Traumatic cardiac arrest

The mortality from traumatic cardiac arrest (TCA) is high with survival rates ranging between 5.1% – 7.5% (with good neurological outcomes ranging between 2-6%-6.6%).¹ Patient with TCA are a heterogeneous group however. Those suffering a TCA as a result of penetrating trauma have been shown to have better survival to discharge (10.6 vs 2.3%) and neurologically intact outcomes (90% vs 59.4%) than those with blunt aetiology.²

Traumatic cardiac arrest management algorithm

traumatic cardiac arrest

Reversible pathology in traumatic cardiac arrest

“HOTT”

Hypovolaemia

• control external haemorrhage
  • compression
  • tourniquets
• minimise pelvic bleeding
  • pelvic binder
• replace blood loss
  • commence blood transfusion

Hypoxia (Oxygenation)

• intubate and optimise ventilation/oxygenation

Tension pneumothorax

• bilateral chest decompression: finger thoracostomies

Cardiac Tamponade

• resuscitative thoracotomy

 

 

Other considerations 

 

“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.

Commotio cordis

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.

Crush syndrome

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

Adrenaline

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

Use of ultrasound to predict survival

Patients with no cardiac activity seen on bedside ultrasound following traumatic cardiac arrest have been found to have extremely low chances of survival (approaching 100%). ^3,4

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

 

References

 

1. ANZCOR guideline April 2016: Management of cardiac arrest due to trauma
   https://www.nzrc.org.nz/assets/Guidelines/Adult-ALS/ANZCOR-Guideline-11.10.1-Trauma-Apr16.pdf
2. Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, Fox N, Jawa RS, Khwaja K, Lee JK, Magnotti LJ. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery. 2015 Jul 1;79(1):159-73.
3. Cureton EL, Yeung LY, Kwan RO, Miraflor EJ, Sadjadi J, Price DD, Victorino GP. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. Journal of Trauma and Acute Care Surgery. 2012 Jul 1;73(1):102-10.
4. Zaf Qasim, “Traumatic Cardiac Arrest – Can we Find Prognostic Factors that Predict Survival?”, REBEL EM blog, July 23, 2020. Available at:
   https://rebelem.com/traumatic-cardiac-arrest-can-we-find-prognostic-factors-that-predict-survival/.