Traumatic cardiac arrest

Aim

To guide staff in the management of patients in cardiac arrest from a suspected traumatic cause in the PCH Emergency Department (ED).

Background

Traumatic cardiac arrest in children and young people is a rare event with a high mortality. It requires a different approach in management than a non-traumatic (medical) cardiac arrest, focusing on interventions to address immediate threats to life and de-emphasising conventional protocolised cardiac arrest management such as cycles of chest compressions and intravenous adrenaline. It is important that a medical cardiac arrest is not misdiagnosed as a traumatic cardiac arrest. If doubt exists, standard APLS medical resuscitation should be started until senior medical staff advise otherwise.

Definitions

Cardiac arrest: unresponsive patient with absent or agonal breathing and no palpable central pulse.

Traumatic cardiac arrest: cardiac arrest following a traumatic injury (either blunt or penetrating).

Key points

• A rapid, simultaneous, multi-disciplinary team approach involving senior staff is essential.
• Immediate priorities are haemorrhage control, securing a definitive airway, providing oxygenation and ventilation, bilateral chest decompression, administering blood products, and assessing need for resuscitative thoracotomy.
• It is reasonable to provide chest compressions however these should not interrupt the procedures described in this guideline.

Summary (address simultaneously)

Airway and ventilation

• Simple airway manoeuvres to open the airway and allow oxygenation and ventilation with a bag valve mask (BVM) or T-piece should be used while preparing to intubate the patient in traumatic cardiac arrest.
• A supraglottic airway (SGA) should be placed if intubation is not immediately achievable.
• In the arrested patient intubation is performed without medications. However, attention should be paid to the adequate preparation of airway equipment and patient positioning. Cervical spine precautions should be maintained if injury is suspected due to the mechanism of trauma.
• If airway patency cannot be achieved by any of these methods, then front of neck airway (FONA) is indicated.
• In Traumatic Cardiac Arrest with chest trauma (penetrating or blunt), bilateral finger thoracostomies should be performed to decompress potential tension pneumothoraces. This should be done empirically - do NOT wait for X-ray or point of care ultrasound (eFAST) confirmation of tension pneumothorax.
  • Refer to Intercostal Catheters and Needle Thoracocentesis
• Placement of intercostal catheters should wait until after return of spontaneous circulation is achieved.

Resuscitative thoracotomy 

• This rare procedure may be indicated in penetrating thoracic trauma with signs of life within the last 10 minutes. Survival is reported up to 28% if cardiac output is maintained at the time of thoracotomy.¹
• The preferred location for this procedure is the operating theatre, and every effort should be made to transport the patient to theatre if signs of life exist.
• This procedure should be performed by the Surgical Consultant. However, if they are not available, it may be performed by senior medical staff who have received formal training including a human cadaver / animal surgical skills workshop.
• At PCH ED, an ED Thoracotomy Trolley is located in Resus Bay 1 with a minor and major equipment tray. The minor tray should be opened first with the immediate goal of gaining access and decompressing the pericardium.
• Thoracotomy for blunt trauma is discouraged due to poor outcomes compared with penetrating trauma.¹ However, if there are signs of life within the last 10 minutes and sonographic evidence of tamponade, this procedure may be indicated for blunt trauma.

Disposition

• If return of spontaneous circulation is achieved, a joint decision by ED / Surgical / Anaesthesia / PCC senior medical staff should be made regarding disposition.
• A medical and nursing team must remain with the patient to provide post resuscitative care until the patient reaches their final destination (PCC, Operating Theatres).

Stopping resuscitation

• The decision to stop resuscitation should be made by agreement amongst senior medical staff.
• Factors to consider may include²
  • Duration of cardiac arrest
  • Lack of response to life saving interventions
  • Persistent low end tidal CO₂
  • Cardiac standstill on bedside point of care ultrasound.

Debrief

• It should be acknowledged traumatic cardiac arrest resuscitation is a stressful event and it is important to perform appropriate debrief and follow up for staff in regard to psychological safety.

Resources

1. Prieto JM et al. Nationwide analysis of resuscitative thoracotomy in pediatric trauma: Time to differentiate from adult guidelines? J Trauma Acute Care Surg. 2020 Oct
2. Vassallo J et al. on behalf of PERUKI (Paediatric Emergency Research in the UK and Ireland), et al. Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation. Emergency Medicine Journal 2018; 35:669-674

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