Makindo Medical Notes

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina |Spinal Cord Anatomy |Initial Trauma Assessment and Management |Cervical Spine Immobilization and Management |Anatomy of the Cervical Vertebrae C1 (Atlas) and C2 (Axis) |Trauma: Spinal Injury

Introduction

Trauma-related cardiac arrest (TRCA) is a critical condition where the heart stops beating effectively due to severe injury. It requires immediate and specialized management to optimize the chances of survival. Unlike medical cardiac arrest, TRCA has different underlying causes and necessitates a tailored approach to resuscitation.

Causes

• Hypovolemia: Severe blood loss from internal or external haemorrhage.
• Tension pneumothorax: Accumulation of air in the pleural space causing lung collapse and mediastinal shift.
• Cardiac tamponade: Accumulation of fluid or blood in the pericardial sac impeding cardiac function.
• Hypoxia: Inadequate oxygenation due to airway obstruction or respiratory failure.
• Massive pulmonary embolism: Blockage of pulmonary arteries, although less common in trauma.
• Hypothermia: Prolonged exposure leading to a drop in core temperature, affecting cardiac function.

Pathophysiology

In TRCA, the primary mechanism is often hypovolemia due to haemorrhage, leading to decreased preload and cardiac output. Obstructive causes like tension pneumothorax and cardiac tamponade prevent effective cardiac filling and output. Hypoxia from airway compromise further exacerbates cellular dysfunction and can precipitate cardiac arrest.

Assessment: follow the Advanced Trauma Life Support (ATLS) protocol:

• A - Airway: Ensure patency and protect the cervical spine.
• B - Breathing: Assess ventilation and oxygenation; look for signs of tension pneumothorax.
• C - Circulation: Control haemorrhage, assess pulse, and initiate IV/IO access.
• D - Disability: Evaluate neurological status.
• E - Exposure: Fully expose the patient to assess for injuries while preventing hypothermia.

Management

Management of TRCA focuses on identifying and treating reversible causes promptly. Standard cardiopulmonary resuscitation (CPR) protocols may need modification in trauma patients.

Immediate Actions

• Ensure Scene Safety: Protect yourself and the patient from further harm.
• Activate Emergency Response: Call for additional help, including trauma and surgical teams.
• Initiate CPR: Start high-quality chest compressions if there are no signs of life.
• Secure Airway: Perform advanced airway management as needed (e.g., intubation).
• Provide Oxygenation and Ventilation: Use 100% oxygen and ensure adequate ventilation.

Treatment of Reversible Causes:Focus on the following reversible cause

Hypovolemia

• Control Hemorrhage: Apply direct pressure, use tourniquets, or hemostatic agents for external bleeding.
• Fluid Resuscitation: Administer warmed intravenous crystalloids and consider blood products as soon as possible.
• Massive Transfusion Protocol: Activate if indicated, aiming for balanced resuscitation with red blood cells, plasma, and platelets.

Tension Pneumothorax

• Needle Decompression: Perform immediate needle thoracostomy in the second intercostal space at the midclavicular line or fifth intercostal space at the anterior axillary line.
• Chest Tube Insertion: Place a chest tube (tube thoracostomy) to allow continuous decompression.

Cardiac Tamponade

• Pericardiocentesis: Emergency pericardial aspiration may be attempted but is often not sufficient.
• Resuscitative Thoracotomy: Consider in penetrating chest trauma with signs of life; allows direct control of bleeding and cardiac massage.

Hypoxia

• Airway Management: Remove obstructions, ensure proper placement of airway devices.
• Ventilation: Provide adequate ventilation and oxygenation; consider mechanical ventilation if necessary.

Hypothermia

• Prevent Heat Loss: Remove wet clothing, use warm blankets, and increase ambient temperature.
• Active Rewarming: Use warmed IV fluids, warming devices, and heated humidified oxygen.

Additional Interventions

• Adjuncts to CPR: Consider the use of mechanical CPR devices if available.
• Ultrasound: Use point-of-care ultrasound (eFAST) to assess for cardiac activity, hemoperitoneum, or pneumothorax.
• Administration of Medications: Limited role in TRCA; focus remains on correcting reversible causes.
• Defibrillation: If a shockable rhythm is present (ventricular fibrillation or pulseless ventricular tachycardia), deliver defibrillation per ACLS guidelines.

Special Considerations

• Resuscitative Thoracotomy: Indicated in specific scenarios, particularly penetrating thoracic trauma with witnessed cardiac arrest and signs of life upon arrival. It is a resource-intensive procedure and should be performed by trained personnel.
• Termination of Resuscitation: Prognosis in TRCA is generally poor. Termination of efforts may be considered if there are no signs of life after appropriate interventions, especially in blunt trauma cardiac arrest.

Prognosis

Survival rates for trauma-related cardiac arrest are low, especially in blunt trauma. Early recognition and rapid correction of reversible causes are essential to improve outcomes. Penetrating trauma has a slightly better prognosis compared to blunt trauma.

Conclusion

Management of trauma-related cardiac arrest requires a focused approach on rapidly identifying and treating reversible causes. Adherence to trauma resuscitation principles and prompt interventions can enhance the chances of survival in this critical condition.

References

• Advanced Trauma Life Support (ATLS) Guidelines, 10th Edition, American College of Surgeons, 2018.
• Soar J, Nolan JP, Böttiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2021: Section 3. Adult advanced life support. Resuscitation. 2021;161:115-151.
• Hopson LR, Hirsh E, Delgado J, et al. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. J Am Coll Surg. 2003;196(1):106-112.