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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Oct 31, 2013

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.

 

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 cant 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?