The right decision?

[Sleeplessbordernights]

18 year old female involved in a high velocity car crash. Arrives to the OR anxious, in pain but stil talking. We do a basic rapid sequence intubation. She has a deep laceration in her back about 40 cm long which has active bleeding, a lot. Vascular surgeo arrive and controls the bleeding. At this point the pt is on levophed .6mg per kg, has bled 2.5 l, we activated MHP. The bleeding is under control but the pt is not improving, trauma arrives and wants xrays (they did not take them in ER because of the bleeding). Anyway we turn the pt and as we are doing that crashes and arrest, after one cycle we get her back. Trauma still tries to move the pt for the xrays but the same happens. After we get her back again my attending says she is not dying in my OR and tells trauma to stop and we send the pt to ICU. She got treatment there and is stable all afternoon. After that trauma finally has their xrays and the pt got pelvis facture, femur fracture, sacrum, tibia, clavicle etc. Later we have her in the OR again for an external fixator in pelvis and femur. This time the pt is stable all the way trough.

My question here, was my attending right stopping them from taking the xrays in the OR and potentially put the external fixator right there?

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[coffeebythelake]

18 year old female involved in a high velocity car crash. Arrives to the OR anxious, in pain but stil talking. We do a basic rapid sequence intubation. She has a deep laceration in her back about 40 cm long which has active bleeding, a lot. Vascular surgeo arrive and controls the bleeding. At this point the pt is on levophed .6mg per kg, has bled 2.5 l, we activated MHP. The bleeding is under control but the pt is not improving, trauma arrives and wants xrays (they did not take them in ER because of the bleeding). Anyway we turn the pt and as we are doing that crashes and arrest, after one cycle we get her back. Trauma still tries to move the pt for the xrays but the same happens. After we get her back again my attending says she is not dying in my OR and tells trauma to stop and we send the pt to ICU. She got treatment there and is stable all afternoon. After that trauma finally has their xrays and the pt got pelvis facture, femur fracture, sacrum, tibia, clavicle etc. Later we have her in the OR again for an external fixator in pelvis and femur. This time the pt is stable all the way trough.

My question here, was my attending right stopping them from taking the xrays in the OR and potentially put the external fixator right there?

Seems like the patient needed big time fluid and blood resuscitation that did not happen until later. Get some large IVs and art line. Transfuse, stabilize, then give surgery a go. Seems like your attending was thinking something else was going on than simply being way behind from hypovolemic shock? With these sorts of injuries there can be plenty of hidden bleeding.. your pt coded twice from positioning changes so I wouldn't try doing that again until they are actually stabilized... if unsure u can slap on a TTE probe to look at preload and filling? I don't think it was necessary to send OR to ICU back to OR..

Also what dose of levophed are u doing? What is 0.6 mg per kg? 🤔

 

[Shimmy8]

Without knowing the ending like you stated, I’d have assumed she had some sort of intra-abdominal injury, retroperitoneal bleeding, etc.

Did they do a FAST in the trauma bay? Trauma CT C/A/P? Line up, MTP, ABG, send off coags, TEG, TEE/TTE.

Stabilize and try to figure out what the hell is going on.

 

[Hoya11]

18 year old female involved in a high velocity car crash. Arrives to the OR anxious, in pain but stil talking. We do a basic rapid sequence intubation. She has a deep laceration in her back about 40 cm long which has active bleeding, a lot. Vascular surgeo arrive and controls the bleeding. At this point the pt is on levophed .6mg per kg, has bled 2.5 l, we activated MHP. The bleeding is under control but the pt is not improving, trauma arrives and wants xrays (they did not take them in ER because of the bleeding). Anyway we turn the pt and as we are doing that crashes and arrest, after one cycle we get her back. Trauma still tries to move the pt for the xrays but the same happens. After we get her back again my attending says she is not dying in my OR and tells trauma to stop and we send the pt to ICU. She got treatment there and is stable all afternoon. After that trauma finally has their xrays and the pt got pelvis facture, femur fracture, sacrum, tibia, clavicle etc. Later we have her in the OR again for an external fixator in pelvis and femur. This time the pt is stable all the way trough.

My question here, was my attending right stopping them from taking the xrays in the OR and potentially put the external fixator right there?

it sounds like that was the right thing to do.

it sounds like even though the bleeding may have been controlled, she was still way behind on fluid and blood.

it was not a good time to be moving her around for xrays that can be done later when she is adequately resuscitated and more HD stable.

ortho is focused on the fixator in the face of a coding patient

 

[ryanjmy]

After we get her back again my attending says she is not dying in my OR and tells trauma to stop and we send the pt to ICU. She got treatment there and is stable all afternoon.

What does it matter where a pt dies?

There is no better place to resuscitate a pt than the OR. It sounds like your attending thought the case was futile. Clearly he was wrong. 18 YOs are extremely resilient.

 

[IMGASMD]

ortho is focused on the fixator in the face of a coding patient

There’s a rhythm I don’t recognize, eh-sys-toli

 

[BobLoblaw78]

What does it matter where a pt dies?

There is no better place to resuscitate a pt than the OR. It sounds like your attending thought the case was futile. Clearly he was wrong. 18 YOs are extremely resilient.

I took it as he wasn't going to mess around in the OR getting XR, etc when the patient was coding. He was telling them to focus on the big picture of resuscitate/stabilize and live to fix another day.

 

[jwk]

What? Nobody has cracked "THERE IS A FRACTURE - I MUST FIX IT" yet???

 

[teacher2md]

At what point were blood products given? Did you really wait until the patient was requiring 0.6mcg/kg/min of norepi to start administering blood? If so, I would argue that this was grossly mismanaged. In hemorrhagic shock, you should start transfusing immediately if the patient is hypotensive-- not start ramping up pressors. Did the surgeons realize that the patient was so hypotensive while they were exploring this back wound?

Also, unclear why the patient wouldnt have had even basic trauma X-rays early in the ED/OR. It sounds like the patient had a pelvic fracture with massive bleeding-- an early pelvic binder may have helped. Also, if bleeding could not be controlled early, a REBOA could have been considered..

From the information you gave us, this seems like some sketchy management...

 

[ERRES2288]

At what point were blood products given? Did you really wait until the patient was requiring 0.6mcg/kg/min of norepi to start administering blood? If so, I would argue that this was grossly mismanaged. In hemorrhagic shock, you should start transfusing immediately if the patient is hypotensive-- not start ramping up pressors. Did the surgeons realize that the patient was so hypotensive while they were exploring this back wound?

Also, unclear why the patient wouldnt have had even basic trauma X-rays early in the ED/OR. It sounds like the patient had a pelvic fracture with massive bleeding-- an early pelvic binder may have helped. Also, if bleeding could not be controlled early, a REBOA could have been considered..

From the information you gave us, this seems like some sketchy management...

This. what access did you have and how much blood products were given. Treating hypovolemic shock with NE gtt is interesting but obviously wasn’t there and don’t know entire picture.

 

[GassYous]

Why didn't they get a ct everything in the ER in a patient that's awake and talking? Fluids and units up front. Did you give opioids? I'd avoid that to keep from taking away her sympathetic drive. A line and big ivs (!4s if you can) up front. CVL if you have time but you probably don't.

 

[vector2]

Why in the world would you move the patient, who just coded, from the OR - which is the gold standard place to be for resuscitation - to a place that is definitely not the gold standard for resuscitation - in the effort to resuscitate her?

Stay in the OR, temporize with pressor while waiting for blood, consider REBOA, check an ABG and TEG, actually continue the MTP to replace what is probably more than 2.5L of blood loss, give calcium, do a TTE or TEE, get the films.

 

[POW16]

To answer the OP's title thread question: no. Questionable management from surgical and anesthesia teams. As others have mentioned, if this patient was talking she needed access, products, Xrays and a FAST as soon as she hit the ER. You could even make the argument to get labs and pan scan her if she gets resuscitated in the ER. It makes no sense to leave the OR and resuscitate in the ICU when you don't even know where all her injuries are.

 

[IMGASMD]

Op, are you in Mexico or in the US? I never got answer the last time you posted.

I trained at a community hospital in the US and worked at many more “resources poor” places. We don’t know exactly where you work, but I just want you to know that there are very different ways of managing patients, especially where you don’t have the proper equipment or personnels. There are plenty of posters here who work in university hospitals, that can push 100+ of blood products. If we have more than 30 unit trauma we’d be in trouble. Where I worked recently, have to call county blood bank for FFPs and platelets before we have any kind of cardiac surgery.

Since there are two camps of thoughts here. Just keep that in mind.

 

[coffeebythelake]

Op, are you in Mexico or in the US? I never got answer the last time you posted.

I trained at a community hospital in the US and worked at many more “resources poor” places. We don’t know exactly where you work, but I just want you to know that there are very different ways of managing patients, especially where you don’t have the proper equipment or personnels. There are plenty of posters here who work in university hospitals, that can push 100+ of blood products. If we have more than 30 unit trauma we’d be in trouble. Where I worked recently, have to call county blood bank for FFPs and platelets before we have any kind of cardiac surgery.

Since there are two camps of thoughts here. Just keep that in mind.

While I agree with you that available resources affect management and outcomes, there was no indication from the OPs post that they did not have the blood products or tools necessary to do this trauma case.

They had a MTP. They had the capability to do imaging if not for someone's rushed decision to bypass secondary survey, fast exam, imaging, and all that other stabilization stuff to go straight to OR without a clear idea of what they were dealing with. Sounds like a series of bad management decisions and delayed recognition of the true extent of blood loss. Stuff like this happens even in the best staffed and resources intensive hospitals. Doesn't matter when it is due to errors in judgement . Fortunately it sounds like the patient survived all this.

 

[GassYous]

Op, are you in Mexico or in the US? I never got answer the last time you posted.

I trained at a community hospital in the US and worked at many more “resources poor” places. We don’t know exactly where you work, but I just want you to know that there are very different ways of managing patients, especially where you don’t have the proper equipment or personnels. There are plenty of posters here who work in university hospitals, that can push 100+ of blood products. If we have more than 30 unit trauma we’d be in trouble. Where I worked recently, have to call county blood bank for FFPs and platelets before we have any kind of cardiac surgery.

Since there are two camps of thoughts here. Just keep that in mind.

Christ lol

We've had a few sick livers that were 100 units+

Haven't hit that in trauma, usually they're good with 10 and haven't seen more than 20

 

[coffeebythelake]

Op, are you in Mexico or in the US? I never got answer the last time you posted.

Why you dissing the medical system in Mexico? You don't think they know how to work trauma cases? 😹

 

[IMGASMD]

Why you dissing the medical system in Mexico? You don't think they know how to work trauma cases?

I only call them “resources poor”. Indirectly.

They probably do more trauma than I do right now.

I had a trauma that got about 10, just poured whatever we had. We used to everything we had, surgeons basically gave up at the end and attributed it to retroperitoneal bleed.

I am just saying everyone should keep an open mind about the anestheia management in Ops hospital. There are things that we just don’t know. I for one, think a lot of those things should have been done in the ED, not OR. If you’re expecting me to do a FAST in OR, we’re in trouble.

 

[Sleeplessbordernights]

I only call them “resources poor”. Indirectly.

They probably do more trauma than I do right now.

I had a trauma that got about 10, just poured whatever we had. We used to everything we had, surgeons basically gave up at the end and attributed it to retroperitoneal bleed.

I am just saying everyone should keep an open mind about the anestheia management in Ops hospital. There are things that we just don’t know. I for one, think a lot of those things should have been done in the ED, not OR. If you’re expecting me to do a FAST in OR, we’re in trouble.

Yeah Im in Mexico, in a border town in a major trauma center, we pretty much have everything we need, regarding the pt we have given at that point 6 blood 6 plasma. The vascular team didnt allow the ER to do more or take xrays.

And tbh I think we have a very toxic culture regarding the attendings, they take great pride boasting that no pt die under their care in the OR

 

[Beeftenderloin]

Problems 1, 2 and 3 for this girl are volume, volume and volume. You mentioned 2.5L of EBL. That’s likely just what you saw her lose in OR. You don’t know how much is sitting in the back of the ambulance, or on the pavement by her car. She’s probably lost close to a blood volume or more by now if she was bleeding as briskly as you say. The Levo (I’m sure you meant 0.6 MCG/kg/min) is just a temporizing measure in this patient to support her long enough for your surgeon to get control of bleeding and for you to get caught up on products. Bleeding trauma patients belong in the OR.

Now having said all that, it is possible for something else to be going on. In trauma patients whom you feel like you have appropriately volume resuscitated them and they are still on escalating doses of pressers, it’s important to have an approach to what else could be going on. This girl was in a high speed MVC. Throw the US probe on her chest and get a quick look to see if there is free fluid in the pericardium (ie tamponade) and look for lung sliding Bilaterally to r/o PTX. Check suprapubic, Morrison’s pouch and splenorenal recess for free fluid to r/o major intra abdominal bleed. Could she be in anaphylaxis from the roc or atbx you gave? Is her QT getting wide, did you forget to replace calcium with all your products? Is her QRS widening out because she took a bunch of grandmas TCAs, then got behind the wheel and crashed on purpose?


The differential changes a little big as the patient get older/more comorbid, but the principle is the same. If you don’t at least consider these things then you’ll never be able to address them.

 

[Radetzky]

a trauma patient went straight to theatre to suture up a back laceration without having pelvic or intraabdominal bleeding ruled out first then got transferred out of the OR when she needed aggressive resuscitation? Yikes

If she was so unstable that she was arresting I would have asked them to open her abdomen there and then in theatre while you pour in the blood

 

[PainDrain]

Here are my thoughts, though others above are far smarter than I claim to be and have excellent answers. First off, the patient has a deep laceration and is hypovolemic with a 2.5L blood loss. My first priority is making up for that loss prior to any other procedure or diagnostic test. When you flipped the patient the first time and they decompensated what was your differential? A code with a change in body position says hypovolemia with decreased venous return, perhaps pneumo with tension. Also possibly tamponade or intrathoracic injury. After the initial code event I would have reassessed, a TEE would have been useful here to determine if the heart was full vs empty. Also, as others have said, a FAST scan would have helped determine if there was major intra-abdominal injury or hemorrhage. I would not have left the OR because you not only have all the tools to resuscitate the patient but you have a diagnostic and therapeutic tool in the surgeons.

 

[coffeebythelake]

And tbh I think we have a very toxic culture regarding the attendings, they take great pride boasting that no pt die under their care in the OR

Arrogant surgeons and sick patients. Not a good combo.

The OR is ultra acute care. It is the best place to resuscitate a patient. I would rather a patient die in the OR getting the full court press from us, as opposed to them dying in the ICU with lesser degree of care to appease someone's ego about "nobody dying in thr OR"

 

[GassYous]

Arrogant surgeons and sick patients. Not a good combo.

The OR is ultra acute care. It is the best place to resuscitate a patient. I would rather a patient die in the OR getting the full court press from us, as opposed to them dying in the ICU with lesser degree of care to appease someone's ego about "nobody dying in thr OR"

Yeah but if they go in the icu its not as much your responsibility

 

[Airway]

Not defending anyone but...Re 'can't die in the OR' there are institutions and states that intraop death triggers automatic high level QI investigation (which can mean find someone to blame) and automatic coroner's case.

I have definitely seen dead patients dragged out of the OR only to declare them dead in the ICU - I'm assuming for the above reasons.

I suspect transplant surgeons don't want that kind of scrutiny (Loss of major revenue if Unos puts your program on hold). All human beings (even anesthesiologists) react to incentives...

 

[Hork Bajir]

Re: the above comments on TEE or TTE- it is not an appropriate test in this situation, IMHO (unless you have reason to suspect tamponade or traumatic aortic injury, which is further down on the differential in this case). At best it’s going to distract the OR team from doing what is really important (vascular access, transfusion, correcting coagulopathy).

“To see if the heart is full or empty”… It’s empty. Trust me. Is it empty because of hypovolemia, or a tension pneumothorax? Rescue echo won’t necessarily tell you that. If you are even having that discussion in an unstable trauma patient, it means that they should have had bilateral chest tubes 10 minutes ago (please for the love of god don’t mention lung US in a coding patient). Not to mention that “volume status” isn’t necessarily an obvious determination, and not one that you should be making without substantial echo training.

Sorry, I’ll get off my soapbox now. It’s been a long fellowship year of getting asked to do echos all over the hospital “to see if the heart is empty” : )

 

[vector2]

Re: the above comments on TEE or TTE- it is not an appropriate test in this situation, IMHO (unless you have reason to suspect tamponade or traumatic aortic injury, which is further down on the differential in this case). At best it’s going to distract the OR team from doing what is really important (vascular access, transfusion, correcting coagulopathy).

“To see if the heart is full or empty”… It’s empty. Trust me. Is it empty because of hypovolemia, or a tension pneumothorax? Rescue echo won’t necessarily tell you that. If you are even having that discussion in an unstable trauma patient, it means that they should have had bilateral chest tubes 10 minutes ago (please for the love of god don’t mention lung US in a coding patient). Not to mention that “volume status” isn’t necessarily an obvious determination, and not one that you should be making without substantial echo training.

Sorry, I’ll get off my soapbox now. It’s been a long fellowship year of getting asked to do echos all over the hospital “to see if the heart is empty” : )

I would never, ever stop lifesaving empiric tx for hemorrhagic shock to do an echo, but this lady suffered massive blunt trauma and came up to the OR without any imaging. If she's got lines in place and is receiving MTP and then some and is *still* very unstable/coding once the apparent external bleeding is controlled then she could certainly use a rescue echo as the surgeon empirically places REBOA/opens the belly to address possible pelvic bleeding, etc. Blunt cardiac injury/ tamponade / TAI is not a stretch given her mechanism.

 

[coffeebythelake]

Re: the above comments on TEE or TTE- it is not an appropriate test in this situation, IMHO (unless you have reason to suspect tamponade or traumatic aortic injury,

Yeah. That's exactly why an echo is useful.
And for the OPs case where they are almost certainly dealing with delayed recognition of massive hypovolemic shock I think doing an echo to confirm this sure beats the hell out of giving up and sending the patient to the ICU. They could even do it thr same time they do that FAST exam that they didn't do in the ER

 

[deleted697535]

Yeah your attending is a ****ing idiot. And a coward.

Also your TTL and entire trauma team must be removed of their duties immediately. Sounds lucky this girl didnt die
There is a thing called ATLS. Pelvic binder in part of the primary survey. xrays done in emerg stat

0.6 of levo during a massive hemorrhage? mmm

18 year old female involved in a high velocity car crash. Arrives to the OR anxious, in pain but stil talking. We do a basic rapid sequence intubation. She has a deep laceration in her back about 40 cm long which has active bleeding, a lot. Vascular surgeo arrive and controls the bleeding. At this point the pt is on levophed .6mg per kg, has bled 2.5 l, we activated MHP. The bleeding is under control but the pt is not improving, trauma arrives and wants xrays (they did not take them in ER because of the bleeding). Anyway we turn the pt and as we are doing that crashes and arrest, after one cycle we get her back. Trauma still tries to move the pt for the xrays but the same happens. After we get her back again my attending says she is not dying in my OR and tells trauma to stop and we send the pt to ICU. She got treatment there and is stable all afternoon. After that trauma finally has their xrays and the pt got pelvis facture, femur fracture, sacrum, tibia, clavicle etc. Later we have her in the OR again for an external fixator in pelvis and femur. This time the pt is stable all the way trough.

My question here, was my attending right stopping them from taking the xrays in the OR and potentially put the external fixator right there?

 

[Sleeplessbordernights]

Yeah your attending is a ****ing idiot. And a coward.

Also your TTL and entire trauma team must be removed of their duties immediately. Sounds lucky this girl didnt die
There is a thing called ATLS. Pelvic binder in part of the primary survey. xrays done in emerg stat

0.6 of levo during a massive hemorrhage? mmm

Yeah tbh this particular attending is old and on The way out he is super kind but I would not get anesthesia from him ever, it gets better, diggin up info, the EM doc was indeed trying to do a proper work up but the vascular team over rode him and had the pt in the OR ASAP, which sucks but surgeons basically own the place so..

 

[woopedazz]

Why we doing CPR in this lady? The empty heart getting external compression gonna make it more or less empty?

Tell people to get off the chest and do bilat finger thoracostomies the moment they went into PEA, which is what they were in.

Everyone else in the room is either holding a 20g cannula or a wire to seldinger in a RIC

 

[coffeebythelake]

Why we doing CPR in this lady? The empty heart getting external compression gonna make it more or less empty?

Tell people to get off the chest and do bilat finger thoracostomies the moment they went into PEA, which is what they were in.

Everyone else in the room is either holding a 20g cannula or a wire to seldinger in a RIC

LoL what?? ACLS applies for cardiac arrest due to hypovolemic shock. The underlying cause is hypovolemia so load them up with blood and fluids at the same time. Raise their legs to transiently increase venous return. But chest compressions for a patient who codes in this situation is appropriate. As is giving epinephrine. You gotta keep whatever little is in the vasculature moving to temporize while you tank them up.

Bilateral finger thoracostomies? 20g IVs with RICs (was there even any mention that the patient was a difficult IV? Or that access was inadequate?)? What the heck are u talking about.

 

[deleted697535]

Yeah tbh this particular attending is old and on The way out he is super kind but I would not get anesthesia from him ever, it gets better, diggin up info, the EM doc was indeed trying to do a proper work up but the vascular team over rode him and had the pt in the OR ASAP, which sucks but surgeons basically own the place so..

That sucks man. Im glad you wrote this case up as both a refresher and a bit of a wake up call to us all...

I dont like algorithmic care in general when we are way beyond that in our training but we still have to know it and revert to it when totally clueless

I got caught myself with my pants down recently with an endobronchial intubation from emerg during a trauma. For shame took me 30 mins to figure it out... But there you go

 

[GassYous]

That sucks man. Im glad you wrote this case up as both a refresher and a bit of a wake up call to us all...

I dont like algorithmic care in general when we are way beyond that in our training but we still have to know it and revert to it when totally clueless

I got caught myself with my pants down recently with an endobronchial intubation from emerg during a trauma. For shame took me 30 mins to figure it out... But there you go

Happens

 

[PainDrain]

What was the final outcome? Patient survive?

 

[Sleeplessbordernights]

What was the final outcome? Patient survive?

She is doing fine out of ICU, awaiting surgery

 

[Radetzky]

Cpr is ineffective in hypovolemia arrest. Standard ACLs does not apply to the trauma patient.

 

[coffeebythelake]

Cpr is ineffective in hypovolemia arrest. Standard ACLs does not apply to the trauma patient.

Reference? I feel you've got a step too far in implying you don't do CPR because it is ineffective. Current guidelines in AHA and ECC does not actually say that. ATLS 10th edition does not say that. It says you need to recognize and rapidly treat hypovolemic / hemorrhagic shock as the underlying reversible cause for the traumatic cardiac arrest. Nothing there about withholding CPR.

 

[Radetzky]

Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest

Closed chest compressions (CCC) are recommended for medical cardiac arrest, but there is little evidence to support their inclusion for traumatic cardiac arrest (TCA).This laboratory study evaluated CCC following haemorrhage-induced TCA and whether resuscitation with blood improved survival...

www.resuscitationjournal.com

All the traumatic arrest I’ve been involved in we’ve not done compressions and focussed on haemorrhage control, chest decompression, and blood tranfusion.

This paper (don’t know why link is coming up weird) shows that chest compressions are associated with worse survival. Granted, it’s an animal study, but it’s the best evidence we’re probably going to be able to achieve in this area.

 

[woopedazz]

LoL what?? ACLS applies for cardiac arrest due to hypovolemic shock. The underlying cause is hypovolemia so load them up with blood and fluids at the same time. Raise their legs to transiently increase venous return. But chest compressions for a patient who codes in this situation is appropriate. As is giving epinephrine. You gotta keep whatever little is in the vasculature moving to temporize while you tank them up.

Bilateral finger thoracostomies? 20g IVs with RICs (was there even any mention that the patient was a difficult IV? Or that access was inadequate?)? What the heck are u talking about.

I stand by my comment. It's extremely uncomfortable to not do CPR, but it isn't achieving anything in a proper trauma arrest.

Edit: but I love that you went back to search for some evidence below, so I'll try to do the same. I agree with pretty much everything you said below, but still think jamming in 2 fingers is the first thing I'd do, and to do so I'd kick everyone off the chest so my fingers don't get sliced open by ribs.

 

[coffeebythelake]

Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest

Closed chest compressions (CCC) are recommended for medical cardiac arrest, but there is little evidence to support their inclusion for traumatic cardiac arrest (TCA).This laboratory study evaluated CCC following haemorrhage-induced TCA and whether resuscitation with blood improved survival...

www.resuscitationjournal.com

All the traumatic arrest I’ve been involved in we’ve not done compressions and focussed on haemorrhage control, chest decompression, and blood tranfusion.

This paper (don’t know why link is coming up weird) shows that chest compressions are associated with worse survival. Granted, it’s an animal study, but it’s the best evidence we’re probably going to be able to achieve in this area.

Notwithstanding the huge dissimilarities between a patient who has a traumatic arrest out in the field (OHCA, where stats show survival anywhere from 2-8%) vs a patient who arrests in the middle of a general anesthetic due to more gradual (patient did tolerate induction of GA), unrecognized, underressucitated hemorrhagic shock...

You will find plenty of studies and opinions that support both sides of the arguments. For example, refer to Konesky and Guo (Eur J of Trauma and Emerg Surg, 2018), Millin et al., in the joint NAEMSP-ACSCOT position statement (J of Trauma and Acutr Care Surg, 2013).

Many of the arguments made against performing chest compressions on traumatic cardiac arrest is that it is resource intensive and may delay other interventions such as establishing large bore iv access, intubating, giving fluids and blood products, obtaining imaging and thoracotomy. Clearly many of these interventions have already been performed on the OP's patient.

Even the European Resuscitation Council (ERC)'s 2015 updated guidelines say that while chest compressions may be ineffective, it should take a lower priority to other interventions to treat reversible causes. They did not say no CPR.

 

[GassYous]

I think it's stupid to be thumping on a chest to try to pump blood through an empty heart when there's no issue with the heart itself except for a lack of blood. You prevent people from placing ivs and lines for no good reason. Just restore the volume and let the heart work.

 

[Radetzky]

Notwithstanding the huge dissimilarities between a patient who has a traumatic arrest out in the field (OHCA, where stats show survival anywhere from 2-8%) vs a patient who arrests in the middle of a general anesthetic due to more gradual (patient did tolerate induction of GA), unrecognized, underressucitated hemorrhagic shock...

You will find plenty of studies and opinions that support both sides of the arguments. For example, refer to Konesky and Guo (Eur J of Trauma and Emerg Surg, 2018), Millin et al., in the joint NAEMSP-ACSCOT position statement (J of Trauma and Acutr Care Surg, 2013).

Many of the arguments made against performing chest compressions on traumatic cardiac arrest is that it is resource intensive and may delay other interventions such as establishing large bore iv access, intubating, giving fluids and blood products, obtaining imaging and thoracotomy. Clearly many of these interventions have already been performed on the OP's patient.

Even the European Resuscitation Council (ERC)'s 2015 updated guidelines say that while chest compressions may be ineffective, it should take a lower priority to other interventions to treat reversible causes. They did not say no CPR.

Neither of those papers are about compressions vs no compressions. Konesky’s paper simply looks at the outcomes of traumatic cardiac arrest, all of whom got cpr, and as far as I can tell Millins statement doesn’t specifically address the issue either.

Its not wrong to do CPR. It’s also not wrong to not do CPR because the best available literature, to me, shows that it’s harmful. I think one is justified in either approach.

 

[coffeebythelake]

I think it's stupid to be thumping on a chest to try to pump blood through an empty heart when there's no issue with the heart itself except for a lack of blood. You prevent people from placing ivs and lines for no good reason. Just restore the volume and let the heart work.

Does data exist out there regarding ROSC and neurologic outcomes from intraoperative cardiac arrest due to hemorrhagic shock, vs inhospital vs out of hospital? I would imagine the rates are quite different. And management should not be the same.

Why am I saying this? Because the time course, recognition of event, and intervention matter. A patient with cardiac arrest out in the field might already have effective no volume in their heart by the time someone gets to them. They need to be extricate, transported, etc. There are fewer hands available. Here it makes a lot of sense to focus on putting in access and running in volume, intubating, etc. A patient with an intraop hemorrhagic arrest would be picked up almost instantly with use of appropriate monitoring and their heart might not be completely empty. Just not enough to effectively generate a pulse (hence PEA, and also why PEA isn't necessarily a concrete diagnosis). Lines, ET tube, were already all in the OPs patient.

 

[coffeebythelake]

Neither of those papers are about compressions vs no compressions. Konesky’s paper simply looks at the outcomes of traumatic cardiac arrest, all of whom got cpr, and as far as I can tell Millins statement doesn’t specifically address the issue either.

Its not wrong to do CPR. It’s also not wrong to not do CPR because the best available literature, to me, shows that it’s harmful. I think one is justified in either approach.

There is a paucity of data particularly as it relates to the intraop situation the OP described. Hence opinions.

 

[woopedazz]

Found some snippets from guidelines from home.

Obviously most are aimed at Pre-hospital/Trauma room settings. However, it's clear this patient is arresting from a non-resuscitated trauma POV so I believe the recommendations are still valid.

My approach would still be to stop compressions and perform the required interventions while getting extra access + blood products --> commence CPR once interventions are done.


Australian and New Zealand Committee on Resuscitation (ANZCOR) Guideline 11.10.1 Management of Cardiac Arrest due to Trauma:

Relevant sections on whether to perform CPR a traumatic arrest:

In cardiac arrest due to trauma, haemorrhage control, restoration of circulating blood volume, opening the airway and relieving tension pneumothorax should have priority over conventional cardiopulmonary resuscitation (CPR) (i.e. external chest compressions, defibrillation and adrenaline) unless a medical cause for cardiac arrest is reasonably suspected to have preceded the traumatic event. However, if there are sufficient resources available and this does not interfere with necessary procedures, conventional CPR should occur simultaneously.

In cardiac arrest due to trauma, all of the interventions aimed at addressing underlying causes take priority over chest compressions, defibrillation and adrenaline. However, if there are sufficient resources available and there is no interference with essential procedures, conventional CPR can occur simultaneously. The effectiveness of conventional CPR will depend on correcting the causes of the cardiac arrest.

An exsanguinated patient theoretically derives little benefit from external cardiac compressions until blood volume is restored to a minimally sufficient quantity. External chest compressions may exacerbate haemorrhage and cardiac tamponade, and positive pressure ventilation may further reduce critically low venous return or cause air embolism.13 Several case series demonstrate that external chest compressions are virtually never effective for patients in traumatic cardiac arrest unless the underlying cause of the arrest is simultaneously and rapidly addressed.13-16 Conversely, there is no clinical evidence that chest compressions worsen outcome in trauma. Therefore, external chest compressions (as recommended in ANZCOR Guideline 6) should be commenced as a secondary priority, after airway opening, commencement of restoration of circulating blood volume (if the required equipment is available), and (if appropriate) decompression of the chest (Class B; LOE IV). If there is any other indication for resuscitative thoracotomy and this is possible in the circumstances, internal cardiac compression is preferable to external chest compressions.17 (Class A; LOE IV). In the absence of the requisite equipment or expertise to address the underlying aetiology of cardiac arrest in trauma, first aiders should summon skilled assistance then proceed directly to BLS.

Adrenaline in traumatic arrest:

There is little evidence for or against the use of adrenaline in cardiac arrest due to trauma.

ANZCOR does not recommend adrenaline for patients in traumatic cardiac arrest until haemorrhage control, opening the airway, commencement of restoration of circulating blood volume and (if appropriate) decompression of tension pneumothorax have been addressed. (Class A; LOE IV). Once spontaneous cardiac output is restored, hypotension is usually the result of hypovolaemia and should be treated initially with ongoing volume replacement. (Class B; LOE IV). In the later phases of post-arrest care, vasodilation or myocardial depression may require adrenaline or other vasoactive infusions.

Defib:

...defibrillation is not the priority for the majority of trauma patients in cardiac arrest. ANZCOR suggests not using defibrillation prior to opening the airway, commencement of restoration of circulating blood volume, and (if appropriate) decompression of the chest (Class B; LOE IV). In the small minority of patients who are in traumatic cardiac arrest with VF or VT, reversible causes must be addressed, and defibrillation should be performed promptly, especially in those suspected of having a cardiac co-morbidity. (Class A; LOE IV).

State/Hospital Guidelines:

Victorian State Trauma System Guideline: Traumatic Cardiac Arrest

In traumatic cardiac arrest, cardiac compressions are unlikely to be as effective as in normovolaemic cardiac arrest. Therefore, commencement of external chest compressions takes less of a priority than treatment of reversible causes. The patient in cardiac arrest from a haemorrhaghic cause receives little benefit until a sufficient circulating volume of blood is returned.
Once an attempt has been made to restore circulating volume and other reversible causes corrected, commence external chest compressions

Traumatic Cardiac Arrest Guidelines - Royal Melbourne Hospital

In traumatic cardiac arrest due to trauma priorities are different from conventional cardiac arrest due to medical causes. Haemorrhage control, restoration of circulating blood volume, airway management and relieving of tension pneumothoraces have priority over conventional CPR (unless there is suspicion of a medical cause for cardiac arrest preceding the trauma). However, if there are sufficient resources (such as a full trauma team) these priorities can be met quickly and CPR can proceed imminently.

Queensland:

UK recommendations:

Royal College of Emergency Medicine - Best Practice Guideline: Traumatic Cardiac Arrest in Adults (2019):

Initial management priorities during TCA include stopping catastrophic external haemorrhage (e.g. tourniquet, haemostatic dressings), ensuring adequate oxygenation & ventilation, performing bilateral thoracostomies, minimising internal haemorrhage (e.g. pelvic binder) and rapid blood transfusion as per major haemorrhage protocols.

Royal College of Surgeons - Faculty of Pre-Hospital Care:
CONSENSUS STATEMENT 2018 MANAGEMENT OF TRAUMATIC CARDIAC ARREST (2018)

Well-recognised advanced life support (ALS) resuscitation techniques including the use of chest compressions and fluid administration remain controversial in TCA management.

The effectiveness of chest compressions in TCA has been debated and the most recent guidelines from the European Resuscitation Council (ERC) suggest that priority should be given to identifying and treating the cause of cardiac arrest rather than the initiation of chest compressions which may or may not be beneficial.

Recommendation 1. Hypovolaemic cardiac arrest should be managed with aggressive haemorrhage control and early surgical intervention. Recommendation 2. Chest compressions may be interrupted in order to provide definitive treatment of hypovolaemia

Review of Traumatic Cardiac Arrest Recommendations (UK):

Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. Journal of the Royal Society of Medicine. 2015;108(1):11-16. doi:10.1177/0141076814560837

Standard Advanced Life Support algorithms should not be used for patients in traumatic cardiac arrest.

European Resuscitation Council: Traumatic Cardiac Arrest/Peri-Arrest Algorithm (2021)

 

[deleted697535]

If a kid like this arrests, im definitely doing cpr.
While also blasting them with o neg and whatever volume is around.

Definitely not giving them milligrams of epi.

The long term implications (on one's career and the kid) of not doing cpr are astronomical. The harm is probably minor

Do you want to be up in front of an ethics committee with a slideshow of pig model evidence for why you 'let a kid die'. This is what they say and think. No way. Not again

 

[coffeebythelake]

Found some snippets from guidelines from home.

Obviously most are aimed at Pre-hospital/Trauma room settings. However, it's clear this patient is arresting from a non-resuscitated trauma POV so I believe the recommendations are still valid.

My approach would still be to stop compressions and perform the required interventions while getting extra access + blood products --> commence CPR once interventions are done.


Australian and New Zealand Committee on Resuscitation (ANZCOR) Guideline 11.10.1 Management of Cardiac Arrest due to Trauma:

Relevant sections on whether to perform CPR a traumatic arrest:



Adrenaline in traumatic arrest:


Defib:


State/Hospital Guidelines:

Victorian State Trauma System Guideline: Traumatic Cardiac Arrest



View attachment 339900

Traumatic Cardiac Arrest Guidelines - Royal Melbourne Hospital



Queensland:

View attachment 339903


UK recommendations:

Royal College of Emergency Medicine - Best Practice Guideline: Traumatic Cardiac Arrest in Adults (2019):



View attachment 339901
Royal College of Surgeons - Faculty of Pre-Hospital Care:
CONSENSUS STATEMENT 2018 MANAGEMENT OF TRAUMATIC CARDIAC ARREST (2018)





Review of Traumatic Cardiac Arrest Recommendations (UK):

Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. Journal of the Royal Society of Medicine. 2015;108(1):11-16. doi:10.1177/0141076814560837


View attachment 339898


European Resuscitation Council: Traumatic Cardiac Arrest/Peri-Arrest Algorithm (2021)

View attachment 339902

Thx for taking the time to put this together

 

[Radetzky]

If a kid like this arrests, im definitely doing cpr.
While also blasting them with o neg and whatever volume is around.

Definitely not giving them milligrams of epi.

The long term implications (on one's career and the kid) of not doing cpr are astronomical. The harm is probably minor

Do you want to be up in front of an ethics committee with a slideshow of pig model evidence for why you 'let a kid die'. This is what they say and think. No way. Not again

Good point, if I didn’t work in an environment where this was an accepted practice, I would probably do CPR.

 

[ChiDO]

Had a guy in our trauma bay the other day who got shot 20 times around 1am. Coded on arrival. They brought him back. 60 units of products in 24 hours eventually. Chest tube 2L our immediately and flowing.

Anesthesia and I, just chilling, waiting to start our next case but had to wait for trauma team to figure out what they wanted to do with this guy. Once he was stable in the trauma bay, got xrays...GSW to femur. I asked trauma since he's now alive, can I add him on for femur nail after thoracic cracks the chest. 😁 I said bone broke, me fix? 🤣