II. Evaluation: Assess Organ perfusion

  1. See Rapid ABC Assessment
  2. Level of Consciousness
  3. Skin Color
  4. Central Pulse
    1. Child or adult: Carotid pulse or femoral pulse
    2. Infant: Brachial Pulse
  5. Sites of rapid blood loss
    1. Chest Injury
    2. Abdominal Injury (especially retroperitoneal)
    3. Pelvic Injury
    4. Extremity Injury (especially femur)

III. Protocol: Pulse Present

  1. Rescue Breathing
  2. Mnemonic: IV-O2-Monitor
    1. Intravenous Access
    2. Oxygen Delivery
    3. Monitor and 12 lead EKG
  3. Consider Endotracheal Intubation
  4. Vital Signs, History and Exam
  5. Assess for suspected cause
    1. Hypotension
      1. Hemorrhagic Shock
      2. Intraabdominal blood loss
      3. Closed Head Injury
      4. Patrick (2002) Am J Surg 184:555-60 [PubMed]
    2. Shock
    3. Acute pulmonary edema
    4. Acute Myocardial Infarction
    5. Arrhythmia
      1. Too fast (Tachycardia)
      2. Too slow (Bradycardia)

IV. Protocol: Pulse Absent - Perform Chest Compressions

  1. See Chest Compressions
  2. General
    1. Pulse check should be <10 seconds
    2. Perform 5 cycles of Chest Compressions and respirations in 2 minutes
    3. Reassess pulse and rhythm every 2 minutes
    4. Focus on compressing hard and fast with minimal interruptions
    5. Connect Automatic External Defibrillator as soon as available
    6. Time interval for lone rescuer calling for help
      1. Sudden Collapse: Call immediately
        1. Minimizes time to AED application
      2. Asphyxial arrest: Perform CPR for 2 minutes
    7. Two rescuers switch places every 2 minutes
      1. Prevents rescuer Fatigue with Chest Compressions
      2. Repeat pulse and rhythm checks with the change
  3. Infants (Under 1 year old)
    1. Place 2 fingers at just below mid-nipple line
    2. Compress over 100 times per minute
      1. Depth: One third of chest depth (1.5 inches or 4 cm)
      2. Ratio: 30 compressions to 2 breaths
  4. Children (1-8 years old)
    1. One hand placed over Sternum at center of chest (superior to xiphoid)
    2. Compress over 100 times per minute
      1. Depth: One third of chest depth (2 inches or 5 cm)
      2. Compression to ventilation ratio
        1. One rescuer: 30:2
        2. Two health care providers: 15:2
  5. Adults (over 8 years old)
    1. Two hands places over Sternum at center of chest (superior to xiphoid)
    2. Compress 100 times per minute
      1. Depth: 2 inches or 5 cm
      2. Compression to ventilation ratio: 30:2 (one or two rescuers)

V. Protocol: Pulse Absent - Other measures (in addition to Chest Compressions above)

  1. Assess Rhythm
    1. Arrhythmia requiring Immediate Defibrillation?
      1. Ventricular Fibrillation
      2. Pulseless Ventricular Tachycardia
    2. Non-shockable rhythms
      1. Pulseless Electrical Activity (PEA)
      2. Asystole
  2. Endotracheal Intubation
    1. Confirm tube placement
    2. Confirm ventilations
  3. Obtain Intravenous Access
  4. Consider potentially reversible causes
    1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)

VI. Management: Trauma

  1. See Hemorrhage Evaluation
  2. Two large bore IVs (14 or 16 gauge)
    1. Shorter tubing provides faster IV rate
  3. Intravenous Fluids and Packed Red Blood Cells
    1. Judicious use of crystalloid in Class II Hemorrhage or higher
      1. ATLS and textbooks still describe the use of NS or LR for 1-2 Liter bolus
      2. However, new guidelines suggest limiting crystalloid in favor of Blood Products
    2. Hemorrhage should be replaced with Blood Products
      1. Indications
        1. Mean arterial pressure 65 (or systolic Blood Pressure 70-90 mmHg)
        2. Poor response to IV fluids
          1. Persistent Tachycardia, Hypotension or Tachypnea
          2. Urine output <50 ml/hour (<1ml/kg/hour)
      2. Start with 2 units (prepare 4 units pRBC for more severe Hemorrhage)
        1. Type specific blood can be ready within 30-40 minutes
        2. In the crashing patient give unmatched type-specific blood, Low titer O or O negative blood
      3. Massive Hemorrhage with administration of more than 4 units requires matching Blood Products
      4. Consider autotransfusion (e.g. Hemovac or Cell Saver)
        1. Indicated for massive bleeding if blood can be drained and not contaminated)
      5. Consider blood warmer
  4. Control external pulsatile bleeding until Primary Survey completed
    1. Temporary Tourniquet
      1. Example: Apply a Blood Pressure cuff to a bleeding extremity and raise pressure to 300 mmHg
    2. Close large actively bleeding Scalp Lacerations with a few passes of a large gauge Suture (replace later with standard closure)
  5. Avoid potentially harmful measures
    1. Vasopressors
    2. Corticosteroids
    3. Sodium Bicarbonate

VII. Pitfalls: Trauma Circulatory

  1. Delayed Tachycardia (e.g. Athletes, Trauma in Pregnancy, Trauma in Children, Trauma in the Elderly)
  2. Inadequate correction of hypovolemia
  3. Intra-abdominal or Intrathoracic injury
  4. Femur Fracture or Pelvic Fracture
  5. Penetrating injuries with large vessel involved
  6. External pulsatile Hemorrhage

VIII. Management: Thoracotomy for Chest Trauma related Cardiac Arrest

  1. Indications
    1. Immediate Trauma surgeon or thoracotomy-skilled ED physician availability and
    2. Cardiac Arrest with recent witnessed signs of life (in the preceding minutes)
      1. Organized Electrocardiogram rhythm (not Asystole)
      2. Reactive pupils
  2. Protocol
    1. Rapid left chest thoracotomy and
    2. Right-sided Chest Tube
  3. Efficacy of thoracotomy in Traumatic Cardiac Arrest
    1. Thoracotomy is best indicated in penetrating Chest Trauma (especially Stab Wound)
      1. Survival after thoracotomy for Chest Trauma is 16.8% for chest Stab Wounds and 4.3% for Gunshot Wounds
      2. However, survival was only 1.4% for thoracotomy for blunt Chest Injury
      3. Rhee (2000) J Am Coll Surg 190(3): 288-98 [PubMed]
    2. Thoracotomy in Blunt Chest Trauma is controversial in 2014
      1. Some data suggests up to 7-8% survival rate with aggressive, rapid initiation of thoracotomy
      2. Inaba and Herbert in Majoewsky (2012) EM:RAP 12(5):3-4

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