Resuscitation of traumatic cardiac arrest is typically considered futile. Recent evidence suggests that traumatic cardiac arrest is survivable. In this article key principles in managing traumatic cardiac arrest are discussed, including the importance of rapidly seeking prognostic information, such as signs of life and point-of-care ultrasonography evidence of cardiac contractility, to inform the decision to proceed with resuscitative efforts. In addition, a rationale for deprioritizing chest compressions, steps to quickly reverse dysfunctional ventilation, techniques for temporary control of hemorrhage, and the importance of blood resuscitation are discussed. The best available evidence and the authors’ collective experience inform this article.
Key points
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Patients arriving at the emergency department with signs of life and/or evidence of cardiac contractility on point-of-care ultrasonography deserve aggressive resuscitative efforts.
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Chest compressions are unlikely to be effective in traumatic cardiac arrest and resources are better directed at addressing treatable causes of the cardiac arrest.
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Empiric bilateral chest decompression should be performed in all traumatic cardiac arrests, preferably via open thoracostomy.
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Simple, temporizing hemorrhage control measures to be considered in all patients include digital pressure, the use of a tourniquet, and empiric pelvic binding.
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Resuscitative thoracotomy should be considered for all patients with traumatic cardiac arrest with signs of life or point-of-care ultrasonography evidence of cardiac contractility, so long as the provider is competent in the procedure and the institution has an established protocol and the required resources.
Introduction
Traumatic cardiac arrest (TCA) is not the same as cardiac arrest from coronary ischemia. Although this statement seems obvious, a clear distinction between the origins of cardiac arrest is essential to reorder and change management priorities. The 2015 International Liaison Committee on Resuscitation (ILCOR) makes this distinction. However, in our experience, health care professionals who infrequently care for patients with TCA often follow standard resuscitation protocols that do not effectively address the pathophysiology of TCA. Management goals for medical cardiac arrest resulting from coronary ischemia are to support coronary perfusion to promote transition from a circulatory to electrically responsive phase to facilitate effective defibrillation. In contrast, the management goals for TCA are to address massive hemorrhage and relieve obstructive causes of shock.
This article synthesizes the best available evidence to guide the management of TCA. Where the evidence is imprecise, and if appropriate, the article describe the authors’ practice. This article compliments the 2015 ILCOR guidelines, providing more helpful detail and description of practice to aid health care professionals who infrequently care for patients with TCA.
This article emphasizes 5 key principles to guide management. Although these principles are arranged in a hierarchical fashion (a function of a traditional manuscript layout), the authors are not providing an algorithm. Algorithms can be helpful as memory aids in situations of high cognitive load. They can also help structure learning for novices encountering complex tasks. However, algorithms are simplistic representations of patient management and do not account for the tacit knowledge required of expert trauma management. Most importantly, algorithms ignore natural decision-making processes, in which experts reorder management priorities in a dynamic fashion, responding to patient context and the unique complexity of each situation. The authors encourage health care professionals to regularly consider these principles, prioritize them for action, and pause implementation when appropriate ( Fig. 1 ). These principles should not be considered as a series of consecutive steps toward a linear conclusion of a trauma resuscitation.
A 54 -year-old woman was the restrained driver in a high-speed, rollover, motor vehicle collision. She is rapidly transported to the closest community hospital by emergency medical services (EMS) because of gross hemodynamic instability. She presents immobilized in spinal precautions, receiving supplementary oxygen. Intravenous access has not yet been established in an effort to prioritize transportation from the scene of the accident. On arrival she is obtunded. While vital signs are being determined and an initial assessment is initiated, her pulse can no longer be palpated and her respirations become erratic and gasping.
Introduction
Traumatic cardiac arrest (TCA) is not the same as cardiac arrest from coronary ischemia. Although this statement seems obvious, a clear distinction between the origins of cardiac arrest is essential to reorder and change management priorities. The 2015 International Liaison Committee on Resuscitation (ILCOR) makes this distinction. However, in our experience, health care professionals who infrequently care for patients with TCA often follow standard resuscitation protocols that do not effectively address the pathophysiology of TCA. Management goals for medical cardiac arrest resulting from coronary ischemia are to support coronary perfusion to promote transition from a circulatory to electrically responsive phase to facilitate effective defibrillation. In contrast, the management goals for TCA are to address massive hemorrhage and relieve obstructive causes of shock.
This article synthesizes the best available evidence to guide the management of TCA. Where the evidence is imprecise, and if appropriate, the article describe the authors’ practice. This article compliments the 2015 ILCOR guidelines, providing more helpful detail and description of practice to aid health care professionals who infrequently care for patients with TCA.
This article emphasizes 5 key principles to guide management. Although these principles are arranged in a hierarchical fashion (a function of a traditional manuscript layout), the authors are not providing an algorithm. Algorithms can be helpful as memory aids in situations of high cognitive load. They can also help structure learning for novices encountering complex tasks. However, algorithms are simplistic representations of patient management and do not account for the tacit knowledge required of expert trauma management. Most importantly, algorithms ignore natural decision-making processes, in which experts reorder management priorities in a dynamic fashion, responding to patient context and the unique complexity of each situation. The authors encourage health care professionals to regularly consider these principles, prioritize them for action, and pause implementation when appropriate ( Fig. 1 ). These principles should not be considered as a series of consecutive steps toward a linear conclusion of a trauma resuscitation.
A 54 -year-old woman was the restrained driver in a high-speed, rollover, motor vehicle collision. She is rapidly transported to the closest community hospital by emergency medical services (EMS) because of gross hemodynamic instability. She presents immobilized in spinal precautions, receiving supplementary oxygen. Intravenous access has not yet been established in an effort to prioritize transportation from the scene of the accident. On arrival she is obtunded. While vital signs are being determined and an initial assessment is initiated, her pulse can no longer be palpated and her respirations become erratic and gasping.
Principle: start or stop?
Overall, rates of survival from traumatic arrest are low, although arguably not significantly different from the 5% to 10% range reported for out-of-hospital medical cardiac arrests. A recent study including 2300 patients from North American Resuscitation Outcomes Consortium sites found a 6.3% overall rate of survival for prehospital traumatic arrest and more favorable outcomes among patients with blunt compared with penetrating mechanisms of injury. Comparable rates of survival have been reported from a range of settings, including combat zones, the prehospital, physician-staffed London Air Ambulance program, and a systematic review examining outcomes of more than 5000 patients. Thus, although rates of survival remain low, health care professionals should guard against inappropriate pessimism toward patients with TCA until further prognostic information from the initial bedside assessment is available.
There is no single variable that can be used to distinguish salvageable from unsalvageable traumatic arrest cases. Overall, there are several clinical variables that have consistently been shown to be associated with a favorable prognosis following TCA ( Box 1 ).
Penetrating mechanism of injury, particularly thoracic
Vital signs at any time since first medical contact
Signs of life (any spontaneous movement, respiratory efforts, organized electrical activity on electrocardiogram, reactive pupils) at any time since first medical contact
Short duration of cardiac arrest (<10 minutes)
Cardiac contractility on point-of-care ultrasonography
Patients without at least 1 of the prognostic factors discussed earlier have an extremely poor (<1%) probability of survival. In these cases, resuscitation efforts should be considered futile. Various guidelines directing resuscitative efforts in TCA are shown in Table 1 .
| Context | Recommendation | Strengths and/or Limitations | |
|---|---|---|---|
| National Association of EMS Physicians and American College of Surgeons Committee on Trauma | Withholding resuscitation efforts | Withhold resuscitation in patients with (1) injuries incompatible with life a ; (2) signs of prolonged cardiac arrest (dependent lividity, rigor mortis); (3) patients with blunt trauma who are apneic, pulseless, and who have no organized electrocardiographic activity; or (4) patients with penetrating trauma who are apneic, pulseless, have no organized electrocardiographic activity, and no other signs of life b | Extensive literature review Multidisciplinary perspective Prehospital focus |
| European Resuscitation Council | Withholding resuscitation efforts | Consider withholding resuscitation efforts if (1) massive trauma incompatible with survival, or (2) no signs of life in the preceding 15 min | International panel Applies to prehospital and in-hospital settings Considers point-of-care-ultrasonography findings |
| Western Trauma Association | Indication for RT | Consider RT in (1) patients with blunt trauma with <10 min of prehospital chest compressions, (2) patients with penetrating torso trauma with <15 min of chest compressions, (3) penetrating neck or extremity trauma with <5 min of prehospital chest compressions, or (4) patients with profound refractory shock | Straightforward stratification based on mechanism and time since cardiac arrest Time since cardiac arrest can be difficult to accurately estimate |
| Eastern Association for the Surgery of Trauma | Indication for RT | Strong recommendation for RT in pulseless patients with signs of life b after penetrating thoracic trauma Conditional recommendation for RT in pulseless patients without signs of life b after penetrating thoracic trauma, present or absent signs of life b after penetrating extrathoracic injury, or present signs of life b after blunt injury Conditional recommendation against RT in pulseless patients without signs of life b following blunt trauma | Rigorous methodology More than 10,000 patients, from 72 studies, included Patient-oriented outcomes |
a Decapitation, hemicorpectomy, exposed brain matter.
b Signs of life include reactive pupils, spontaneous movement, agonal respiratory efforts, organized electrocardiographic activity.
The Spectrum of Output States in Traumatic Cardiac Arrest
Patients with TCA represent a heterogeneous patient population with a spectrum of physiologic states, ranging from having no signs of life to being severely hypotensive, but with detectable electrical cardiac activity and contractility on point-of-care ultrasonography ( Table 2 ). Occasionally, patients present after the return of spontaneous circulation (ROSC) physiology following prehospital resuscitative interventions.
| (4) Dead | (3) PEA | (2) Pseudo-PEA | (1) Spontaneous Circulation | |
|---|---|---|---|---|
| Cardiac Output | None | None | Very low | Variable a |
| Palpable Pulses | None | None | None | Present |
| Signs of Life | Absent | Absent | ± Present | Present |
| ECG Rhythm | Asystole | Nonsinus | Nonsinus | Often sinus tachycardia |
| Bedside US | No contractility | No contractility | Contractility present | Contractility present (may be hyperdynamic) |
| End-tidal CO 2 | Low/undetectable | Low/undetectable | Low | Low to moderate |
Considering patients with TCA along this physiologic spectrum allows physicians to integrate multiple prognostic variables from the bedside assessment and does not solely rely on imprecise estimates of time since cardiac arrest. This framework also emphasizes TCA as a being a critical low-flow state”, in which point-of-care ultrasonography plays a critical role in differentiating patients in so-called pseudopulseless electrical activity from true pulseless electrical activity (PEA) states. Distinguishing these two groups is important, because their prognoses are significantly different.
Patients in pseudo-PEA are in severe, end-stage shock. They have cardiac output that is not detectable by palpation of the pulse, but they may have other signs of life, including weak respiratory efforts, reactive pupils, or occasional spontaneous movement. In contrast, patients with true PEA have no cardiac output. Cardiac contractility on point-of-care ultrasonography has been reported to have 100% sensitivity for identifying survivors following TCA and should be used early during resuscitation for its prognostic information.
In our practice, pulseless patients with no signs of life, asystole, and no cardiac contractility on bedside ultrasonography (group 4, dead; Table 3 ) do not receive further resuscitative efforts. These patients do not survive. Further attempts at resuscitation would waste scarce resources (eg, blood products), divert resources from other patients, and risk exposing staff to blood-borne pathogens. It is our practice to aggressively resuscitate all other patients, particularly those in pseudo-PEA states.
| Traumatic Cardiac Arrest | Medical Cardiac Arrest | |
|---|---|---|
| Common causes | Hypovolemia/hemorrhage Tension pneumothorax Cardiac tamponade Hypoxia/respiratory failure Severe central nervous system injury | Dysrhythmia Myocardial infarction Pulmonary embolism Stroke/intracerebral hemorrhage Electrolyte disturbances (eg, hyperkalemia) Sepsis Drug/toxin |
| Effective treatments | Oxygenation/ventilation Chest decompression Blood transfusion Control of hemorrhage Resuscitative thoracotomy | Oxygenation/ventilation Electrical cardioversion Chest compressions Targeted temperature management |
The physician team leader performs a rapid assessment. The patient does not have palpable pulses. The patient has gasping irregular respirations and reactive pupils. A single point-of-care ultrasonography cardiac window reveals a hyperdynamic heart. Additional point-of-care ultrasonography information is not sought. The physician team leader indicates that the patient is in pseudo-PEA and indicates to the team that they should begin their resuscitative roles.
Principle: deprioritize chest compressions
It is critical for lead physicians to take a step back, reminding themselves and the other resuscitation team members that patients with TCA cannot be resuscitated using standard advanced cardiac life support (ACLS) algorithms. In most settings, especially outside the emergency department or trauma suite (eg, in the prehospital setting), chest compressions are considered standard of care regardless of the cause of the cardiac arrest. Although current ACLS algorithms that prioritize chest compressions are important in medical cardiac arrest, they can impede timely interventions to correct blood loss and alleviate obstructive causes of shock in TCA. Deprioritizing chest compression early in TCA resuscitation is key. Later in the resuscitation, chest compressions may be beneficial to support cerebral and cardiac perfusion, while intravascular blood resuscitation is ongoing.
A comparison of the causes and treatments of traumatic versus medical cardiac arrest is provided in Table 3 .
There are several physiologic as well as logistical reasons to consider withholding chest compressions, at least initially, in the resuscitation of patients with TCA. First, unlike patients in medical cardiac arrest, who are presumed to be euvolemic, most patients with TCA are profoundly hypovolemic because of severe hemorrhage or functionally hypovolemic because of impaired preload from either a tension pneumothorax or cardiac tamponade. Although well-performed external chest compressions may be able to deliver close to a third of the normal cardiac output in the euvolemic state, in animal models with tamponade or hypovolemia this is not true. In animal models with tamponade physiology, chest compressions seem to increase intrapericardial pressures and worsen cardiac output. Meanwhile, in severe hypovolemic states, external chest compressions do not increase output. Establishing intravascular blood volume and relieving any obstruction to cardiac filling must take precedence over chest compressions.
In our experience, team members are often more comfortable withholding chest compressions when the physician team leader is able to articulate to the team why chest compressions do not work in TCA and why they might be harmful. Most often, performing chest compressions impedes the team from performing the procedures that address the cause of TCA. Other downsides to chest compressions potentially include iatrogenic injuries to thoracic and abdominal organs, worsening existing injuries, and slowing the flow of blood via rapid infuser devices.
Of special note, if the patient’s presentation and mechanism of injury do not fit with a primary traumatic arrest but are more consistent with a primary medical arrest followed by a trauma (eg, elderly patient with minor trauma, single-vehicle collisions, ventricular fibrillation or ventricular tachycardia as the presenting rhythm, paucity of physical findings of trauma on the patient), the resuscitation is best approached using standard ACLS strategies.
With EMS prehospital notification, the physician team leader has assembled and briefed the health care team on their roles. Included in the team are a respiratory therapist, 2 experienced emergency nurses, and a second emergency physician. The blood bank has been informed about the need for blood. Anticipating the potential for TCA, the physician team leader has reminded the team that cardiopulmonary resuscitation (CPR) is not the first priority. CPR is not performed and the members quickly prepare to perform other, time-sensitive, procedures.
Principle: fix ventilation
All patients with traumatic arrest require early airway control to relieve airway obstruction, deliver oxygen, optimize ventilation, and prevent aspiration. Airway obstruction may be managed temporarily with oral or nasal airways and bag-mask ventilation, but ventilation through a bag-mask device may prove difficult in patients with facial trauma, especially with midface fractures and significant bleeding. The need for a definitive airway should be anticipated.
Airway Management
The authors suggest initially providing 100% oxygen through a bag-mask device to ensure adequate oxygenation. If ROSC is obtained, oxygen levels should be titrated to avoid hyperoxemia, which may worsen traumatic brain injury.
A cuffed endotracheal tube in the trachea remains the gold standard for airway management, because it allows precise titration of oxygen, protection from aspiration, and controlled ventilation. Most patients with TCA do not require any sedation or paralysis for laryngoscopy and intubation. However, some patients with minimal cardiac output (group 2, pseudo-PEA; see Table 2 ) may retain muscle tone and protective airway reflexes, requiring a dose of a short-acting paralytic. The low cardiac output state requires a doubling of the standard paralytic dose. Sedation is not necessary in this clinical context. Confirmation of endotracheal placement with an end-tidal carbon dioxide detector is standard of care.
Intubation may be difficult in patients with traumatic arrest for several reasons, including facial trauma, blood or emesis obscuring laryngoscopy, and the need to maintain cervical spine precautions. If difficulties are encountered or there are not adequate personnel to intubate the patient and perform other time-sensitive procedures, a supraglottic airway device can be placed. Multiple intubation attempts have the potential to distract the team from other important tasks that need to be performed simultaneously. A supraglottic device provides adequate oxygenation and ventilation for the duration of the resuscitation. With ROSC, conversion of a supraglottic device to an endotracheal tube should be prioritized based on other tasks to be performed and the complexity of airway injury.
Chest Decompression
Tension pneumothorax is notoriously difficult to diagnose in patients with blunt traumatic arrest. The authors agree with existing guidelines suggesting that empiric bilateral chest decompression be performed on all patients with blunt and penetrating thoracic TCA to avoid missing a tension pneumothorax. In addition, tension physiology may develop during the course of resuscitating a patient with blunt chest trauma and bilateral chest decompression also prevents this complication.
Our practice is to perform open thoracostomies (ie, sharp and blunt dissection of the chest wall at the anterior axillary line, fourth to fifth intercostal space, to facilitate internal palpation of the hemithorax) rather than needle thoracostomies for chest decompression. The rationale for this approach is that it ensures that a potential tension pneumothorax is fully decompressed (the clinician can palpate the lung). The second advantage of the open thoracostomy is in diagnosing massive hemothorax as a cause of the arrest. The open thoracostomy can be converted to a chest tube once the patient has stabilized.
If the physician performs a needle thoracostomy, the authors recommend placement in the anterior axillary line at the fourth to fifth intercostal space (where the chest wall is thin). Data from a meta-analysis suggests a 13% failure rate at this site, compared with a 38% failure rate at the traditional landmark of the second intercostal space in the midclavicular line when using a 4-cm (1.5-inch) needle. Use of a 6.44-cm (2.5-inch) needle will penetrate the chest wall and decompress the pleura in 95% of the population.
The physician team leader directs the respiratory therapist to insert a supraglottic airway and ventilate the patient by hand using 100% oxygen. An excessively rapid ventilation rate that impedes venous blood return to the heart is avoided, as is an excessively slow ventilation rate that does not correct hypoxia or respiratory and metabolic acidosis. The plan is to intubate the patient after the initial set of procedures is performed. The second physician performs bilateral open thoracostomies using a clean technique (ie, sterile gloves, rapid skin cleaning, and the use of a sterile towel for local draping). No air or blood returns from the right hemithorax, whereas on the left side there is a large return of air and ongoing, oozing blood loss.
Principle: stop the bleeding
Control of hemorrhage can be divided into temporizing and definitive procedures. In TCA caused by massive hemorrhage, the clinician must identify and provide temporizing control of hemorrhage while the patient’s intravascular volume is simultaneously restored via blood transfusion. To this end, there are several potential options to achieve temporary hemorrhage control, including use of manual pressure and topical hemostatic agents for external hemorrhage, tourniquets for peripheral vascular hemorrhage, pelvic ring closure for pelvic hemorrhage, and thoracotomy for control of cardiac or major vascular hemorrhage. These options are all bridges to definitive hemorrhage control, which occurs in an operating theatre, angiography suite, or a hybrid operating theater that combines both capabilities. Institutional processes for accessing local or regional resources must be developed and not spontaneously developed in an ad hoc fashion.
Manual Pressure and Topical Hemostatic Agents
Manual pressure is the basis for control of all surgical bleeding. The ability to occlude a bleeding source is reliant on the ability to effective apply pressure to it (ie, can it be pinched between fingers or compressed against something firm like a bony structure?) and on the size of the area of hemorrhage (ie, is it a vessel or the entire surface of an organ?).
Topical hemostatic agents can be divided into mechanical hemostats, active hemostats, flowable hemostats, and fibrin sealants. They are often used in combination. External topical hemostatic agents include gauze bandages impregnated with a hemostatic agent. These bandages can be applied to the surface of a bleeding area in combination with pressure or potentially packed into bleeding open wounds. Long used in the military, hemostatic bandages, such as HemoCon, Quikclot, are now being deployed for civilian trauma as part of a national American effort to optimize care provided by immediate responders (ie, the public) ( http://www.bleedingcontrol.org ). The application of manual pressure using gauze or hemostatic gauze to any bleeding site is the first maneuver to obtain temporary hemorrhage control.
Tourniquets for Peripheral Vascular Hemorrhage
The use of tourniquets has waxed and waned for decades but, based on valuable experience from recent military conflicts and in civilian trauma, the use of tourniquets is now standard care. Tourniquets are indicated for significant extremity hemorrhage if direct pressure is ineffective or impractical. Commercially produced windlass, pneumatic, or ratcheting devices that occlude arterial flow are preferred, whereas the use of narrow, elastic, or bungee-type devices is not recommended. Preferred tourniquets include the Combat Application Tourniquet and the pneumatic tourniquet. Although some junctional hemorrhage devices have been developed to control bleeding from the groin (the so-called Black Hawk Down injury) or axilla, they are not typically available outside of the military setting and their application is not straightforward. The application of an improvised tourniquet should only be considered if a commercial device is unavailable. Tourniquets placed in the prehospital setting should not be released until the patient has reached definitive care. The time of placement of a tourniquet should be recorded, preferably on the patient or tourniquet.
Pelvic Binders for Pelvic Hemorrhage
Bleeding from pelvic fractures continues to be a leading cause of preventable traumatic death in major trauma centers. The bleeding from pelvic fractures is often multifocal (ie, arterial, venous, and bony hemorrhage), diffuse, and difficult to compress. Minimizing pelvic bleeding requires reapproximation of the bony pelvic architecture to prevent further injury to the myriad of pelvic vessels. Our practice is to use a folded sheet positioned over the greater trochanters and anterior iliac spines and held snug with a simple square knot or pair of large, straight, Kelly hemostats. In our experience, this approach is preferable to commercially available devices for both fiscal reasons and more readily accessible groin access (by cutting a hole in the sheet without releasing the pelvic binder) if subsequent angiography or resuscitative endovascular balloon occlusion of the aorta (REBOA) is required. Our practice is to empirically apply a pelvic binder to patients with TCA with blunt abdominal or pelvic injury. It is a fast and simple procedure with insignificant side effects, whereas the physical examination of a mechanically unstable pelvis can be unreliable.
Another maneuver to control pelvic hemorrhage is preperitoneal packing. However, such a procedure requires a skilled operator, typically a trauma surgeon or orthopedic trauma surgeon, as well as the necessary surgical equipment. This maneuver is typically performed in the operating theater, sometimes concurrently with abdominal exploration. This maneuver is not our standard practice in blunt TCA.
Thoracotomy for Control of Intrathoracic Cardiac or Vascular Hemorrhage
Resuscitative thoracotomy (RT) is the ultimate invasive procedure to attempt reanimation of patients with TCA. This procedure is controversial, especially when accounting for the risks of infectious disease exposure to health care providers and the futility of the procedure when applied without appropriate patient selection. There are consensus guidelines on indications to perform an RT (see Table 1 ). The best outcomes occur when RT is performed for patients with thoracic stab injuries who arrive with signs of life in the emergency department.
The primary goals of RT are to release pericardial tamponade and to control intrathoracic bleeding. Evacuation of bronchovenous air embolism, elimination of a bronchopleural fistula, performing open cardiac massage, and temporary occlusion of the descending thoracic aorta to optimize brain and cardiac perfusion or control abdominal or pelvic hemorrhage are also indications for RT. However, these are rarely indications for performing an RT in a center without significant experience and appropriate surgical support.
Historical indications for RT have changed because comparisons of open cardiac massage with closed-chest compressions for superior hemodynamics have failed to show improved patient-oriented outcomes. Patients requiring occlusion of the descending thoracic aorta to restore perfusion of the brain and heart have shown mortalities greater than 90% in some studies.
RT is, at best, a temporizing maneuver. To have any chance of a successful outcome, the patient needs to be rapidly transported to a well-equipped and staffed operating theater with a surgeon immediately available who is capable of repairing the underlying injury. Regardless of clinical discipline, the physician performing the RT must be competent in the procedure with the ability to successfully address the cause of the patient’s TCA. The hospital must identify a priori a process to perform an RT and to provide definitive care if the patient is reanimated.
The steps to performing an RT are well described elsewhere. Although typically started as a left anterolateral thoracotomy, extension across the sternum into a bilateral thoracotomy or clamshell incision may be required for adequate exposure to the heart, superior mediastinum, or right pulmonary hilum. Cadaver-based experiments suggest that access time may be equivalent for these incisions, but time to control of a cardiac injury may be shorter for the clamshell incision.
A primary objective of an RT is releasing pericardial tamponade by opening the pericardium. Any bleeding from a ventricular injury may be temporized with judicious finger pressure by the pads of the finger, which move with the beating of the heart. Larger defects not controlled by finger pressure may be closed using a skin stapler and/or occluded via the inflated balloon of a Foley catheter. Of note, a novel device has recently been described that provides temporary hemorrhage control for ventricular injuries without the negative effects on cardiac function that Foley balloon catheters often create. Atrial ruptures are best controlled with application of a clamp to close the defect. Although suturing of cardiac injuries is required for definitive control, this requires a skilled operator and equipment not typically available in the emergency department. It is best accomplished in the operating theater. However, cardiac tamponade secondary to trauma is poorly treated by percutaneous pericardiocentesis, although it may be used as a temporizing measure in centers without the ability to perform an RT.
The second goal of controlling intrathoracic hemorrhage can be accomplished by inspecting for bleeding sources. Chest wall bleeding can be packed and focal bleeding from the lung or major vessels can be controlled with focal pressure. If this is ineffective, clamping of the pulmonary hilum or a pulmonary hilar twist may also be used for severe bleeding, although the latter maneuver requires division of the inferior pulmonary ligament. Occlusion of the hilum with a clamp or external compression is simpler to perform than a hilar twist. If significant blood loss is present from a right-sided open thoracostomy, a bilateral thoracotomy is necessary to identify and control the source of bleeding.
Our practice is to perform an RT if a physician competent in the procedure is present, the patient in TCA has signs of life in the emergency department, or there is cardiac contractility on point-of-care ultrasonography. Our practice is to perform a left anterolateral thoracotomy, only extending to a clamshell incision if initial decompression of the right hemithorax reveals significant blood loss. If ROSC is achieved, our practice is to cover the incision with dry, sterile surgical towels in anticipation of rapid transportation of the patient to an operating theater. The open thoracostomy of the right hemithorax is then converted to a right-sided chest tube. Our practice is to continue the resuscitation until all reversible causes of TCA have been treated.
Resuscitative Endovascular Balloon Occlusion of the Aorta for Control of Abdominal or Pelvic Hemorrhage
The use of REBOA, although first described in the Korean War, is being rapidly adopted in the care of civilian patients with trauma. The greatest utility of REBOA is as an alternative to RT for the occlusion of the thoracic descending aorta to stop abdominal or pelvic hemorrhage. Its use is covered in more detail in Steven Skitch and colleagues’ article, “ Acute Management of the Traumatically Injured Pelvis ”; and Megan Brenner and Christopher Hicks’s article, “ Major Abdominal Trauma: Critical Decisions and New Frontiers in Management ,” in this issue. Our current practice does not include REBOA in the management of TCA.
Other Direct Pressure Maneuvers
A few specific scenarios worth mentioning include penetrating injuries to zone 1 of the neck. Severe hemorrhage from such wounds often originates from the subclavian vessels or from intrathoracic vessels, both of which are difficult to compress externally. The placement of a Foley catheter into the wound with subsequent inflation may be considered (See Angelo Mikrogianakis and Vincent Grant’s article, “ The Kids are Alright: Pediatric Trauma Pearls ,” in this issue).
Penetrating injuries to the face or facial smashes can create severe bleeding that may require facial packing. However, with complete disruption of the bony architecture there is no ability to obtain tamponade, because there is nothing to pack against. In such scenarios, consideration for external bolstering by completely wrapping the face and head circumferentially may be considered.
As a principle, hemorrhage control in patients with TCA must be obtained, at least in a temporizing manner, in order to have any possibility of ROSC. Table 4 lists temporizing measures to use as appropriate.
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