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Traumatic Cardiac Arrest Guidelines

Traumatic Cardiac Arrest Guidelines. Emily Kraft, M.D. IUSM EMS Fellow. Traumatic Cardiac Arrest (TCA). Causes of TCA. Severe h ead trauma Hypovolemia Tension Pneumothorax Pericardial Tamponade Hypoxia Injury to vital structures

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Traumatic Cardiac Arrest Guidelines

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  1. Traumatic Cardiac Arrest Guidelines Emily Kraft, M.D. IUSM EMS Fellow

  2. Traumatic Cardiac Arrest (TCA)

  3. Causes of TCA • Severe head trauma • Hypovolemia • Tension Pneumothorax • Pericardial Tamponade • Hypoxia • Injury to vital structures • Rare ventricular dysrhythmia (Commotiocordis vs medical etiology)

  4. Causes of TCA Don’t forget medical causes… especially if things don’t add up!

  5. Survival Rates Historically, survival rates generally very poor! 0-2%

  6. Survival Rates More recent studies have showed possibly higher rates in certain subsets. But…. 1-17%

  7. Standard of Care

  8. NAEMSP EB Guidelines • EMS Systems should have protocols for termination/withholding resuscitation. • Resuscitative efforts may be withheld on blunt & penetrating trauma patients who are pulseless, apneic, & without organized rhythm.

  9. NAEMSP EB Guidelines • Asystole TCA  <1% survival • PEA >40  greater survival • Ventricular dysrhythmias  highest survival • TCA + >15 min transport time  low survival

  10. NAEMSP EB Guidelines • Asystole TCA  <1% survival • PEA >40  greater survival • Ventricular dysrhythmias  highest survival • TCA + >15 min transport time  low survival

  11. Without Organized Electrical Activity Means we may have to place the pads on them Rate < 40  No resuscitation indicated Rate > 40  Begin resuscitation & transport to trauma center

  12. Meets DOA Criteria TCA Protocol NO YES Position patient if possible Apply c-spine stabilization Apply cardiac monitor Do not initiate resuscitation. Document DOA criteria. Asystole/ PEA <40 VF/VT PEA >40 Terminate resuscitation Defibrillate Initiate rapid transport – do not delay Control obvious external hemorrhage Start chest compressions BVM or advanced airway as indicated. Needle thoracostomy if indicated. IV or IO and initiated fluid resuscitation.

  13. NAEMSP EB Guidelines • Asystole TCA  <1% survival • PEA >40  greater survival • Ventricular dysrhythmias  highest survival • TCA + >15 min transport time  low survival

  14. Protocol Development Things to consider: • Access to Trauma Center (<15min transport time?) 2. Available resources 3. Risks of RLS transport 4. Helicopter pros/cons

  15. Clinical Controversies ? DOA Criteria Rapid Transport Needle Thoracotomy? Withholding CPR? Termination Monitor? Fluids? Airway?

  16. Clinical Controversies Epinephrine: Chest Compressions: Needle Thoracostomy: Ultrasound: POC Testing:

  17. Clinical Controversies Epinephrine: Chest Compressions: Needle Thoracostomy: Ultrasound: POC Testing: MAYBE Limited to no role in TCA

  18. Clinical Controversies Epinephrine: Chest Compressions: Needle Thoracostomy: Ultrasound: POC Testing: YES CPR still considered standard by NAEMSP, but limited evidence. Should not impede procedural interventions in TCA.

  19. Clinical Controversies Epinephrine: Chest Compressions: Needle Thoracostomy: Ultrasound: POC Testing: YES Aggressive use in TCA resuscitation when indicated. Recommend longer needles and mid-axillary line.

  20. Clinical Controversies Epinephrine: Chest Compressions: Needle Thoracostomy: Ultrasound: POC Testing: MAYBE Feasible, but no current literature showing improvement in patient treatment.

  21. Clinical Controversies Epinephrine: Chest Compressions: Needle Thoracostomy: Ultrasound: POC Testing: NO No current literature to support prehospital use of POC testing in TCA.

  22. Diversity of Protocols 33 large urban EMS system polled 21% transport asystolic blunt trauma or ”leave to paramedic discretion” 46% transport asystolic penetrating trauma 82% transport PEA (unspecified rate) penetrating trauma 61% transport PEA (unspecified rate) blunt trauma *2010 Brywczynski J

  23. Challenges • Crime scene disturbance. • ”Incompatible with life” clarification • Documentation • QI & review with multiagency feedback.

  24. Summary • Have guidelines for DOA/Withholding Resuscitation • Have TCA protocol that reflects NAEMSP Position • Anticipate challenges/issues • Provide continuous oversight/medical direction

  25. Questions? Emily M. Kraft, MD emkraft@iupui.edu Indianapolis Metropolitan EMS Protocols available at: http://mobile.indianapolisems.org/pnp.html

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