reverse and save a life. One of those is a tension pneumothorax. If there is no rush of air or improvement of condition, proceed to step 3.

Step 3. Circulation

Perform a bedside cardiac echo.

If there is no cardiac activity, the resuscitation is over and the patient is dead.

If there is cardiac tamponade, remove the blood. In trauma, this usually means cracking the chest (ED throacotomy) and delivering the heart from the pericardium. You can try a pericardiocentesis, but that is less likely to be successful.

If there is cardiac activity, your patient is in hemorrhagic shock. Give blood with massive transfusion protocol.

Step 4. Look for sources of bleeding

Did your patient exsanguinate from a scalp laceration?

Is there bleeding into chest? You would have discovered this with finger throacostomy

Is there bleeding inside the peritoneal cavity? Perform a FAST ultrasound

Is there bleeding in the retroperitoneum? Squeeze the pelvis and bind if there is mobility

Is there bleeding from  or into the extremities?

 

Is CPR beneficial in a trauma arrest?

This is such deeply entrenched dogma that I was shocked when Scott suggested that there is no functional reason that closed chest compressions will help in a traumatic arrest. But when you break down the reversible causes of blunt trauma arrest, it makes sense…

Exsanguination: you can’t pump an empty circulatory system

Tension pneumothorax: you can’t pump with a zero venous return system

Pericardial tamponade: you can’t pump a heart that can’t accept any more blood

That being said, I still do CPR in a trauma arrest, but don’t let it interfere with critical procedures. What do you think?

 

Bonus section #1

Scott gives his thoughts on how to master video laryngoscopy (VL).

Pearls:

When entering the mouth with your video laryngoscope blade, do not watch the video screen. Watch the blade enter the mouth. Once it’s in, go to the screen.

If you haven’t had formal training on a VL device, you can train yourself. As long as you don’t have a hyperangulated blade, you can use your VL device as a direct laryngoscope (DL). Take a look with your DL. What do you see? At this point, look at the screen. Does it look different than your DL view? One thing to avoid is filling the whole screen with the vocal cords. If your blade is in that far, it will be hard to pass the tube.

Bonus Section #2

Rob and Scott give their thoughts on how to prepare for a lecture

Comments

  1. kangaroobeach

    This rings true to my heart -- I’m one of those solo operators (rural Oz). I also direct on ATLS (EMST here in Oz) but with use of FOAMed am increasingly frustrated that we still teach useless dogma on these courses.

    Thing’s I’d love to change on ATLS (gonna take a decade…)

    Points

    -- no CPR in traumatic arrest? Absolutely. It ain’t going to work…

    -- finger thoracostomies? Absolutely. Dunno why we still teach needle thoracocentesis on ATLS. Need to bring the curriculum up to date…

    -- ETCO2? Absolutely. Not emphasised (enough) in ATLS. Useful as adjunct for hypoventilation as well as tube placement….

    -- Bedside ultrasound for cardiac activity? Absolutely. We brush over FAST on ATLS…but more in assessment for tamponade/intra-abdo bleed.

    -- LUCAS or other ‘granny smasher’ device? Absolutely. We’re resource limited in terms of person power…devolving CPR (if you need to use it) to a machine makes sense. Still pricey though!

    -- VLs and hyperangulated devices? Absolutely. Don’t advance for grade I view -- hold the blade back to allow tube passage

    -- Scoring CL grade with DL vs VL -- absolutely. A comment on ease of BMV and placement of SGA also useful in notation of airway management for the next time around!

    …as for “it’s all in the wrist?”. Absolutely!

    -- You didn’t cover drugs in trauma intubation in this podcast -- ATLS still cracks on about either ‘no drug’ or fent/mdz’ intubation. We need to get Scott to write the one page chapter on drugs in traumatic intubation based on blogs/podcasts/lectures passim….

    Only things I’d challenge would be

    (i) bung a binder on based on mechanism. Wouldn’t be springing the pelvis. Can always take it off..

    (ii) massive transfusion protocol

    -- use a RIC
    -- we’re often limited (only two units of O neg where I am).

    A Major Transfusion Protocol is a pipe-dream for us. Autotransfusion & live blood banks are a work around….

    Casey Parker’s done a great blog post on managing traumatic bleeding over at BroomeDocs

    http://wacdocs.csp.uwa.edu.au/2011/10/managing-traumatic-bleeding-how-can-we-apply-the-evidence-in-smaller-hospitals/

    or we cover it at RuralDoctorsNet

    http://ruraldoctors.net/2013/08/24/case-6-find-the-bleeding-stop-the-bleeding/

    (iii) Creating a team

    Solo Doc/Nurse in community hospital? We need to create team members using cleaners/admin/ambos/fire service/family. Cliff Reid’s ‘making things happen’ video distills this. Don’t be afraid as a solo operator to stand back and delegate…it’s too easy to get funnelled into one task which ‘only docs can do’.

    Otherwise, ripper podcast for us guys who don;t work as part of a tertiary trauma team -- Rob/Scott -- either of you going to come and do a locum on Kangaroo Island for me?

    Finally -- a checklist for speaking! Oh, Minh le Congs gonna LOVE that for the smaccGOLD checklist debate!!!

  2. mayooran thevendra

    Great episode and some very sensible ideas about managing traumatic arrest from Dr Weingart. However, my colleagues would be keen to see evidence before implementing this (specifically non-utility of closed chest CPR in the context of traumatic arrest) in our department. Do you know if any exists?

  3. Bill Hinckley

    Gentlemen, that was pure gold. Thank you. Sakles is in Arizona (by way of UC). Regarding VL with hyperangulated blades, Steve Carleton, our airway guru in Cincinnati, likes to say “right behind the dugout is no good; you want the cheap-seats view.”

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  5. Carrie Wassel RN

    Thank you so much for this podcast! I am adding it to our education process for new flight RN’s and medics. Please don’t take it down! Or if you do, please let me know how to download and save it.

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