What 5 things cause arrest following trauma:
Severe TBI/ high cervical transection
Airway obstruction
Tension pneumothorax
Pericardial tamponade
Hypovolaemia (haemorrhage)
—> incl. Aortic transection, haemothorax etc.
GENERAL APPROACH TO TRAUMATIC ARREST:
Per ANZCOR:
Priorities are:
1- Restore blood volume
2- Decompress the pleura
3- Thoracotomy within 10 mins (if indicated)
Although not a priority: if it doesn’t otherwise interfere, convential CPR can occur concurrrently (LUCAS). ALS meds have no role.
Causes:
- Severe HI
- UAO
- Haemorrhage
- Tension
- Tamponade
Consider special circumstances:
- Crush syndrome
- Major head injury
- Commotio cordis
Consider calling off at 10 mins after correctable factors addressed
_____________________
A:
B:
Bilateral finger thorocostomies and sweep. ICC as soon as practicable. One-way seal is alternative.
Can leave open a while if PPV. Def ICC once sponting.
Consider resweep if deteriorates.
If >1000ml out immediately —> CTx.
C:
Credo —> MTP. Target BP 90/ conscious.
Consider resuscitative thoractomy.
Tamponade needs OT. Needle poor alternative option.
Indications for RESUSCITATIVE thoracotomy:
Consider if:
1- Thoracic trauma (blunt or pen)
2- Arrest with recent signs of life (<10ish mins ago),
OR
Periarrest and tamponade seen on FAST
3- Absence of clear unsurviveable injury
4- Cardiothoracics available/nearby
Survival 5 - 35%
Best outcomes when:
- Penetrating thoracic injury
- Arrest <10mins ago
- Isolated injury
*’Signs of life’ includes PEA, pupillary response
Procedure: resuscitative thoracotomy
Brief the room
PPE
Rapid antiseptic wash
Should already have bilateral thorracostomies 5th IC/midaxillary.
Start with unilateral LEFT thoracotomy
- Extend thoracostomy along ribs to sternum
- Use rib spreader (ensure handle in axilla)
- Lift, snip and sweep pericardium avoiding phrenic nerve
- Deliver heart and inspect
- Consider clamping aorta
Extend to ‘clamshell’ if indicated
- Mirror incision on R side
- Shears or Gigli to cut horizontal
through sternum
- Reposition rib spreaders in midline
Consider:
-Hilar twist
-Control bleeders
-Crossclamp aorta
-Manual cardiac compressions
- Cannulate for bypass
-Internal defib 15J
