PCTH - Trauma Cardiac Arrest Medical Directive Flashcards
Trauma Cardiac Arrest Medical Directive
Indications
Cardiac arrest secondary to severe blunt or penetrating trauma
Trauma Cardiac Arrest Medical Directive
Conditions for: CPR, Manual Defib, AED Defib, and Trauma TOR
CPR: Altered LOA, other: performed in 2 minute intervals
Manual Defibrillation: Age ≥24 hours, altered LOA, other: VF or pulseless VT
AED Defibrillation: Age ≥24 hours, altered LOA, other: defibrillation indicated
Trauma TOR:
- Age ≥16 years
- altered LOA
- HR 0
- RR 0
- Other:
- No palpable pulses AND
- no defibrillation delivered AND
- Rhythm asystole AND no signs of life at any time since fully extricated OR Signs of life when fully extricated with closest ED ≥30 min transport time away
- OR PEA with closest ED ≥30 min transport time away
What is considered signs of life (as per trauma arrest TOR requirements)?
- any spontaneous movements
- adequate respiratory efforts
- organized electrical activity on ECG
- reactive pupils
If a trauma cardiac arrest pt is in PEA, what do you need to consider for a TOR?
Consider transport time:
* if <30 min away, transport
* >= 30 min, consider TOR
If a trauma arrest pt is asystolic, what do you have to consider for TOR?
If Signs of Life (SOL) are present:
- If no SOL since extricated, then consider TOR
- If SOL present, then consider transport time:
* if transport <30 min, transport
* if transport >= 30 min, consider TOR
Trauma Cardiac Arrest Medical Directive
Contraindications for: CPR, Manual Defibrillation, AED Defibrillation, Trauma TOR
CPR:
- Obviously dead as per BLS PCS
- Meet conditions of DNR Standard
Manual Defibrillation: Rhythms other than VF or pulseless VT
AED Defibrillation: Non-shockable rhythm
Trauma TOR:
- <16 y.o.
- defibrillation delivered
- SOL at any time since fully extricated medical contact
- PEA and closest ED <30 min transport time away
- Pt with penetrating trauma to torso or head/neck and LTH <30 min away
Trauma Cardiac Arrest Medical Directive
Treatment
1) Consider CPR as per current HSF
2) Consider manual defibrillation (if available and authorized)
-
Age: ≥24 hrs to <8 years
- Dose: 1 defibrillation
- Initial dose: 2J/kg
- Max # of doses: 1
-
Age: ≥8 years
- Dose: 1 defibrillation
- Initial dose: As per BH/manufacturer
- Max # of doses: 1
3) Consider AED/SAED defibrillation (if not using manual defibrillation)
-
Age: ≥24 hours to <8 years -WITH OR WITHOUT PEDIATRIC ATTENUTATOR CABLE
- Dose: 1 defibrillation
- Initial dose: as per RBHP/manufacturer
- Max # of doses: 1
-
Age: ≥8 years
- Dose: 1 defibrillation
- Initial dose: As per BH/manufacturer
- Max # of doses: 1
Mandatory Provincial Patch Point
Patch to BHP for authorization to apply the Trauma TOR if applicable. If BHP patch fails or Trauma TOR does not apply, transport to closest appropriate receiving facility following 1st analysis/defibrillation.
Trauma Cardiac Arrest Medical Directive
Clinical Considerations
- If no obvious external signs of significant blunt trauma, consider medical cardiac and treat according to the appropriate medical cardiac arrest directive
- SOL: any spontaneous movement, respiratory efforts, organized electrical activity on ECG, and reative pupils
- An IV bolus may be considered where it does not delay transport and should not be prioritized over management of other reversibly pathology
Can you shock a patient with a metal embedded object?
Yes
Describe the CPR guidelines for a neonate (>= 24h to <30 days), including CPR ratio, indications for CPR, defibrillation, and trauma/medical TOR.
Age: <30 days is considered neonate (Day 1 = day after their expected due date) but >= 24 hours to defib
Ratio: 3:1
CPR Indications: Pulse <60 and poor perfusion (usually unconscious)
defib: defib applicable
No trauma or medical TOR
Describe how the CPR ratio changes for a neonate when non-intubated vs. intubated.
Ratio does not change! Both non-intubated and intubated follows a 3:1 ratio
Describe the CPR guidelines for a child, including what age range constitutes a child, CPR ratio, indications for CPR, defibrillation, and trauma/medical TOR.
Age Range: ≥30days to puberty
CPR Ratio: 15:2
Indications for CPR: pulse <60 and poor perfusion (i.e. unconscious)
Defibrillation: SAED applicable
Trauma TOR/Medical TOR: N/A
Describe how the CPR ratio changes for a child intubated vs non-intubated.
Non-intubated: ratio of 15:2
Intubated: non-interrupted chest compressions
S/S of puberty when determining if a patient has reached puberty
hair in facial region, armpit, pubic/genital, breast development
Describe the CPR guidelines for a patient who has reached puberty but <16 years old, including CPR ratio, indications for CPR, defibrillation, and trauma/medical TOR.
Ratio: 30:2 unless secured (then continuous compressions with breaths 1 every 6-8 seconds)
CPR indications: No pulse
Defibrillation: SAED applicable
Trauma TOR/Medical TOR: N/A
Describe the CPR guidelines for a patient ≥16 y.o., including CPR ratio, indications for CPR, defibrillation, and trauma/medical TOR.
CPR Ratio: 30:2 unless secured (then continuous compressions with breaths 1 every 6-8 seconds)
CPR indications: No pulse
Defibrillation: SAED applicable
Trauma TOR: YES
Medical TOR: YES
Describe the defibrillation pad placement and general considerations when applying pads to ensure contact.
- R midclavicular line x L midaxillary line
- away from bony processes
- hair on chest (shave if necessary)
- dry pt if wet
What is the #1 cause of impedence in defibrillation?
poor pad contact
If patient has a pacemaker in the R midclavicular region (where you would typically put defib pad), how would you problem solve this?
just switch pads to the opposite side, it’ll do the same thing
i.e. one pad on top L chest under clavicle, one pad on R flank
If defibs pads are too close to each other, what alternative placements can you use?
Anterior-posterior (AP) - like a sandwich
You want pads to be ~hand width apart or more
What does a biphasic AED machine do and what is the purpose of it?
Biphasic machine shocks the patient twice basically (the charge goes through from one pad through the heart and then to the other and back the same way, eventually going through the heart twice)
The goal is to hit as many +vely charged cells in the heart as possible and this increases the likelihood of converting the rhythm
What are the preset adult defibrillation joule settings in the Medtronic Lifepack series?
200, 300, 360 joules
What are the preset adult defibrillation joule settings in the Philips MRX/FR2 series?
150 joules non-escalating
What are the preset adult defibrillation joule settings in the Zoll E, M or X Series?
120, 150, 200 joules
Describe the trauma cardiac arrest flow chart.
If a bystander used an AED on trauma arrest patient prior to your arrival, do you have to transport?
Yes, whether from fire, public, lifeguards, a shock is a shock so you have to transport
How many times do you shock the patient if they are in a traumatic cardiac arrest?
once and then if you shock em, you gotta transport em
What are the TOR requirements?
Patient is ≥16y.o.
monitored HR = 0
If HR > 0, then ER ≥30 minutes
AGAIN NO SHOCKS DELIVERED
On an ACR, which sections specifically would outline details regarding the cardiac arrest?
“Cardiac Arrest Information” section & “Clinical Treatment/Procedure”
Alternative airways besides OPAs
supraglottic, supralaryngeal, extraglottic
Why use supraglottic airways?
1) back up for failed intubation
2) poor success rates for pre-hospital tracheal intubation
3) need is to ventilate, not necessarily intubate
Supraglottic airways sit _______ the glottic opening.
above (they do not go through the glottic opening)
King LTs are sized based on:
patient’s height
Igels are sized based on:
patient’s weight
Describe the components of a king LT.
Advantages of advanced airways
- emergency ventilation can take place within 15 seconds without a laryngoscope
- requires minimal movement of patient head
- requires minimal education to insert
- King laryngeal airway is designed to be inserted without direct visualization
- minimal risk of aspiration
Preparation of king LT
1) Sizing - based on pt height
2) pre-inflate with syringe (amount of air to fill is based on size chosen)
3) lubricate
4) deflate
King LT Sizing #5 (Colour, cuff volume to fill in syringe, height)
Colour: Purple
Cuff volume: 70-90 mL
Height: >6 ft (>180cm)
King LT Sizing #4 (Colour, cuff volume to fill in syringe, height)
Colour: Red
Cuff volume: 60-80 mL
Height: 5-6 ft (155-180 cm)
King LT Sizing #3 (Colour, cuff volume to fill in syringe, height)
Colour: yellow
Cuff volume: 45-60mL
Height: 4-5ft (122-155cm)
King LT Sizing #2.5 (Colour, cuff volume to fill in syringe, height)
Colour: orange
Cuff volume: 30-40 mL
Height: 41-51 inch (105-130cm)
King LT Sizing #2 (Colour, cuff volume to fill in syringe, height)
Colour: Green
Cuff volume: 25-35 mL
Height: 35-45 inch (90-115cm)
Supraglottic Airway Medical Directive - AUXILIARY
Indications
Conditions
Contraindications
Treatment
Clinical Considerations
Indications: Need for ventilatory assistance or airway control; AND other airway management is ineffective
Conditions: Patient must be in cardiac arrest (for PCP, unless patched to BHP)
Contraindications:
- Active vomiting - because you cannot control airway
- inability to clear the airway - consider blood and secretions
- airway edema - not going to fit
- stridor - due to potential trauma/edema
- caustic ingestion - potential damaged esophagus + you want them to vomit caustic materials OUT of body
Treatment:
- Consider supraglottic airway insertion → the max number of supraglottic airway insertion attempts is 2
-
Confirm supraglottic airway placement
- Primary: ETCO2 (Waveform capnography)
- Secondary: ETCO2 (Non-waveform device); auscultation (xiphoid process); chest rise
Clinical Considerations:
- An attempt at supraglottic airway insertion is defined as the insertion of the supraglottic airway into the mouth (anything past the lips)
- confirmation of supraglottic airway must use ETCO2 (waveform capnography). If waveform capnography is not available or not working, then at least 2 secondary methods must be used
When applying a King LT, where should the blue orientation line ultimately face?
faces the CHIN of the patient (so you start with the king LT approaching laterally and pointed towards the cheek, and then you rotate tube back to midline so it’s sitting the right way)
You should advance the king LT down the airway until the base of connector is aligned with _______ or ______.
teeth or gums
For trauma arrests, what sorts of reversible causes should you address?
- Hypovolemia: control external hemorrhage. splint pelvis/fractures
- Oxygenation: prioritize basic AW management and ventilation to correct hypoxia. use advanced AW only as needed
Algorithm for Trauma Arrest
