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DOI: 10.1161/CIRCULATIONAHA.105.166569
2005;112;146-149; originally published online Nov 28, 2005; Circulation
Part 10.7: Cardiac Arrest Associated With Trauma
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Part 10.7: Cardiac Arrest Associated With Trauma
B
asic and advanced life support for the trauma patient are
fundamentally the same as that for the patient with a
primary cardiac arrest, with focus on support of airway,
breathing, and circulation. In trauma resuscitation providers
perform the Primary Survey (called the initial assessment in
the National Highway Traffic Safety Administration
[NHTSA] EMS Curricula), with rapid evaluation and stabi-
lization of the airway, breathing, and circulation. This is
followed by the Secondary Survey (called the focused history
and detailed physical examination in the NHTSA courses),
which detects more subtle but potentially lethal injuries.
Cardiopulmonary deterioration associated with trauma has
several possible causes:
●
Hypoxia secondary to respiratory arrest, airway obstruc-
tion, large open pneumothorax, tracheobronchial injury, or
thoracoabdominal injury
●
Injury to vital structures, such as the heart, aorta, or pulmonary
arteries
●
Severe head injury with secondary cardiovascular collapse
●
Underlying medical problems or other conditions that led
to the injury, such as sudden cardiac arrest (eg, ventricular
fibrillation [VF]) in the driver of a motor vehicle or in the
victim of an electric shock)
●
Diminished cardiac output or pulseless arrest (pulseless
electrical activity [PEA]) from tension pneumothorax or
pericardial tamponade
●
Extreme blood loss leading to hypovolemia and diminished
delivery of oxygen
Despite a rapid and effective out-of-hospital and trauma
center response, patients with out-of-hospital cardiac arrest
due to trauma rarely survive.
1–4
Those patients with the best
outcome from trauma arrest generally are young, have treat-
able penetrating injuries, have received early (out-of-hospital)
endotracheal intubation, and undergo prompt transport (typ-
ically H1134910 minutes) to a trauma care facility.
3–6
Cardiac
arrest in the field due to blunt trauma is fatal in all age
groups.
7–9
Extrication and Initial Evaluation
For years there has been a debate over whether ACLS
providers should deploy a full armamentarium of interven-
tions when treating victims of severe trauma at the scene. A
number of studies have questioned the clinical effectiveness
of on-site advanced airway management via endotracheal
intubation as well as circulatory support with rapid intrave-
nous (IV) infusions. The case against these interventions
centers on 2 arguments: whether they are truly safe and
effective and whether they adversely delay transport to, and
definitive management at, a hospital or emergency depart-
ment (ED).
There is considerable evidence that out-of-hospital endo-
tracheal intubation is either harmful or at best ineffective for
most EMS patients.
10–13
Researchers and emergency medical
services (EMS) leaders have also questioned the safety and
effectiveness of aggressive out-of-hospital IV fluid resusci-
tation in an urban environment.
14–17
In addition, field ACLS
interventions unquestionably prolong time at the scene, delay
transport to the ED or trauma center, and thereby delay
essential interventions, such as surgical control of life-
threatening bleeding.
17–20
With the above discussion in mind, the focus of prehospital
resuscitation should be to safely extricate and attempt to
stabilize the patient and to minimize interventions that will
delay transport to definitive care. Strict attention should be
paid to stabilizing the spine during care. Patients suspected of
having severe traumatic injuries should be transported or
receive early transfer to a facility that can provide definitive
trauma care. Attempts to stabilize the patient are typically
performed during transport to avoid delay.
BLS for Cardiac Arrest Associated
With Trauma
Airway
When multisystem trauma is present or trauma involves the
head and neck, rescuers must stabilize the spine during all
BLS maneuvers. A jaw thrust is used instead of a head
tilt–chin lift to open the airway, with the priority to establish
a patent airway. If at all possible, a second rescuer should be
responsible for manually stabilizing the head and neck during
BLS maneuvers and until spinal immobilization equipment is
applied by trained providers. When the airway is open, clear
the mouth of blood, vomitus, and other secretions.
Breathing/Ventilation
Once a patent airway is established, assess for breathing. If
breathing is absent, agonal, or slow and extremely shallow,
manual ventilation is needed. When ventilation is provided
with a barrier device, a pocket mask, or a bag-mask device,
the rescuer must still maintain cervical spine stabilization if
cervical spine injury is suspected. Deliver breaths slowly to
reduce risk of gastric inflation. If the chest does not expand
during ventilation despite the presence of an adequate and
patent airway, rule out tension pneumothorax or hemothorax.
Circulation
The provider should stop any visible hemorrhage using direct
compression and appropriate dressings. After opening the
airway and delivering 2 effective rescue breaths, the health-
care provider should attempt to feel a carotid pulse. If the
healthcare provider does not definitely feel a pulse within 10
seconds, the provider should begin chest compressions and
(Circulation. 2005;112:IV-146-IV-149.)
? 2005 American Heart Association.
This special supplement to Circulation is freely available at
http://www.circulationaha.org
DOI: 10.1161/CIRCULATIONAHA.105.166569
IV-146
provide cycles of compressions and ventilations. During
CPR, rescuers should provide compressions of adequate
number and depth (rescuers should push hard and fast), allow
full chest recoil after each compression, and minimize inter-
ruptions in chest compressions.
When CPR is provided for a victim with an advanced
airway in place, 2 rescuers no longer deliver cycles of
compressions interrupted with pauses for ventilation. Instead,
the compressing rescuer should deliver 100 compressions per
minute continuously, without pauses for ventilation. The
rescuer delivering the ventilations should give 8 to 10 breaths
per minute and should be careful to avoid delivering an
excessive number of ventilations. The 2 rescuers should
change compressor and ventilator roles approximately every
2 minutes to prevent compressor fatigue and deterioration in
quality and rate of chest compressions. When multiple
rescuers are present, they should rotate the compressor role
about every 2 minutes.
If an automated external defibrillator (AED) is available,
turn it on and attach it. The AED will evaluate the victim’s
cardiac rhythm and advise delivery of a shock if appropriate.
If VF is present, note that the VF may have been the cause
rather than the consequence of the trauma (eg, an automobile
driver develops VF sudden cardiac arrest and when he loses
consciousness he crashes the car). The victim may require
further cardiac evaluation following resuscitation.
Disability
Throughout all interventions, assess the victim’s response and
monitor closely for signs of deterioration.
Exposure
To define the extent of injury, remove the victim’s clothing.
When the assessment for injuries is complete, cover the
patient to prevent the development of hypothermia.
ACLS for Cardiac Arrest Associated
With Trauma
ACLS includes continued assessment and support of the
airway, oxygenation and ventilation (breathing), and circula-
tion. Some of these procedures may be performed only after
the patient has arrived at the hospital.
Airway
Indications for immediate intubation of the trauma patient
include
●
Respiratory arrest or apnea
●
Respiratory failure, including severe hypoventilation or
hypoxemia despite oxygen therapy
●
Severe head injury (eg, Glasgow Coma Scale score [GCS]
H110218)
●
Inability to protect the upper airway (eg, loss of gag reflex,
depressed level of consciousness)
●
Thoracic injuries (eg, flail chest, pulmonary contusion,
penetrating trauma)
●
Injuries associated with potential airway obstruction (eg,
crushing facial or neck injuries)
Endotracheal intubation is performed while maintaining
cervical spine stabilization. If intubation is performed in the
field, it should be done during transport. Generally orotra-
cheal intubation is performed. Avoid nasotracheal intubation
in the presence of severe maxillofacial injuries. Confirm
proper tube placement by clinical examination and use of a
confirmation device (eg, an exhaled CO
2
monitor) immedi-
ately after intubation, during transport, and after any transfer
of the patient (eg, from ambulance to hospital stretcher).
Unsuccessful endotracheal intubation for the patient with
massive facial injury and edema is an indication for crico-
thyrotomy by experienced providers.
When an endotracheal tube or other advanced airway is in
place during CPR, simultaneous ventilations and compres-
sions may result in a tension pneumothorax in an already
damaged lung, especially if fractured ribs or a fractured
sternum is present. Providers should suspect the development
of a tension pneumothorax if there is a decrease in chest
expansion and breath sounds, increased resistance to hand
(bag-tube) ventilation, or if the patient’s oxygen saturation
falls.
Ventilation
Provide high inspired concentrations of oxygen even if the
victim’s oxygenation appears adequate. Once a patent airway
is established, assess breath sounds and chest expansion. A
unilateral decrease in breath sounds associated with inade-
quate chest expansion during positive-pressure ventilation
should be presumed to be caused by tension pneumothorax or
hemothorax until those complications can be ruled out.
Healthcare providers will perform needle aspiration of the
pneumothorax followed by insertion of a chest tube (this
procedure typically is performed in the hospital).
Rescuers should look for and seal any significant open
pneumothorax, allowing an exhalation port so that tension
pneumothorax will not occur.
Hemothorax may also interfere with ventilation and chest
expansion. Treat hemothorax with blood replacement and
insertion of a chest tube, and check the initial volume of
blood that comes out of the chest tube. Ongoing hemorrhage
from the chest tube is an indication for surgical exploration.
Circulation
When the airway, oxygenation, and ventilation are adequate,
evaluate and support circulation. Immediately control obvi-
ous visible bleeding. Volume resuscitation is an important but
controversial part of trauma resuscitation. ACLS providers
should establish large-bore IV access while en route to the ED
or trauma center, limiting attempts to two. Isotonic crystalloid
is the resuscitation fluid of choice because research has not
clearly established any specific type of solution as superior.
21
When replacement of blood loss is required in the hospital, it
is accomplished with a combination of packed red blood cells
and isotonic crystalloid.
Aggressive fluid resuscitation is not required for trauma
patients who have no evidence of hemodynamic compromise.
Recommendations for volume resuscitation in trauma pa-
tients with signs of hypovolemic shock are determined by the
type of trauma (penetrating vs blunt) and the setting (urban vs
Part 10.7: Cardiac Arrest Associated With Trauma IV-147
rural). A high rate of volume infusion with the therapeutic
goal of a systolic blood pressure H11350100 mm Hg is now
recommended only for patients with isolated head or extrem-
ity trauma, either blunt or penetrating. In the urban setting,
aggressive prehospital volume resuscitation for penetrating
trauma is no longer recommended because it is likely to
increase blood pressure and consequently accelerate the rate
of blood loss, delay arrival at the trauma center, and delay
surgical intervention to repair or ligate bleeding vessels.
4,14,22
Such delay cannot be justified when the patient can be
delivered to a trauma center within a few minutes. In rural
settings, transport times to trauma centers will be longer, so
volume resuscitation for blunt or penetrating trauma is
provided during transport to maintain a systolic blood pres-
sure of 90 mm Hg.
As noted above, if pulseless arrest develops, outcome is
poor unless a reversible cause can be immediately identified
and treated. Successful trauma resuscitation often depends on
restoration of an adequate circulating blood volume.
The most common terminal cardiac rhythms observed in
victims of trauma are PEA, bradyasystolic rhythms, and
occasionally VF/ventricular tachycardia (VT). Treatment of
PEA requires CPR and identification and treatment of revers-
ible causes, such as severe hypovolemia, hypothermia, car-
diac tamponade, or tension pneumothorax.
23
Development of
bradyasystolic rhythms often indicates the presence of severe
hypovolemia, severe hypoxemia, or cardiorespiratory failure.
VF and pulseless VT are treated with CPR and attempted
defibrillation. Although epinephrine is typically administered
during the ACLS treatment of these arrhythmias, it will likely
be ineffective in the presence of uncorrected severe
hypovolemia.
Since publication of the ECC Guidelines 2000 several
centers have reported their retrospective observations about
resuscitative thoracotomies for patients in traumatic cardiac
arrest.
24–27
For example, one series reported 49 patients with
penetrating chest trauma who underwent resuscitative thora-
cotomy in the ED.
27
None of the patients in cardiac arrest or
without signs of life before thoracotomy survived to hospital
discharge.
In a 2002 report of resuscitative thoracotomies for trauma
patients in the ED,
24
the 3 survivors of 10 victims of
penetrating trauma all had signs of life and vital signs on
arrival at the ED. In contrast, all 19 patients with blunt trauma
died, despite the fact that 14 of the 19 “had vital signs” at the
time of the thoracotomy. In a database of 959 resuscitative
thoracotomies,
26
22 victims of penetrating trauma and 4
victims of blunt trauma survived to hospital discharge after
receiving prehospital CPR (overall survival rate of 3%).
In 2001 the Committee on Trauma of the American
College of Surgeons published a systematic review of 42
studies of ED thoracotomies involving nearly 7000 patients,
published from 1966 to 1999.
28
In this database, survival was
11% (500 of 4482) for victims of penetrating trauma and
1.6% (35 of 2193) for victims of blunt trauma.
These studies suggest that there may be a role for open
thoracotomy in specific patients or situations. The Table
describes conditions under which an open thoracotomy may
be considered. Open thoracotomy does not improve outcome
from out-of-hospital blunt trauma arrest but can be lifesaving
for patients with penetrating chest trauma if the patient has an
arrest immediately before arrival at the ED or while in the
ED. During concurrent volume resuscitation for penetrating
trauma, prompt emergency thoracotomy will permit direct
massage of the heart, relief of cardiac tamponade, control of
thoracic and extrathoracic hemorrhage, and aortic cross-
clamping.
2,4
This procedure should be performed only by
experienced providers.
Cardiac contusions causing significant arrhythmias or im-
paired cardiac function are present in approximately 10% to
20% of victims of severe blunt chest trauma.
29
Myocardial
contusion should be suspected if the trauma victim has
TABLE. Suggested Indications for Resuscitative Thoracotomy: Patients With Traumatic Cardiac Arrest
Type of Injury Assessment
Blunt trauma ● Patient arrives at ED or trauma center with pulse, blood pressure, and spontaneous
respirations,
and
● then experiences witnessed cardiac arrest
Penetrating cardiac trauma ● Patient experiences a witnessed cardiac arrest in ED or trauma center
or
● Patient arrives in ED or trauma center after H110215 minutes of out-of-hospital CPR and with
positive secondary signs of life (eg, pupillary reflexes, spontaneous movement, organized ECG
activity)
Penetrating thoracic (noncardiac) trauma ● Patient experiences a witnessed cardiac arrest in ED or trauma center
or
● Patient arrives in ED or trauma center after H1102115 minutes of out-of-hospital CPR and with
positive secondary signs of life (eg, pupillary reflexes, spontaneous movement, organized ECG
activity)
Exsanguinating abdominal vascular trauma ● Patient experiences a witnessed cardiac arrest in ED or trauma center
or
● Patient arrives in ED or trauma center with positive secondary signs of life (eg, pupillary
reflexes, spontaneous movement, organized ECG activity)
plus
● Resources available for definitive repair of abdominal-vascular injuries
IV-148 Circulation December 13, 2005
extreme tachycardia, arrhythmias, and ST–T-wave changes.
Cardiac biomarkers (see Part 8: “Stabilization of the Patient
With Acute Coronary Syndromes”) are not sensitive indica-
tors of cardiac contusion.
30
The diagnosis of myocardial
contusion is confirmed by echocardiography or radionuclide
angiography.
Transfer
If a patient arrives at a facility with limited trauma capability,
hospital staff should treat identifiable and reversible injuries
to their capability. The patient should then be rapidly trans-
ferred to a facility that can provide definitive trauma care.
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Part 10.7: Cardiac Arrest Associated With Trauma IV-149