II. Evaluation: Recognize pre-arrest changes

  1. Agonal respirations or apnea
  2. Weak pulses
  3. Decreasing mental status

III. Precautions

  1. CPR should not interfere with acute life-threatening measures
    1. Unless medial Cardiac Arrest was concurrent with Trauma or massive blood loss, CPR is unlikely to offer benefit
    2. CPR interferes with diagnostic Ultrasound, Finger Thoracostomy, Emergency Thoracotomy
  2. Key initial diagnostics
    1. Bedside Ultrasound for Tension Pneumothorax, Pericardial Tamponade, Hemothorax, cardiac activity
    2. Bilateral Finger Thoracostomy
  3. References
    1. Orman and Hicks in Herbert (2018) EM:Rap 18(2): 17

IV. Management: Key Lifesaving Interventions

  1. See Primary Survey
  2. Airway Obstruction
    1. Early definitive airway (Advanced Airway, Cricothyrotomy)
  3. Tension Pneumothorax
    1. Needle Thoracostomy or Finger Thoracostomy (followed by Chest Tube)
  4. Massive Hemothorax
    1. Autotransfusion of blood from Chest Tube
    2. Surgical repair (for >1500 ml blood loss or 200 ml/h for >3 hours)
  5. Open chest wound
    1. Occlusive Dressing and Chest Tube
  6. Cardiac Tamponade
    1. Emergency Pericardiocentesis
    2. Emergency Thoracotomy (Penetrating Trauma)
  7. Commotio Cordis
    1. Blunt Chest Trauma at the Cardiac Cycle time of T-Wave results in pulseless Arrhythmia (Ventricular Fibrillation, Asystole)
    2. Greatest chance of survival is for early cardiac Defibrillation within first 5 minutes
  8. Massive Hemorrhage
    1. Obtain two large bore (16 to 18 gauge) Intravenous Access sites (or IO Access)
      1. Obtain central venous access as available
    2. Control Bleeding
      1. Apply direct pressure, then Tourniquet, Suture or Topical Hemostatic Agent
    3. Massive Blood Transfusion
      1. May require 4 or more units pRBC within first hour
      2. Replace 1 unit FFP per pRBC unit and 1 unit apheresis Platelets per 8 pRBC units
  9. Epidural Hematoma
    1. Trephination (burr hole) if imminent Herniation signs
    2. Emergent surgical decompression

V. Management: Cessation of efforts

  1. Blunt Trauma
    1. No pulse, pupillary activity, organized EKG activity or cardiac motion on Ultrasound after 10 minutes
  2. Pentrating Trauma
    1. Consider Emergency Thoracotomy if presenting with Asystole and Cardiac Tamponade
    2. No pulse, pupillary activity, organized EKG activity or cardiac motion on Ultrasound after 15 minutes

VI. Prognosis: Predictors of Survival

  1. Initial cardiac rhythm
  2. Signs of life on hospital arrival (11.5% survival vs 2.6%)
  3. Pupillary response (highly predictive of survival)
  4. Glasgow Coma Scale (GCS) >3
  5. Cardiac activity on Bedside Ultrasound
    1. Absence of cardiac activity is an indication to cease Resuscitation
  6. Organized cardiac rhythm
    1. Ventricular Fibrillation (90% survival)
    2. Pulseless Electrical Activity (60% survival)
    3. Asystole (low survival rate)
  7. References
    1. Cera (2003) Am Surg 69(2): 140-4 [PubMed]
    2. Leis (2013) J Trauma Acute Care Surg 74(2): 634-8 [PubMed]
    3. Rhee (2000) J Am Coll Surg 190(3): 288-98 [PubMed]

VII. References

  1. Pascual (2015) Crit Dec Emerg Med 29(6): 10-7

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