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
Control the airway. If your patient is already intubated, you're done. If not, intubate or place a supraglottic device.
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.
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.
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?
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?