ACLS in Trauma

[Venko]

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I have heard debates recently about the utility of chest compressions, epinephrine etc in traumatic arrests. What do people think?

 

[pseudoknot]

All the literature I've seen indicates that the survival rate for out of hospital arrests secondary to blunt trauma is basically zero and thus no treatment is indicated. I'd be very interested in hearing about anything I've missed on this, however.

 

[docB]

I think ACLS when used in the setting of trauma does very little good. It does tend to allow victims to die in hospitals rather than at scene on on the rigs.

I think ACLS in general is an overall poor use of resources. If you took all the medical people who are required to stay certified in ACLS and had them donate one day every 2 years to some other cause like prevention of some sort we'd probably do more good.

As for chest compressions in trauma you'll note that the military uses sternal IOs a lot which get in the way of compressions. The theory being that if you're to the point of doing compressions you're done.

 

[deleted6669]

you'll note that the military uses sternal IOs a lot which get in the way of compressions. The theory being that if you're to the point of doing compressions you're done.

I had assumed that this was because they are cheaper than EZ- IO's....

 

[Rendar5]

I have heard debates recently about the utility of chest compressions, epinephrine etc in traumatic arrests. What do people think?

Well, traumatic arrests is essentially treated the same way as loss of vitals is. blunt trauma: you're done. penetrating trauma: thoracotomy if you have a CT surgeon on hand.

 

[Paseo Del Norte]

I had assumed that this was because they are cheaper than EZ- IO's....

The injury patterns typically make sternal access a necessity. With fairly good body armour and SAPI plates, the torso can be fairly well preserved following IED and VBIED detonation. The extremities, not so well. Therefore in this setting, sternal access is preferred.

Another consideration is any device that requires electricity and complex moving parts may have inherent flaws in the durability department when considering the environmental exposure and other elements in the operational theatre.

 

[The White Coat Investor]

The injury patterns typically make sternal access a necessity. With fairly good body armour and SAPI plates, the torso can be fairly well preserved following IED and VBIED detonation. The extremities, not so well. Therefore in this setting, sternal access is preferred.

Another consideration is any device that requires electricity and complex moving parts may have inherent flaws in the durability department when considering the environmental exposure and other elements in the operational theatre.

EZ-IOs are all over the theatre and work fine. That's what most of those sternal IOs are.

 

[Paseo Del Norte]

EZ-IOs are all over the theatre and work fine. That's what most of those sternal IOs are.

Off lable use 😀. I am glad to hear the EZ works well over there. Before I hit my ETS date, this was the current rationale for using the fast. The FAST has served me well in actual use. However, most of my colleagues prefer the EZ IO.

I must admit that the literature I have seen does support the EZ in terms of successful placement.

 

[Venko]

So, I have seen some trauma surgeons in different hospitals rely on ACLS in blunt trauma arrest, and others (more military folks as mentioned above) use a different algorithm. They believe that blunt agonal arrest = bilateral needle thoracostomy, then bilateral tube thoracostomy, and then pericardiocentesis / echo, and large volume blood transfusion.

My personal view is more in line with the military one, that if you die in trauma and I can bring you back its because it is related to pneumo or hemothorax, pericardial effusion, or hemorrhage.

 

[Tiger26]

Also kinda interesting, but the military is putting in a ton of crichs as a quasi-first line airway as well, mainly because whipping out a laryngoscope at night while you're getting shot at is a not-so-subtle giveaway for where to return fire . . . .

 

[Venko]

Also kinda interesting, but the military is putting in a ton of crichs as a quasi-first line airway as well, mainly because whipping out a laryngoscope at night while you're getting shot at is a not-so-subtle giveaway for where to return fire . . . .

Interesting, I hadn't thought of that!

 

[Paseo Del Norte]

Interesting, I hadn't thought of that!

Supraglottic airways were pretty popular in Afghanistan among the civi contractor population when I was there.

 

[deleted6669]

Supraglottic airways were pretty popular in Afghanistan among the civi contractor population when I was there.

which brand?

 

[Paseo Del Norte]

which brand?

LMA's and Combitubes. The company I worked at had a line on cheap facsimiles of the LMA unique. I spent many an hour packing aide bag orders with these devices.

 

[deleted6669]

I prefer the king LT over the combitube but it probably costs more...

 

[n2b8me]

😉

 

[Arcan57]

We simplified it that if it was a blunt traumatic arrest, it was game over. Even the people that got ROSC never made it out of the unit. Penetrating trauma was game on if they had a pulse just before they were offloaded from the ambulance.

 

[EMS5]

We simplified it that if it was a blunt traumatic arrest, it was game over. Even the people that got ROSC never made it out of the unit. Penetrating trauma was game on if they had a pulse just before they were offloaded from the ambulance.

Agreed, I once had a chat with a local doc about what they would prefer we do in the field. It broke down simply to blunt trauma - call it on scene or transport and call it at the ER....penetrating trauma - work it if we observed vitals at any time during treatment

I've seen/worked 5 severe traumas...4 were blunt and all were called on scene or arrival at ED...one penetrating which had an emergency thoracotomy and the patient later died on the OR table

 

[Paseo Del Norte]

I prefer the king LT over the combitube but it probably costs more...

The Combi is around 50-60 bucks a pop while you can get a King for about 40 bucks a pop. The Combi comes in two sizes and the King has three adult sizes. Realistically, size 4 is most often utilised. Therefore, I would say cost is roughly comparable.

Anecdotally, I prefer the Combi simply because I was using the Combi back in the 90's when the other options included the EOA, EGTA and PTLa. Obviously, a no brainer on what to use if you are looking at an EOA versus Combitube. Additionally, I have much more real world experience with the Combi. However, I am not sure the literature definitively supports one over the other at this point. I know the King can theoretically be exchanged with a bougie; however, I feel exchanging a functional device in the field is above my pay grade and I am happy to leave well enough alone.

 

[deleted6669]

I learned eoa's and egta's in medic school as well. I remember having to put in eoa's and then do blind et tube placement around them as a test scenario. I didn't use them much as I could usually get an oral or nasal tube.
the thing I like about the king is it is one balloon to inflate instead of 2 and getting it in the trachea is almost impossible. simple is better and faster in my book.