The mortality from traumatic cardiac arrest is high with survival rates ranging between 5.1% – 7.5% (with good neurological outcomes ranging between 2-6%-6.6%).1
Traumatic cardiac arrest management algorithmtraumatic cardiac arrest
Reversible pathology in traumatic cardiac arrest
The aim of resuscitation is to identify immediately reversible pathology.
- control external haemorrhage
- minimise pelvic bleeding
- replace blood loss
- commence blood transfusion
- intubate and optimise ventilation/oxygenation
“Medical” causes of cardiac arrest
Some patients may have suffered trauma due to a medical event. If the patient is suspected to have had cardiac arrest due a medical cause, then standard ACLS protocols should be followed.
A special cause of cardiac arrest in trauma is “commotio cordis”. This occurs when a patient suffers a direct blow to the chest at a critical time in the cardiac cycle causing VF arrest. Immediate effective CPR and rapid defibrillation is lifesaving.
Head injury with apnoea
An increasingly recognised phenomenon is “impact brain apnoea” which can occur in patients with head injury (often occurs without serious underlying structural damage) due to a sudden surge in catecholamines. A prolonged period of apnoea can then cause hypoxic cardiac arrest. These patients should be managed as per standard ACLS, with an emphasis on assisting respiration.
Patients that have had part of their body crushed for a period of time (a rule of thumb is that one limb crushed for one hour can cause crush syndrome) can suffer cardiac arrest when the crushed area is freed due to a sudden release of potassium and other mediators into the circulation.
These patients should be treated as per standard ACLS with the addition of medication to treat hyperkalaemia
- Calcium gluconate (10ml of 10%)
- Insulin 10U in 500ml 10% dextrose (or 50ml 50% dextrose)
- Sodium bicarbonate 1mmol/kg
CPR in traumatic cardiac arrest
This is an area of controversy, but there is little physiological utility of CPR in patients who have suffered a traumatic cardiac arrest due to hypovolaemia or obstructive shock.1 The emphasis should be managing the cause of the cardiac arrest and as CPR makes performing procedures on a patient very difficult, it should be ceased in preference of addressing reversible causes of traumatic cardiac arrest (see ANZCOR guidelines).1
Similarly, ACLS drugs such as IV adrenaline are also controversial in the setting of traumatic cardiac arrest – there is not much evidence for or against administration. ANZCOR does not recommend the administration of adrenaline until the reversible causes of traumatic cardiac arrest have been addressed.1
Stopping or withholding resuscitation
Patients with injuries that are not compatible with life (eg: hemicorpectomy, unsurvivable head injury) should not be resuscitated.
There is no consensus as to when to stop resuscitation in potentially salvageable patients – ANZCOR recommends ceasing resuscitative efforts 10 minutes after all reversible causes have been addressed (with continuation of full BLS/ACLS with external cardiac compressions).1
- ANZCOR guideline April 2016: Management of cardiac arrest due to trauma
About this guideline
Published: February 2018
Author: Emma Batistich
Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB
Review due: 2 years