Traumatic Cardiac Arrest

Objectives

To guide the management of patients in cardiac arrest due to traumatic injury.

Scope

This guideline describes the management of patients in Traumatic Cardiac Arrest (TCA) in a forward medical context or deployed Emergency Department and includes a quick reference graphic as an aide-memoire.

There are separate guidelines for the management of medical cardiac arrest. Consideration should always be given to whether there may be a medical cause in patients who present in cardiac arrest without obvious injury or having been involved in a low energy mechanism.

Resuscitation of patients in TCA should not be started with injuries clearly incompatible with life (decapitation, hemi-corpectomy, massive cranial destruction, decomposition, incineration, hypostasis or rigor mortis).

This guideline does not describe advanced surgical techniques used that may be used beyond the Emergency Department in a Deployed Hospital Care (DHC) or forward surgical setting.

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical location, a Resus facility or an Emergency Department on deployed operations.

Initial Assessment & Management

TCA is defined as the absence of signs of life (including no central pulse, absent or agonal breathing and no response to stimulation) in the context of significant trauma to a patient.

The reversible causes of TCA are different to medical cardiac arrest and a different approach to management is required. These reversible causes are often summarised with the mnemonic HOTT:

Hypovolaemia – cardiac arrest secondary to exsanguination.

Oxygenation – cardiac arrest secondary to airway obstruction, traumatic asphyxia or significant lung injuries.

Tension pneumothorax – cardiac arrest secondary to obstructive shock with air trapped in the pleural cavity.

Tamponade (Cardiac) – cardiac arrest secondary to obstructive shock with blood/clot trapped in the pericardial space.

Treatment should focus on the rapid correction of these through focused application of the MARCH algorithm:

Massive Haemorrhage

External haemorrhage controlled using tourniquets, haemostatic and pressure dressings.

In the pre-hospital environment this should be concurrent with an immediate request for enhanced pre-hospital care (e.g. MERT) if available +/- mobilisation of the nearest asset carrying blood products for resuscitation.

Airway

Airway opened and maintained by iGel, endotracheal intubation or surgical airway depending on patient factors and the skill level of the treatment team.

End-Tidal CO2 (ETCO2) monitoring should be applied where this is available.

Respiration

Bilateral chest decompression should be completed. Where skills exist this should be via finger thoracostomy, otherwise this should be via needle decompression. See appropriate CGOs for procedural details.

Ventilation should continue at 12-18 breaths per minute with high flow oxygen where this is available.

Circulation

Suspected pelvic fractures should be splinted with a pelvic binder.

Femoral fractures should be initially pulled to length. Splintage may further be considered once all other interventions are completed.

IV or IO access should be gained (consider central venous access if skills and equipment are available).

Volume resuscitation should be delivered ideally with blood products in accordance with the emergency transfusion guideline, but 500ml boluses of crystalloid are acceptable initially if these are unavailable. Blood or fluid must be given through a warmer if available.

Tranexamic Acid should be given IV/IO.

Defibrillation pads should be applied and heart rate/rhythm monitored.

Hypothermia / Head injuries

Consider mitigation of hypothermia where possible around interventions.

Additional Considerations

Chest compressions are de-prioritised in TCA management but may be considered after the above interventions have been completed OR earlier if oxygenation is felt to be the isolated cause of TCA (e.g. following isolated head injury with impact brain apnoea) OR if resources allow chest compressions may occur whilst HOTT principles are being addressed if these do not get in the way of interventions.

Standard ALS drugs, including adrenaline, are not beneficial in TCA and should usually not be administered. If blood products are given appropriate doses of IV/IO calcium (chloride or gluconate) should be administered concurrently as per the major haemorrhage CGO.

Peri-arrest patients following major trauma may present with a “Low Output State in Trauma” with tachy/bradycardia, critical hypotension and severely reduced level of consciousness. In this situation consideration may be given to applying the TCA principles as rapid, aggressive management may prevent cardiac arrest.

Advanced Assessment & Management

Cardiac Tamponade

TCA due to cardiac tamponade presents specific challenges and will require surgical skills that may be offered by an enhanced pre-hospital care team or in a deployed surgical facility

Cardiac Tamponade may be suspected where there is a penetrating wound to the thorax or epigastrium, particularly in lower velocity penetrating trauma (stabbing, small fragmentation, handgun etc). It is rare in penetrating injuries outside of these areas or in blunt trauma and should only then be considered with evidence of tamponade on point of care ultrasound.

The definitive management of Cardiac Tamponade is Resuscitative Thoracotomy (RT). This should be considered by appropriately trained teams with a patient in TCA, where cardiac tamponade is suspected AND where the onset of the TCA is less than 15 minutes prior AND where the tactical situation AND resources allow for both the procedure and timely onward evacuation of the patient to a facility able to deliver definitive surgical care.

Resuscitative thoracotomy should not be undertaken if there is a concurrent injury which is likely to be unsurvivable (e.g. significant head injury AND cardiac tamponade).

Other Advanced Interventions

Patients with TCA or peri-arrest state secondary to hypovolaemia may benefit from advanced interventions if these can be initiated rapidly around the time of arrest. These interventions should be considered by expert teams only and the ongoing tactical situation as well as resources available must be factored in to decision making.

Resuscitative Thoracotomy – may be considered to allow direct pressure to the descending thoracic aorta and therefore proximal haemorrhage control OR in the case of massive haemothorax to allow direct haemorrhage control measures.

REsuscitative Balloon Occlusion of the Aorta (REBOA) – may be considered at Zone 1 or 3 depending on suspected bleeding site. This should only be undertaken by appropriately trained personnel in line with the REBOA CGO.

Surgical control – select teams/individuals may be trained and capable in additional advanced surgical haemorrhage control techniques. These techniques should be employed only by these teams/individuals with expert clinical judgement and consideration of the tactical situation.

Prolonged Casualty Care

Guidance on ROSC and futility is detailed below. Prolonged Casualty Care in a forward location of a patient following ROSC from a TCA is likely to be extremely challenging and such patients should be evacuated to a higher level of care if at all possible. Otherwise first principles of re-assessment and prioritisation of interventions should be followed. There are no other specific interventions or considerations.

Paediatric Considerations

Paediatric TCA is managed following the same principles as for adults. Care should be taken for all interventions as per the relevant CGOs to ensure appropriate medication doses, fluid/blood volumes and equipment sizes are used throughout. There are no other specific interventions or considerations.

Teams should also consider the psychological impact of caring for children in traumatic cardiac arrest, as this can be very significant.