Traumatic Cardiac Arrest (TCA) Flashcards
Traumatic Cardiac Arrest (TCA)
Recognise TCA as being different
Medical Cardiac Arrest – Primarily intrinsic cardiac problem
Traumatic Cardiac Arrest – Secondary cardiac problem following some traumatic aetiology which can results in;
H No blood for the myocardium to pump, such as hypovolemic arrest – the “empty heart”
O A loss of cardiac function due to hypoventilation / hypoxaemia
T An inability for the myocardium to perform due to external constriction / block to filling, such as cardiac tamponade or tension pneumothorax
TCA - Reversible CausesWhat are they?
Hypoxia
Hypovolaemia
Hypo/Hyperkalaemia
Hypothermia
Thrombosis
Tamponade - Cardiac
Toxins
Tension Pneumothorax
TCA Management
Think HOT!
H - Hypovolaemia
O - Oxygenation
T - Tension Pneumothorax
Hypovolemia
Use Tourniquets, Pelvic Binder, Haemostatic Gauze, TXA, splinting and straightening of limbs as treatment for Haemorrhage.
EVERY RED CELL COUNTS!
Splint fractures of the pelvis and long bones - (femurs)
IV/IO access, Fluid (5ml/kg Paeds), Blood, TXA (1g/10min)
Immediate diagnosis may be difficult, therefore chest compressions should be continued whilst hemorrhage control and fluid replacement is commenced.
However In profound hypovolemia chest compressions are likely to be ineffective due to poor cardiac filling and compression of an empty heart
Oxygenation
Hypovolaemia
(reduced perfusion, Blood flow to Capillaries)
Hypoxia
(reduced oxygenation of the Alveoli)
V/Q Mismatch
(hypoventilation)
Tension Pneumothorax
The diagnosis of tension pneumothorax in TCA is very challenging.
Unless clearly NO evidence of chest trauma, the default position should be to Bi-laterally decompress the potentially “obstructed chest”
First site - 2nd intercostal space - Mid Clavicular Line (MCL)
Second site - 5th intercostal space - Anterior Axilla Line (AAL)
HART, HEMS, EMICS Dr’s can Perform Thoracostomy’s
Tamponade – Cardiac
Blood around the heart within the pericardium
Reduces venous return and cardiac filling leading to decreased cardiac output – Signs of Obstructive Shock!
In deteriorating patients think Beck’s Triad!
Hypotension
Muffled Heart Sounds
Distended Neck veins
You need help! Patient will need a thoracotomy- What are your options? BE BRAVE – Treat the Patient and not yourself!
TCA Approach - DR ‘C’ ABC
The flow chart follows the HOT guidance (Hypovolaemia, Oxygenation, Tension Pneumothorax). These should ideally be simultaneously and actively managed (JRCALC 2016)
Catastrophic Haemorrhage:
In a traumatic cardiac arrest, before commencing BLS, ensure that any catastrophic haemorrhage is dealt with first. (Hypovolaemia)..
JRCALC 2016 guidelines have been amended to state that the tourniquet should be applied ‘on the limb over a single bone as close to the joint as practical’
Airway:
Ensure that the airway is open and clear. Take into consideration the requirement to protect the C-Spine (See below on C-spine)
A jaw thrust may be all that is needed to open the airway. At this point, you could use a Pharyngeal Airway to further protect the airway.
Its strongly advocated to just go straight into using an igel in an arrest, by the time you’ve measured up an OP and NP airway you could have a Igel in place.
The benefits for this are some protection against aspiration, lower inflation pressures (especially in chest injuries) If the clinician is well practiced then a ET can be placed, especially in a patient with chest injuries and a dirty airways.
Breathing:
Assist ventilations using high concentration oxygen therapy. Search for and manage a sucking chest wound or tension pneumothorax at this point, Mid clavicular or laterally if this fails. Although no BLS has commenced, we need to find and correct life threatening problems. (Oxygenation and Tension Pneumothorax)
Circulation:
If not all ready done get assess for circulation, Gain IO access (bilaterally if Hypovolaemia is a prominent cause) ASAP and start issuing a healthy fluid challenge.
Then consider begin chest compressions if absent.
Splintage
Assess for circulation, Gain IO access (bilaterally if Hypovolaemia is a prominent cause) ASAP and start issuing a healthy fluid challenge.
Then consider begin chest compressions if absent.
Remember that full circulating volume can be lost into the pelvic cavity so apply a pelvic binder as soon as possible
Remember to consider the use of other haemostatic dressings and also pelvic binders/splints to reduce the amount of blood lost into the abdomino-pelvic cavity.
FRV’s should ‘Front load’ the management of reversible causes, these will not stay reversible forever and need priority management over CPR (especially in hypovolemic patients)
C-spine – This is difficult to maintain in a TCA, it shouldn’t be forgotten about but less emphasis should be placed on its management.
Collars should NOT be placeOnce resuscitation has commenced we do a minimum of 20 Min of ALS / Reversing cause and then consider its Futility.
If pregnant or a child then resuscitation must be continued to hospital.
ROLE procedure to follow termination of cardiac arrest
Penetrating Trauma - ALS on route to MTC – Minimal on Scene Time
Dynamic thinking for advice, Don’t be Afraid to ask for help!!
d before reversible causes have been addressed, it only slows this process down.
Also if the patient is in a car etc and in TCA then just drag them out as quick as possible, do not use a long board etc.
Also Remember
Once resuscitation has commenced we do a minimum of 20 Min of ALS / Reversing cause and then consider its Futility.
If pregnant or a child then resuscitation must be continued to hospital.
ROLE procedure to follow termination of cardiac arrest
Penetrating Trauma - ALS on route to MTC – Minimal on Scene Time
Dynamic thinking for advice, Don’t be Afraid to ask for help!!
Regulation 28: Prevention of Future Deaths Report.
As the result of the outcome of a Coroners enquiry, EMAS are adopting the following approach to the management of cardiac arrest:
Actively cross check with another Clinician whether a shockable rhythm is present.
If uncertain as to whether the rhythm is shockable or non-shockable, switch the defibrillator to AED mode for analysis.
Think of TCA as a different disease to MCA
Survival from TCA is comparable to MCA with appropriate interventions
Think HOT - In TCA, Standard BLS / ALS without urgent attention to reversible pathology is unacceptable and unlikely to result in ROSC
Reversible causes become irreversible if not managed as a priority
Survival with good neurological outcome is possible with rapid, effective intervention of potential reversible causes
Think of TCA as a different disease to MCA
Survival from TCA is comparable to MCA with appropriate interventions
Think HOT - In TCA, Standard BLS / ALS without urgent attention to reversible pathology is unacceptable and unlikely to result in ROSC
Reversible causes become irreversible if not managed as a priority
Survival with good neurological outcome is possible with rapid, effective intervention of potential reversible causes
