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.
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).
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